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IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update
  1. Margo Mountjoy1,
  2. Jorunn Kaiander Sundgot-Borgen2,
  3. Louise M Burke3,4,
  4. Kathryn E Ackerman5,6,
  5. Cheri Blauwet7,
  6. Naama Constantini8,
  7. Constance Lebrun9,
  8. Bronwen Lundy3,
  9. Anna Katarina Melin10,
  10. Nanna L Meyer11,
  11. Roberta T Sherman12,
  12. Adam S Tenforde13,
  13. Monica Klungland Torstveit14,
  14. Richard Budgett15
  1. 1Department of Family Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
  2. 2Department of Sports Medicine, The Norwegian School of Sport Sciences, Oslo, Norway
  3. 3Sports Nutrition, Australian Institute of Sport, Beclonnen, Australia
  4. 4Centre for Exercise and Nutrition, Mary MacKillop Institute for Health Research, Melbourne, Victoria, Australia
  5. 5Divisions of Sports Medicine and Endocrinology, Boston Children’s Hospital, Boston, Massachusetts, USA
  6. 6Neuroendocrine Unit, Massachuetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  7. 7Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital/Brigham and Women’s Hospital, Boston, Massachusetts, USA
  8. 8Heidi Rothberg Sport Medicine Center, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
  9. 9Department of Family Medicine, Faculty of Medicine and Dentistry, Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada
  10. 10Department of Nutrition, Exercise and Sport, University of Copenhagen, Frederiksberg, Denmark
  11. 11Health Sciences Department Colorado Springs, University of Colorado, Denver, Colorado, USA
  12. 12Independent researcher, USA
  13. 13Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
  14. 14Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
  15. 15IOC Medical and Scientific Department, Lausanne, Switzerland
  1. Correspondence to Dr Margo Mountjoy, Department of Family Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON N2G 1C5, Canada; mmsportdoc{at}

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In 2014, the IOC published a consensus statement entitled ‘Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport (RED-S)’. The syndrome of RED-S refers to ‘impaired physiological functioning caused by relative energy deficiency and includes, but is not limited to, impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis and cardiovascular health’. The aetiological factor of this syndrome is low energy availability (LEA).1

The publication of the RED-S consensus statement stimulated activity in the field of Female Athlete Triad science, including some initial controversy2 3 followed by numerous scientific publications addressing:

  1. The health parameters identified in the RED-S conceptual model (figure 1).1 4

  2. Relative energy deficiency in male athletes.

  3. The measurement of LEA.

  4. The performance parameters identified in the RED-S conceptual model (figure 2).1 4

The IOC RED-S consensus authors have reconvened to provide an update summary of the interim scientific progress in the field of relative energy deficiency with the ultimate goal of stimulating advances in RED-S awareness, clinical application and scientific research to address current gaps in knowledge.

Figure 1

Health consequences of Relative Energy Deficiency in Sport (RED-S) showing an expanded concept of the Female Athlete Triad to acknowledge a wider range of outcomes and the application to male athletes (*Psychological consequences can either precede RED-S or be the result of RED-S).1 4

Figure 2

Potential Performance consequences of Relative Energy Deficiency in Sport (*Aerobic and anerobic performance).1 4

Low energy availability

LEA, which underpins the concept of RED-S, is a mismatch between an athlete’s energy intake (diet) and the energy expended in exercise, leaving inadequate energy to support the functions required by the body to maintain optimal health and performance. Operationally, energy availability (EA) is defined as:

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where exercise energy expenditure (EEE) is calculated as the additional energy expended above that of …

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