The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)

Correspondence to Dr Margo Mountjoy, Department of Family Medicine, Michael G. DeGroote School of Medicine, McMaster University Waterloo Regional Campus, 10-B Victoria Street South, Kitchener, Ontario, Canada N2G 1C5; [e-mail]

Introduction

Protecting the health of the athlete is one of the goals of the International Olympic Committee (IOC).¹ The Olympic Movement Medical Code, which governs the actions of the IOC Medical Commission and sport organisations, also emphasises the importance of protecting the health of the athlete.² In 2005, the IOC published the Consensus Statement (Consensus Statement) and the IOC Position Stand (Position Stand)³ on the Female Athlete Triad.⁴ Based on scientific evidence published in the intervening period, this Consensus Statement serves to update and replace these documents and provide guidelines to the athlete health support team to guide risk assessment, treatment and return-to-play decisions for affected athletes.

Relative energy deficiency in sport

In the 2005 IOC Consensus Statement,⁴ the Female Athlete Triad (Triad) was defined as ‘the combination of disordered eating (DE) and irregular menstrual cycles eventually leading to a decrease in endogenous oestrogen and other hormones, resulting in low bone mineral density’(BMD) based on the original scientific evidence of Drinkwater et al.⁵ In 2007, following progress in scientific understanding, the American College of Sports Medicine redefined the Triad as a clinical entity that refers to the ‘relationship between three inter-related components: energy availability (EA), menstrual function and bone health’. Added was an understanding of the pathophysiology describing the concept that over a period of time, the athlete moves along on a continuous spectrum ranging from the healthy athlete with optimal EA, regular menses and healthy bones to the opposite end of the spectrum characterised by amenorrhoea, low EA and osteoporosis.⁶

Since 2007, scientific evidence and clinical experience show that the aetiological factor underpinning the Triad is an energy deficiency relative to the balance between dietary energy intake (EI) and the energy expenditure required to support homoeostasis, health and the activities of daily living, growth and sporting activities. It is also evident that the clinical phenomenon is not a triad of three entities of EA, menstrual function and bone health, but rather a syndrome resulting from relative energy deficiency that affects many aspects of physiological function including...