The Athlete Who Is Running on Empty

Your child is still making the team and may even be improving. But injuries are harder to shake. Meals cause more tension, or rest brings a new level of distress. Does good performance mean there is no health problem? It does not. A sports result tells you what happened in a game or race. It cannot show whether every part of the body is doing well.

These changes can have many causes. Sport, growth, and daily life all place demands on the body. One possible problem is that food intake does not meet those needs. Another is an eating disorder. The two can overlap, but they are not the same diagnosis. A health assessment should look at both. Being devoted to sport is not, by itself, an illness.1

Zoom

Three terms that should not be treated as one

Energy availability means the energy left for the body’s needs after exercise. Low energy availability can occur when those needs are not met. It may be intentional. It can also stem from busy schedules, food access, or poor appetite. Needs may change while food intake stays the same. The label alone does not tell us why it happened.1

Relative energy deficiency in sport is now often written REDs, and was previously RED-S. It refers to harmful effects on health and performance linked to problematic low energy availability. The International Olympic Committee (IOC) draws a distinction here. Some short-term cases may allow the body to adapt. They differ from the more harmful exposure linked to REDs. A simple food or exercise calculation cannot tell a reader which is which.1

An eating disorder has its own clinical pattern. This may involve fear that drives food restriction, binge eating, or actions to compensate for eating. An athlete may have REDs without an eating disorder. They may have an eating disorder without a confirmed REDs diagnosis. Or they may have both. The assessment should clarify what care the person needs.1

For a growing child or teen, care must include growth and puberty. Sport is only one part of the picture. Findings from elite adult athletes may not apply to a child on a local team. The medical lead should know the athlete’s age and stage of growth. They also need to know the sport’s demands.23

Look at change across a person’s life

Several changes can raise concern in the right context. These include bone stress injuries, changes in periods or other hormones, and fatigue. Trouble recovering, mood changes, and repeated illness may also raise concern. None of these signs points only to REDs. Other causes include infection, poor sleep, other health conditions, and training stress. A clinician should check these possibilities, too.13

Changes in periods deserve assessment, but periods are not a complete health test. Ongoing periods do not prove that food intake and bone health are adequate. Some people do not have periods, so that signal is not available. Clinicians should still check for problems. People of all genders can have health concerns tied to inadequate intake and sport.1

An athlete may feel better before their bones have fully recovered. Most of a person’s adult bone is built during the teen years, so a problem in that window can matter for a long time. That is a reason to get assessed, not a reason to panic. A better mood or a strong race does not prove sport is safe. Nor does the return of a single body function. The 2025 Female Athlete Triad update appeared in its 2026 journal issue. It calls for assessment that fits the athlete’s age. It also calls for ongoing checks of energy, reproductive, and bone health.34

Some heart symptoms may also signal broader medical risks from an eating disorder. Fainting, chest pain, collapse, or severe confusion requires emergency medical assessment. Do not wait for a routine sports clearance visit. After prolonged food restriction, a person may need medical supervision as nutrition is restored. Showing up for practice does not mean it is safe to wait.25

What current frameworks agree on, and what is less settled

The IOC REDs framework helps clinicians weigh several kinds of evidence. These include symptoms, health history, a physical exam, and other findings. Its clinical assessment tool supports a process led by a physician. Parents and coaches cannot use it as a traffic-light chart to clear someone for sport.16

Current expert frameworks place weight on different parts of the evidence. The newer Female Athlete Triad consensus stresses links between energy deficiency and reproductive and bone health. It questions some broader REDs claims. Can low energy availability alone account for those other outcomes? How strong is the evidence? The frameworks differ on definitions, measurement, and the strength of findings. These differences do not make concerning symptoms safe to ignore.3

Research on the IOC tool is still developing. One study applied a changed version of the tool to elite adult athletes. Risk groups were linked with later reports of bone stress injuries. But some groups were small, and the estimates were imprecise. This does not validate every use of the tool in other groups. Those include children, people who play sport for fun, para-athletes, and gender-diverse groups.7

A recent review found that screening tools differ in what they measure. They also differ in how well they have been tested. An eating-disorder questionnaire, an exercise-dependence measure, and a REDs screen assess different things. The team should explain what a score can and cannot tell them.8

For a family, the next step is to ask for an assessment. A qualified clinician should lead it and explain any uncertainty. You should not have to work out a specialist tool yourself. You do not need to reach a home cutoff to be heard.

