Are You Looking in the Wrong Places?
My response to the 2025 Female Athlete Triad Consensus[1], as a Sports Dietitian and Eating Behavior Specialist
Dealing with my own tibial fracture and working with more athletes navigating bone stress injuries has catapulted me into the literature on bone health and healing, particularly in athletes. This led me to finally take the time to sit down and dissect the updated Female Athlete Triad consensus statement.
While it has helped me update my knowledge and clinical protocols, it’s also been validating to see additional evidence of what I’ve been preaching for years, especially on why so many nutrition issues are missed by otherwise savvy providers and athletes.
For context, the Female Athlete Triad is a condition that was previously defined as the presence of three conditions: disordered eating, stress fracture, and low weight. In 2014, the International Olympic Committee introduced the term Relative Energy Deficiency in Sport (RED-S) to expand beyond the Triad, though it remains a distinct, independently researched condition within the REDs umbrella.
Note: the current term is REDs, mostly because it gets everyone on the same page of calling it “reds” and not “red S”, plus it is easier to hashtag on socials! (I’m not kidding, that’s why they changed it).
In 2025, the Female Athlete Triad Coalition released an updated consensus statement to reflect the variety and complexity of energy status, the spectrum of bone health, and the incomplete nature of weight as a diagnostic tool. The update was much needed for modern times.
I loved that the new consensus statement directly rebuts some of the things I hear that tell me we are looking in the wrong places for athlete health and energy status.
“My weight is fine!” or “They haven’t lost weight, so they must be eating enough”
The new guidelines highlight something that is part of the REDs consensus statement as well: weight is a poor indicator of energy status.
The REDs consensus statement considers Low Energy Availability to be the underlying driving force of the multi-system condition of REDs, and considers a compromised metabolism and its downstream effects to be hallmarks of the condition. As dietitians, we spend many hours in school and clinical identifying the impact of malnutrition on all body systems, so I see this as an organization of the potential outcomes of malnutrition specific to athletes.
The new Female Athlete Triad consensus brings the concept of metabolic compensation front and center because what we actually see in practice is that weight typically stabilizes. In weight-focused approaches, this may be called a “plateau” in weight loss. This reflects the ever-so-wise body’s ability to survive and adapt in periods of famine.
The guidelines look beyond weight status and consider a deeper look at what is going on below the surface– shifts in bloodwork and measured basal metabolic rate tell us a more complete story. The body is striving to find balance when it doesn’t have the tools necessary to maintain bone. While measuring metabolic rate is not feasible for many, it’s something to consider in university or medical settings to evaluate beyond weight trends, as well as bloodwork that indicates the same.
Hopefully, metabolic testing is something that will become standard practice in outpatient settings in the future.
“My problem is eating too much!” (or bingeing, or emotional eating, or sugar cravings)
The consensus explicitly names restriction, rather than loss of control eating, as an issue to address as restriction is a driver and consistent element in all eating disorders (including binge eating disorder).
I see it often: skipped breakfast, minimal fueling before practice, and then massive cravings and inability to feel fullness at night.
And yet, we blame the evening eating without looking at the role restrictive eating plays. I am always curious when I have someone who feels shame and guilt around eating too much- do they feel the same way about fasting, cutting carbs, and going into training hungry? Do they hold a badge of honor for disciplined eating?
This always gives me so much more information, and I believe all athlete providers can get curious here and help to shift the narrative around restriction, overeating, and fueling proactively.
“I’m fueling a lot better than when I had my first stress fracture, so why do I need to keep doing this?”
There were a few misunderstandings that I actually had about bone stress injuries that were better clarified by reading the guidelines and in my research.
First, I had no idea how long it actually would take to see a difference in bone density once energy is increased to restart a regular menstrual cycle and theoretically influence bone. The authors reference the REFUEL study, a 12 month randomized control trial that looked at this question in-depth[2]. The goal of the study was increasing nutrition by around 350 calories a day to induce a menstrual cycle and monitor its effect on reproductive hormones and bone markers. While bone turnover markers improved, there were no clinically significant changes in bone density. It’s suggested that meaningful changes in bone may take much longer than the study allowed, perhaps up to 2 years. However, menstrual cycle regularity (>2 cycles lasting <36 days) was an indicator that predicted bone recovery in another review.
Bone density recovery is a multi-year process, not a result of a single menstrual cycle, and also reflects why optimizing bone health through adolescence is crucial as the majority of bone is accrued by age 20.
My other misconception was that low bone density is the driver or “cause” of bone stress injuries, rather than a risk factor.
Someone’s bone density more or less reflects the capacity of the tissue at the microscopic level. Bone stress injuries essentially occur because the loading pattern and/or volume is beyond what the tissue can recover from. Microfractures occur, accumulate without having a chance to repair, and lead to injury.
However, an athlete with normal range bone density (which is up to one standard deviation below average by the way) can also develop a stress fracture if training volume increases rapidly- in as little as 3 to 4 weeks[3]!
