Letters to the Editor

Broadening the Female Athlete Triad: Relative Energy Deficiency in Sport


Am Fam Physician. 2019 Jan 15;99(2):76-77.

Original Article: The Female Athlete Triad: Recommendations for Management [Editorial]

Issue Date: April 15, 2018

See additional reader comments at: https://www.aafp.org/afp/2018/0415/p499.html

To the Editor: We thank Dr. Chamberlain for a thorough editorial on the management of the female athlete triad. In 2014, the International Olympic Committee (IOC) published a consensus statement encouraging a broader approach to the female athlete triad.1 The IOC introduced the more comprehensive term relative energy deficiency in sport to describe a syndrome in which low energy availability can lead to multiple medical problems in men and women.2

In relative energy deficiency in sport, an athlete's dietary energy intake is insufficient to support his or her energy expenditure.3 Cyclists, rowers, runners, jockeys, and athletes in weight class combat sports (e.g., wrestling, boxing) are particularly susceptible.4 The uncoupling of energy availability with energy expenditure negatively affects not only the skeletal and endocrine systems, but also the cardiovascular, renal, gastrointestinal, reproductive, and central nervous systems.5

The IOC has developed a clinical assessment tool (available at http://bjsm.bmj.com/content/bjsports/early/2015/04/17/bjsports-2015-094873.full.pdf) for primary care clinicians to help diagnose relative energy deficiency in sport, as well as guide decisions on return to play.6 There is still much to learn about this condition. Family physicians have a key role in recognizing and preventing this syndrome by educating athletes, their families, coaches, school administrators, and communities about proper nutrition and healthy athletic participation.

Author disclosure: No relevant financial affiliations.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Army, Department of the Air Force, Department of Defense, or the U.S. government.


show all references

1. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the female athlete triad—relative energy deficiency in sport (RED-S). Br J Sports Med. 2014;48(7):491–497....

2. Female athlete issues for the team physician: a consensus statement-2017 update. Med Sci Sports Exerc. 2018;50(5):1113–1122.

3. Mountjoy M, Sundgot-Borgen J, Burke L, et al. Authors' 2015 additions to the IOC consensus statement: relative energy deficiency in sport (RED-S). Br J Sports Med. 2015;49(7):417–420.

4. Mountjoy M, Sundgot-Borgen JK, Burke LM, et al. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med. 2018;52(11):687–697.

5. Nattiv A, Loucks AB, Manore NM, Sanborn CF, Sundgot-Bergen J, Warren MP. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 2007;39(10):1867–1882.

6. Mountjoy M, Sundgot-Borgen J, Burke L, et al. RED-S CAT. Relative energy deficiency in sport (RED-S) clinical assessment tool (CAT). Br J Sports Med. 2015;49(7):421–423.

In Reply: Thank you for your thoughtful letter regarding this editorial. My goal was to draw attention to a disorder that family physicians are well positioned to identify and treat and to have a significant impact on the health of the athlete. You are right to highlight that female athlete triad is part of a broader disorder: relative energy deficiency in sport, which can affect male and female athletes' health and performance. Family physicians can be instrumental in identification and treatment of this disorder.

Author disclosure: No relevant financial affiliations.

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This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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