When commitment becomes hard to choose

A large training load alone does not establish compulsive exercise. Look at how fixed the rules are and how much distress they cause. What role does exercise play? Does the athlete feel driven to train to compensate for eating? Does rest bring intense guilt or panic? Do exercise rules push aside relationships or persist despite harm? These are questions for an assessment, not a checklist for diagnosis.9

Eating-disorder research describes compulsive exercise as a drive that is hard to resist. It is linked to distress or fear of what will happen without exercise. The proposed clinical definitions should not label every devoted athlete. What matters is the person’s experience and the effect on health and daily life.9

An athlete may want more strength or muscle, or fear becoming smaller. They may worry about how they look in a uniform. These concerns are not limited to boys or men. Muscle dysmorphia is a form of body dysmorphic disorder, not an eating disorder, and a person can have both. The muscle dysmorphia essay provides that bridge; the boys and men essay focuses on missed eating-disorder recognition.

How adults can begin the conversation

Try describing a change in comfort, health, or daily life. “You seem more distressed when plans change” leaves room for an answer. Comments about looking leaner, stronger, or more disciplined can miss the problem. You do not need to make the child’s body the focus of the talk.

A coach can share concerns with the right caregiver and medical team. They should follow their group’s process for safety and privacy. A parent can ask for medical assessment without a coach’s permission. Symptoms deserve to be taken seriously. Neither adult should ask the athlete to prove dedication by training through a health concern.

Keep the athlete involved. Ask what feels hard about meals, sport, rest, or asking for help. A young person may fear losing friends or a role on the team. Sport may be a source of pride. Care should address these real concerns. That remains true when medical safety requires a change in sport.

The aim is to help the athlete explain what is happening and get assessed. Medical clearance is not something to negotiate at home. If the first talk is brief, arrange another chance. Silence does not prove that nothing is wrong.

Participation decisions need a medical lead

The care team may include a physician trained in sports or teen health. It may also include a dietitian with relevant training and an eating-disorder mental-health clinician. Each has a different role. The physician brings medical risk findings together and guides decisions about sport. The team helps with nutrition, eating-disorder symptoms, and barriers to care.4

Caregivers usually have key duties when the athlete is a minor. The athlete should still have a voice. They need an explanation suited to their age. Coaches can help carry out an agreed plan. They should not interpret the clinical tool on their own or declare recovery. The team must also check the school, league, or sport rules that apply.

Ask which findings the team will track. Who will explain changes to the plan? No preset return date fits every athlete. One reassuring test or better performance cannot replace follow-up. The team should explain its reasoning and what remains uncertain.4

Sometimes the available outpatient care cannot meet a person’s nutrition or mental-health needs. They may need more intensive care. The levels-of-care essay explains those settings. The atypical anorexia essay explains why a larger body does not rule out restrictive illness.

A useful action this week

You can say to the athlete and clinician:

“I have noticed changes in recovery, injuries, or distress around eating and rest. I want us to understand what is happening and get an assessment that considers growth, nutrition, mental health, and sport.”

This week, request a medical appointment. Write a short account of the changes, relevant injuries, and current medicines. Include concerns the athlete wants heard. Ask who will lead the assessment and work with the other clinicians. You do not need calorie calculations, target body measures, or a home exercise test.

Seek emergency care for collapse, fainting, a seizure, chest pain, a very slow, racing, or irregular heartbeat, severe confusion, or vomiting blood. Severe dehydration, including being unable to keep fluids down, also requires emergency care. Do not wait for a team meeting. New or worsening symptoms need prompt clinical review, even without these examples.5

In the United States, call 911 for an emergency or immediate danger. Call or text 988 for a suicidal or mental-health crisis. This service does not replace emergency medical care. The athlete does not need to stop caring about sport. They deserve care that takes the whole person seriously.10

This article is for education and does not replace care from your own health professional. Eating disorders can affect people at any body size. If you are concerned about eating, exercise, or related symptoms, ask for an assessment. Do not start, stop, or change medication based on this article.

This article is for education only. It does not diagnose REDs, an eating disorder, or compulsive exercise, does not clear anyone for sport or set a return-to-play date, and does not set an energy, calorie, body-composition, or training target. Participation decisions belong to the athlete’s medical team. Reading it does not create a clinician-patient relationship.

Eating disorder support and referrals

These are specialized eating disorder helplines, not 24/7 crisis lines. For urgent help any time, use the crisis resources below.

• National Alliance for Eating Disorders Helpline, 1-866-662-1235, Monday to Friday, 6 a.m. to 4 p.m. Pacific (9 a.m. to 7 p.m. Eastern). Staffed by licensed therapists who specialize in eating disorders; free referrals to all levels of care. allianceforeatingdisorders.com
• ANAD Helpline, 1-888-375-7767, Monday to Friday, 7 a.m. to 7 p.m. Pacific (9 a.m. to 9 p.m. Central). Peer support and treatment referrals.
• F.E.A.S.T., feast-ed.org. Free caregiver resources, online support groups, and family guides for those supporting a loved one with an eating disorder.

