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#REDS (Relative Energy Deficiency in Sport): time for a revolution in sports culture and systems to improve athlete health and performance
  1. Kathryn E Ackerman1,2,
  2. Trent Stellingwerff3,4,
  3. Kirsty J Elliott-Sale5,
  4. Amy Baltzell6,
  5. Mary Cain7,
  6. Kara Goucher8,
  7. Lauren Fleshman9,
  8. Margo L Mountjoy10,11
  1. 1 Divisions of Sports Medicine and Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
  2. 2 Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
  3. 3 Canadian Sport Institute, Victoria, British Columbia, Canada
  4. 4 Department of Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
  5. 5 Musculoskeletal Physiology Research Group, Sport Health and Performance Enhancement Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, UK
  6. 6 Author, Consultant, Olympian, Past-President of the Association of Applied Sport Psychology, Boston, Massachusetts, USA
  7. 7 Professional Runner, Bronxville, New York, USA
  8. 8 Professional Runner and Olympian, Athlete Advocate, Boulder, Colorado, USA
  9. 9 Professional Runner, Athlete Advocate, Bend, Oregon, USA
  10. 10 Department of Family Medicine, McMaster University Michael G DeGroote School of Medicine, Hamilton, Ontario, Canada
  11. 11 IOC Medical Commission Games Group, Lausanne, Switzerland
  1. Correspondence to Dr Kathryn E Ackerman, Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA; kathryn.ackerman{at}

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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 practices. 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 education 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 effects 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 monitoring body composition/weight.

  3. Eliminating toxic training environments featuring abusive body shaming.

Overexercising or underfueling, occurring consciously or subconsciously, can cause Relative …

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