Sports participation among women and girls has dramatically increased over the past decade, reflected in a record numbers of girls competing in high school and collegiate sports and women competing in the recent Olympic and Paralympic Games. For women and girls, sport participation is associated with opportunities to develop physical competence, improve components of fitness, and positively influence overall well-being. Sport can also foster confidence, teamwork, identity, belonging, and a sense of community.
At the same time, sport environments introduce unique challenges such as injury, burnout, mental health concerns, pressure related to performance and/or body composition, demanding training and competition schedules, and competing academic, work, or social responsibilities.
An additional requirement for optimal health and performance is adequate nutrition. At a basic level, individuals need sufficient energy intake relative to their total energy requirements. This includes the energy needed to maintain essential bodily functions, support everyday movement, and fuel exercise and sport training. There are a number of reasons that athletes at all levels may experience inadequate intake, including but not limited to, a lack of understanding of nutritional requirements related to the energy cost of their training, prioritizing other demands over fueling, and/or factors related to food access. These include meal planning and preparation, financial constraints, living arrangements, and insufficient access to qualified nutrition support. In other cases, inadequate nutrition may arise intentionally through dietary restriction, weight-control practices, or disordered eating.
Psychological stress, body image concerns, pressure to alter body composition, and sport-specific cultural norms may contribute further. These factors may interact in complex ways, contributing to inadequate energy intake and/or excessive energy expenditure, and in some cases, low energy availability (LEA). LEA occurs when the energy available to the body after exercise is insufficient to adequately support normal physiological functions, such as reproduction, bone health, energy metabolism, and immune function. Relative Energy Deficiency in Sport (REDs) is the syndrome of impaired physiological and psychological functioning associated with prolonged/severe LEA, which can have detrimental consequences for health and performance.
The 2023 International Olympic Committee (IOC) REDs consensus reported estimated prevalence ranging from 23% to 80% in female athletes. The wide range reflects challenges in consistently identifying and measuring LEA and REDs, including differences in how these concepts are defined or assessed across studies, as well as differences in the athletes and sports studied.
Importantly, LEA and REDs are related but distinct and should not be used interchangeably when characterizing these constructs. Given the potential adverse physiological outcomes associated with REDs, identifying athletes at risk before more significant health or performance consequences emerge is an important component of athlete care. Screening can provide a practical first step by identifying athletes who may warrant further evaluation based on symptoms, behaviors, or other indicators of potential nutritional or health concerns. However, the tools used to identify risk have important limitations.
Our 2026 methodological review of 13 highly cited REDs screening questionnaires found substantial gaps in the psychometric and pragmatic evidence supporting many of these tools, with validation studies also heavily focused on young female athletes and specific sports or geographic regions. These limitations warrant careful consideration when selecting, administering, and interpreting REDs screening tools, particularly across diverse athlete populations and settings. Screening should be viewed as the first step in identifying athletes who may need further evaluation, rather than as a means of establishing a diagnosis. Regardless of the quality of a screening tool, its results should inform, not replace, a comprehensive clinical assessment instrument.
Athletes identified as “at-risk” should receive an individualized clinical assessment to determine whether energy intake is sufficient to meet their physiological demands, whether associated health consequences have emerged, and what other factors may be contributing. As adequate nutrition is fundamental to athlete well-being, prevention of REDs and associated consequences should be prioritized.
Sports nutrition and REDs education should be provided to all individuals in athletic environments, including athletes, coaches, strength and conditioning professionals, athletic trainers, sports medicine providers, parents, and other members of the athlete’s support network. Education should extend beyond nutrient recommendations to include how nutritional needs change with training and competition, how to recognize signs that they may not be meeting those needs, and when to seek additional support – athletes need help taking action to support their nutritional needs.
Additionally, consultation with a registered dietitian should occur to address individual needs based on age, body composition, growth and development, reproductive life stage if recommended. These factors along with dynamic changes in training volume and intensity, competition and travel schedule and injury/illness can be more fully addressed with guidance from a trained sports dietitian. Importantly, all education interventions should emphasize that adequate nutrition supports health, recovery, adaptation, and performance rather than framing nutrition primarily around body weight or body composition.
Optimal sport performance does not occur in isolation from health. Rather, the ability to train, adapt, recover, and perform is supported by an athlete’s overall health and well-being. In turn, athlete health and well-being depend on adequate nutrition that provides sufficient energy and nutrients to support the physiological demands of exercise and sport training and functioning of body systems. Adequate nutrition is therefore not simply a strategy for improving performance; it is a fundamental component of female athlete health.
Melissa T. Lodge, PhD, earned her PhD in Health Sciences from the University of Rhode Island and conducted her doctoral research in the Centering Women’s Health Research Laboratory. Her research examines how exercise and nutrition influence health and performance in women, with a particular focus on the prevention of REDs among collegiate athletes.
Christie L. Ward-Ritacco, PhD, is an associate professor and director of the Centering Women’s Health Research Laboratory at the University of Rhode Island. Her research examines the independent and interactive effects of dietary intake, physical activity and quality of life in women across the lifespan.