If you or your loved one has chest pain, fainting, seizures, severe weakness, confusion, signs of refeeding syndrome, or any other life-threatening symptom, call 911 or go to the nearest emergency room. Eating disorders are medical illnesses, and medical emergencies are common.

Related reading on NP FADY

• Boys Get Eating Disorders Too
• You Can Be Very Sick at Any Weight
• Muscle Dysmorphia

References

1. Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2023;57(17):1073-1098. Corrected February 2024. DOI: 10.1136/bjsports-2023-106994. https://doi.org/10.1136/bjsports-2023-106994. Accessed September 7, 2026.

2. Society for Adolescent Health and Medicine. Medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2022;71(5):648-654. DOI: 10.1016/j.jadohealth.2022.08.006. PMID: 36058805. https://escholarship.org/content/qt7dz1c6ds/qt7dz1c6ds.pdf. Accessed September 7, 2026.

3. De Souza MJ et al. 2025 Female Athlete Triad Coalition Consensus Statement, Part 1. Online December 2025; issue 2026. DOI: 10.1007/s40279-025-02333-z. https://link.springer.com/article/10.1007/s40279-025-02333-z. Accessed September 7, 2026.

4. Williams NI et al. 2025 Female Athlete Triad Coalition Consensus Statement, Part 2. Online December 2025; issue 2026. DOI: 10.1007/s40279-025-02332-0. https://link.springer.com/article/10.1007/s40279-025-02332-0. Accessed September 7, 2026.

5. Royal College of Psychiatrists. MEED, CR233. 2022; updated December 2025. https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/college-reports/2022-college-reports/cr233. Accessed September 7, 2026.

6. Stellingwerff T et al. IOC REDs CAT2 scientific rationale, development and validation. 2023. DOI: 10.1136/bjsports-2023-106914; correction 2024. https://doi.org/10.1136/bjsports-2023-106914. Accessed September 7, 2026.

7. Heikura IA et al. Application of IOC REDs CAT2 in elite athletes. 2025; online 2024. DOI: 10.1136/bjsports-2024-108121. https://pubmed.ncbi.nlm.nih.gov/39164063/. Accessed September 7, 2026.

8. Lodge MT, Catrambone ZR, Kraus E, Cirella SM, Logan NE, Ward-Ritacco CL. From validation to application: a methodological review of relative energy deficiency in sport (REDs) screening. Performance Nutrition. 2026;2:5. DOI: 10.1186/s44410-026-00020-2. https://link.springer.com/article/10.1186/s44410-026-00020-2. Accessed September 7, 2026.

9. Dittmer N, Jacobi C, Voderholzer U. Compulsive exercise in eating disorders: proposal for a definition and a clinical assessment. J Eat Disord. 2018;6:42. DOI: 10.1186/s40337-018-0219-x. https://link.springer.com/article/10.1186/s40337-018-0219-x. Accessed September 7, 2026.

10. 988 Suicide & Crisis Lifeline. Current U.S. service information. https://988lifeline.org/. Accessed September 7, 2026.

If you or someone you know is in crisis

• Call 911 or go to your nearest emergency room for any life-threatening emergency.
• 988 Suicide & Crisis Lifeline — call or text 988, available 24/7. En español: marque 988 y oprima 2. Veterans: 988 and press 1, or text 838255.
• Crisis Text Line — text HOME to 741741.
• The Trevor Project (crisis support for LGBTQ+ young people) — call 1-866-488-7386, or text START to 678-678.
• National Sexual Assault Hotline (RAINN) — call 1-800-656-HOPE (4673) or text HOPE to 64673; free, confidential, 24/7. Online chat at RAINN.org/hotline.
• National Domestic Violence Hotline — call 1-800-799-SAFE (7233) or text START to 88788; 24/7, help in 200+ languages. Online chat at TheHotline.org. If your phone or computer may be monitored, calling from a safer device is an option.
• Riverside County — Inland SoCal Crisis Helpline 951-686-HELP (4357), 24/7 (Inland SoCal United Way / 211+, in partnership with RUHS-BH); Community Access, Referral, Evaluation and Support (CARES) Line 800-499-3008, 24/7.
• San Bernardino County — Access Unit (Behavioral Health Helpline) 888-743-1478, 24/7; Mobile Crisis/CCRT 800-398-0018 (24/7, all ages) or text 909-420-0560. Arrowhead Regional Medical Center (ARMC) has a dedicated walk-in adolescent psychiatric ER (ages 13–17).
• Children under 13 — call 911 for immediate danger, contact your county's mobile crisis team (they respond to all ages), or go to the nearest pediatric emergency room.
• California Peer-Run Warm Line (non-crisis — someone to talk to) — call or text 1-855-600-WARM (9276); daytime and evening hours, not a 24/7 line.
• NP Fady (non-emergency) — for routine scheduling or questions, call (909) 707-6261. This line is not monitored for emergencies.