The path towards progress: a critical review to advance the science of the female and male athlete Triad and relative energy deficiency in sport
Abstract
Energy status plays a key role in the health of athletes and exercising individuals. Energy deficiency/low energy availability (EA), referring to a state in which insufficient energy intake and/or excessive exercise energy expenditure has resulted in compensatory metabolic adaptations to conserve fuel, can affect numerous physiological systems in women and men. The Female Athlete Triad, Male Athlete Triad, and Relative Energy Deficiency in Sport (RED-S) models conceptualize the effects of energy deficiency in athletes, and each model has strengths and limitations. For instance, the Female Athlete Triad model depicts relationships between low EA, reproductive, and bone health, underpinning decades of experimental evidence, but may be perceived as limited in scope, while the more recent RED-S model proposes a wider range of potential health effects of low EA, though many model components require more robust scientific justification. This critical review summarizes current evidence regarding the effects of energy deficiency on athlete health by addressing the quality of the underlying science, the strengths and limitations of each model, and highlighting areas where future research is needed to advance the field. With the health and wellness of athletes and exercising individuals as the overarching priority, we conclude with specific steps that will help focus future research on the Female and Male Athlete Triad and RED-S, and encourage all researchers, clinicians, and practitio…
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Some perturbations to body systems from LEA might be considered mild and/or transient, representing physiological plasticity, and could be termed adaptable LEA.
“Some of these perturbations to body systems might be considered mild and/or transient, representing physiological plasticity 35 and could be termed adaptable LEA”
From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [35]
There has been increased awareness of the risk factors for and consequences of REDs, where psychological factors contributing to LEA and mental health consequences have been highlighted, although less well understood.
“A parallel focus has been the increased awareness of the risk factors for and the consequences of REDs, where psychological factors contributing to LEA and mental health consequences have been highlighted, 5 although less well understood.6 35 66”
From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [35]
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“Thus, this study and others [65, 68, 96] do not provide causal evidence for a link between energy deficiency/low EA and GI or immune function, but rather imply that participants are in an energy-deficient state despite limited or no physiological evidence of energy deficiency.”
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Mountjoy, M., Ackerman, K. E., Bailey, D. M., Burke, L. M., Constantini, N., Hackney, A. C., Heikura, I. A., Melin, A., Pensgaard, A. M., Stellingwerff, T., et al. (2023) · British Journal of Sports Medicine · doi:10.1136/bjsports-2023-106994 · Cited by 724 · see citing works
- Authors
- De Souza, M. J., Strock, N. C. A., Ricker, E. A., Koltun, K. J., Barrack, M., Joy, E., Nattiv, A., Hutchinson, M., Misra, M., & Williams, N. I.
- Affiliations
- Pennsylvania State University (US)
- Henry M. Jackson Foundation (US)
- University of Pittsburgh (US)
- California State University, Long Beach (US)
- Intermountain Healthcare (US)
- University of California, Los Angeles (US)
- University of Illinois Chicago (US)
- Massachusetts General Hospital (US)
- Corresponding author
- Williams, Nancy I.
- ORCID
- Venue
- Sports Medicine
- Published
- 2021-10-19
- Volume
- 52
- Issue
- 1
- Pages
- 13-23
- ISSN
- 0112-1642 (ISSN-L)
- 1179-2035
- OpenAlex
- W3206462714
- Cited by
- 39
- References
- 13
- Citations by year
- 2026: 8 · 2025: 7 · 2024: 9 · 2023: 10 · 2022: 3 · 2021: 1
- FWCI
- 0.76
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Sports Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
- Physical Sciences › Engineering › Biomedical Engineering › Lower Extremity Biomechanics and Pathologies
- Keywords
- female athlete triad, relative energy deficiency in sport, low energy availability, energy deficiency, athletes, reproductive health, bone health, metabolic adaptation, exercise energy expenditure, energy intake
- MeSH terms
- Relative Energy Deficiency in Sport, Bone and Bones, Energy Metabolism, Female, Humans, Male, Female Athlete Triad Syndrome, Athletes
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