Prevalence of impaired physiological function consistent with Relative Energy Deficiency in Sport (RED-S): an Australian elite and pre-elite cohort
Abstract
Objectives: Athlete health, training continuity and performance can be impeded as a result of Relative Energy Deficiency in Sport (RED-S). Here we report the point prevalence of symptoms described by the RED-S model in a mixed-sport cohort of Australian female athletes. Methods: Elite and pre-elite female athletes (n=112) from eight sports completed validated questionnaires and underwent clinical assessment to assess the point prevalence of RED-S symptoms. Questionnaires included the Depression, Anxiety and Stress Questionnaire (DASS-21), Generalized Anxiety Disorder (GAD-7), Center for Epidemiological Studies Depression Scale (CES-D), SCOFF questionnaire for disordered eating, Low Energy Availability in Females Questionnaire (LEAF-Q), and a custom questionnaire on injury and illness. Clinical assessment comprised resting metabolic rate (RMR) assessment, dual-energy X-ray absorptiometry-derived body composition and bone mineral density, venous and capillary blood samples, and the Mini International Neuropsychiatric Interview (MINI 7.0.2). Descriptive prevalence statistics are presented. Results: Almost all (80%) participants (age 19 (range 15–32) years; mass 69.5±10.3 kg; body fat 23.1%±5.0%) demonstrated at least one symptom consistent with RED-S, with 37% exhibiting between two and three symptoms. One participant demonstrated five symptoms. Impaired function of the immunological (28%, n=27), haematological (31%, n=33) and gastrointestinal (47%, n=51) systems were most prevalent. A moderate to high (11%–55%) prevalence of risk of low energy availability was identified via RMR and LEAF-Q, and identified mental illnesses were prevalent in one-third of the assessed cohort. Conclusion: Symptoms described by the RED-S model were prevalent in this cohort, supporting the need for improved awareness, monitoring and management of these symptoms in this population.
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Other studies required athletes to exhibit symptoms such as menstrual dysfunction, impaired bone health, endocrine dysfunction, metabolic dysfunction, hematological abnormalities, psychological decline, or cardiovascular dysfunction to meet the criteria for REDs.
“Other studies stated that athletes must exhibit symptoms such as menstrual dysfunction, impaired bone health, endocrine dysfunction, metabolic dysfunction, hematological abnormalities, psychological decline, or cardiovascular dysfunction to meet the criteria for REDs [82].”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [82]
In Rogers et al.'s study of elite and pre-elite Australian female athletes across multiple sports, 80% of participants were determined to have REDs based on the presence of at least one listed symptom.
“In a study of elite and pre-elite Australian female athletes across multiple sports by Rogers et al., 80% of participants were determined to have REDs based on the presence of at least one of the symptoms listed in the previous sentence [82].”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [82]
Depressive symptoms and affective disorders, subjectively reported reduced well-being, primary or secondary exercise dependence/addiction, anxiety related to injury and/or recovery, sport-specific issues such as difficulty coping with weight requirements and the development of EDs are additional adverse mental health outcomes associated with problematic LEA and REDs.
“Depressive symptoms and affective disorders, 8 78 79 subjectively reported reduced well-being, 73 primary or secondary exercise dependence/addiction, 80 81 anxiety related to injury and/or recovery, sport-specific issues such as difficulty coping with weight requirements 67 76 and the development of EDs 1 82 are additional adverse mental health outcomes associated with problematic LEA and REDs.”
From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [78]
There is a bi-directional association between iron deficiency and low energy availability (LEA).
“There is a bi-directional association between iron deficiency and LEA.”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [54]
Energy-deficient athletes are at risk for iron deficiency due to decreased dietary intake, impaired absorption, and foot strike hemolysis.
“Energy-deficient athletes are at risk for iron deficiency due to decreased dietary intake, impaired absorption, and foot strike hemolysis [5,54].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [54]
Iron deficiency from decreased dietary intake can promote energy deficiency by shifting ATP production away from oxidative phosphorylation.
“Additionally, iron deficiency from decreased dietary intake can also promote energy deficiency by shifting ATP production away from oxidative phosphorylation [5,54].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [54]
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Is RED-S in athletes just another face of malnutrition?
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- Authors
- Rogers, M. A., Appaneal, R. N., Hughes, D., Vlahovich, N., Waddington, G., Burke, L. M., & Drew, M.
- Affiliations
- University of Canberra (AU)
- Research Institute for Sport and Exercise, University of Canberra, Bruce, Australian Capital Territory, Australia
- Sports Medicine, Australian Institute of Sport, Bruce, Australian Capital Territory, Australia
- Australian Catholic University (AU)
- Corresponding author
- Rogers, Margot Anne
- ORCID
- Venue
- British Journal of Sports Medicine
- Publisher
- BMJ
- Published
- 2020-11-16
- Volume
- 55
- Issue
- 1
- Pages
- 38-45
- ISSN
- 0306-3674 (ISSN-L)
- 1473-0480
- OpenAlex
- W3099367898
- Cited by
- 89
- References
- 6
- Citations by year
- 2026: 10 · 2025: 19 · 2024: 28 · 2023: 13 · 2022: 12 · 2021: 7
- FWCI
- 3.20
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- British Journal of Sports Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- University of Canberra (Research Institute for Sport and Exercise (interna)
- Australian Institute of Sport (High Performance Research Fund (Immune Health Mult)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Health Sciences › Nursing › Nutrition and Dietetics › Nutrition, Health and Food Behavior
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
- Keywords
- relative energy deficiency in sport, female athletes, low energy availability, immune dysfunction, gastrointestinal symptoms, mental health, disordered eating, bone mineral density, body composition, resting metabolic rate, LEAF-Q, DASS-21, GAD-7, CES-D, SCOFF questionnaire
- MeSH terms
- Cardiorespiratory Fitness, Relative Energy Deficiency in Sport, Adolescent, Adult, Australia, Basal Metabolism, Mental Disorders, Competitive Behavior, Cross-Sectional Studies, Female, Health Surveys, Humans, Interview, Psychological, Risk Factors, Biomarkers, Absorptiometry, Photon, Prevalence, Leptin, Young Adult
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