You can’t cheat biology and poorly managed training programs, but you can optimize the conditions for bone to repair and adapt through nutrition. And by the way, erring on the side of more energy than less is preferable- and this takes planning, support, and can be challenging long term, which is why seeing a sports dietitian is recommended for addressing bone health.
“I get regular periods (on birth control)”
For whatever reason, the myth won’t die that a period induced by birth control shows that hormones are in a good place.
You see, one of the reasons that oligo(meaning few)- and a(meaning no)menorrhea is bad news for skeletal health is because it reflects the presence of low reproductive hormones. Those hormones play a crucial role in promoting bone formation, and without it the scale tips towards breakdown.
However, a period induced by birth control is considered breakthrough bleeding (with IUDs and implants) or withdrawal bleeding (with the pill), not a true reflection of reproductive health.
Having a period with birth control can also mask low energy status because everything looks okay from the surface. There’s a reason a regular cycle is sometimes called a vital sign!
The new guidelines emphasize this, and also recommend other methods for health care providers to replace hormones for bone health, specifically through estrogen delivered transdermally[4].
Body image is more than an afterthought
Body image and the culture within sport is seen as a “soft science” or just simply not part of the process in identifying and treating bone issues.
These guidelines suggest otherwise.
While not all energy deficiency is driven by intentional restriction, eating attitudes have a strong association with energy deficiency. Enough so that the guidelines explicitly state that assessing athletes for drive for thinness is a useful proxy for energy deficiency.
A 2018 online screening tool that had 3,509 athletes participate identified 88% as meeting eating disorder/subthreshold eating disorder characteristics[5]. Screening tools are not diagnostic, but to me this shows a gap in sports culture and how normalized dysfunctional eating can be.
Education about appropriate energy intake for athletes and recognizing signs and symptoms are critical, although the culture of many sports reinforces the unfortunate belief that undereating to maintain a lean physique is what allows athletes to succeed.
I would argue that not only does it impede performance, it directly contributes to early burnout and injury. In most cases, changes in bone health will last far beyond sports participation.
My dream is a sporting culture that puts an athlete’s mental and physical health above any potential short term perceived benefit of chasing “race weight” or the lean ideal.
More and more, committees and researchers are urging sports programs to educate coaches and athletes about REDs and the Triad as well as multi-modal prevention[6]. As an athlete provider, it can be challenging to “raise the alarm bells” for athletes when they don’t present with typical signs of eating issues or fit the stereotype for an eating disorder.
I am hopeful though that with ongoing research and publications, there will be more willingness to recognize the athletes that might slide under the radar.
I believe athletes deserve better, and knowledge is only one piece of the puzzle. Guidelines such as these are just the starting point. It’s up to dedicated providers- stakeholders, coaches, athletic trainers, physical therapists, and dietitians- to move the needle towards a fueling positive culture.
Em Palmerton is a sports dietitian (CSSD, CEDS) who works with athletes navigating performance, disordered eating, and body image. She supports teen and adult athletes, helping them fuel for the long game without compromising their relationship with food or their body. Want to bring an eating disorders and REDs-informed provider to your program? Get in touch to connect.
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References:
[1] De Souza, M.J., Williams, N.I., Misra, M. et al. 2025 Update to the Female Athlete Triad Coalition Consensus Statement Part 1: State of the Science and Introduction of a New Adolescent Model. Sports Med56, 327–373 (2026). https://doi.org/10.1007/s40279-025-02333-z
[2] Salamunes, A. C. C., Williams, N. I., Ricker, E. A., Mallinson, R. J., Koltun, K. J., & De Souza, M. J. (2026). Bone mineral density and bone turnover changes with advanced menstrual recovery: The REFUEL study. Bone, 206, 117834. https://doi.org/10.1016/j.bone.2026.117834
[3] Kardouni, J. R., McKinnon, C. J., Taylor, K. M., & Hughes, J. M. (2021). Timing of Stress Fractures in Soldiers During the First 6 Career Months: A Retrospective Cohort Study. Journal of athletic training, 56(12), 1278–1284. https://doi.org/10.4085/1062-6050-0380.19
[4] Ackerman, K.E., Singhal, V., Slattery, M., Eddy, K.T., Bouxsein, M.L., Lee, H., Klibanski, A. and Misra, M. (2020), Effects of Estrogen Replacement on Bone Geometry and Microarchitecture in Adolescent and Young Adult Oligoamenorrheic Athletes: A Randomized Trial. J Bone Miner Res, 35: 248-260. https://doi.org/10.1002/jbmr.3887
[5] Flatt RE, Thornton LM, Fitzsimmons-Craft EE, et al. Comparing eating disorder characteristics and treatment in self-identified competitive athletes and non-athletes from the National Eating Disorders Association online screening tool. Int J Eat Disord. 2021; 54: 365–375. https://doi.org/10.1002/eat.23415
[6]Patel B, Schneider N, Vanguri P, et al. (March 02, 2024) Effects of Education, Nutrition, and Psychology on Preventing the Female Athlete Triad. Cureus 16(3): e55380. doi:10.7759/cureus.55380
