Under-Fueled: RED-S, Weight Culture and the Coach's Duty

Timeline

1. Apr 2014IOC consensus statement introduces Relative Energy Deficiency in Sport (RED-S), replacing its 2005 statement on the Female Athlete Triad.
2. Oct 2014More than 30 researchers publish a rebuttal, 'Misunderstanding the female athlete triad'.
3. Nov 7, 2019Mary Cain describes weight pressure under Alberto Salazar at the Nike Oregon Project.
4. Nov 8, 2019Nike says it will investigate; other former Oregon Project athletes describe similar experiences.
5. Jun 16, 2022The Whyte Review into British Gymnastics is published.
6. Sep 2023IOC publishes an updated consensus statement on REDs with a new clinical assessment tool.

The ethical issues

• Coaches' influence over athletes' weight and eating.
• Weighing and body-shaming as coaching practices.
• Protecting young athletes, especially girls, from under-fueling.
• Organizational responsibility for coaching cultures.
• Balancing performance goals with long-term health.

Stakeholders

Stakeholder	Interests & obligations
Athletes, especially young athletes	Health, development and careers.
Coaches	Performance and their own results.
Parents	Their children's wellbeing and success.
Sports medicine clinicians	Accurate diagnosis and safe treatment.
Governing bodies and funders	Medals and a safe, credible sport.

The case

In many sports, lighter can look faster, higher or more graceful. That belief has shaped coaching for generations, and for some athletes it has meant years of being weighed, judged and told to eat less. Sports medicine now has a name for what happens when athletes take in too little energy for the demands of training and life: Relative Energy Deficiency in Sport, or RED-S. Athlete accounts from running and gymnastics show how coaching cultures can push athletes toward it. The case asks what duty coaches and sports organizations have to prevent under-fueling.

Background

For years, sports medicine discussed the “Female Athlete Triad,” linking energy availability, menstrual function and bone health. In 2014 an IOC expert panel updated the IOC’s 2005 statement on the triad and introduced a broader term, RED-S. The panel said the new term pointed “to the complexity involved and the fact that male athletes are also affected.” It described a syndrome of “impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency.” Its cause was energy deficiency relative to what the body needs for health, daily living, growth and sport. Psychological problems could either precede RED-S or result from it.^[1]

Not everyone agreed. Later in 2014, more than 30 researchers led by Mary Jane De Souza published a rebuttal titled “Misunderstanding the female athlete triad: refuting the IOC consensus statement on Relative Energy Deficiency in Sport (RED-S).”^[2] The debate over terminology reflected wider questions about whether a broader label would help or dilute attention to female athletes.

The rules and governance

There is no single rule on athlete weight. Consensus statements guide clinicians, not coaches, and safeguarding codes vary by sport and country. Coaches often have great influence over what young athletes eat and how they see their bodies, and the people who could intervene, such as doctors, parents and governing bodies, may not see what happens in training. The 2014 statement offered a “Sport Risk Assessment and Return to Play Model” that sorted athletes into three risk groups with clinical recommendations.^[1]

Mary Cain’s account

In November 2019, Mary Cain, who had qualified for the 2013 world championships at 17, described her years at the Nike Oregon Project to the New York Times. She said the all-male staff convinced her that “to get better I had to get thinner … and thinner … and thinner.” “Alberto was constantly trying to get me to lose weight,” she said. “He created an arbitrary number of 114lbs and he would usually weigh me in front of my teammates and publicly shame me if I wasn’t hitting weight.” She said she had suicidal thoughts and self-harmed.^[4] The BBC reported her account that the methods resulted in her losing her period for three years and broken bones; the Guardian reported she broke five bones because of osteoporosis.^[6][5]

“I got caught in a system designed by and for men, which destroys the bodies of young girls,” Cain said. “We have to protect them.”^[4] Salazar, who was then banned for doping offences and appealing, denied many of her claims and said he had supported her health and welfare.^[4] His former assistant Steve Magness, who had earlier blown the whistle on the program, said he had been told to make a female athlete lose weight and that when he showed data on her low body fat, he was told: “I don’t care what the science says I know what I see with my eyes.”^[4] Other former athletes, including Amy Yoder Begley, described similar experiences.^[5] The wider story is told in The Nike Oregon Project and Alberto Salazar.

Nike’s response

Nike said it would investigate. “We take the allegations extremely seriously,” it said, adding that the allegations had “not been raised by Mary or her parents before” and that she had sought to rejoin the program as recently as April 2019.^[5] The response illustrates a common pattern: organizations often learn of problems only when athletes go public.

The Whyte Review

In June 2022 the Whyte Review, commissioned by UK Sport and Sport England, reported on British Gymnastics. It received more than 400 submissions, and more than 25% referred to excessive weight management.^[7] Anne Whyte found that some coaches weighed gymnasts “as a matter of course, sometimes daily,” even though this was not a useful index of body composition. “The tyranny of the scales was coach-led and quite unnecessary,” she wrote. Some gymnasts purged or dehydrated themselves to meet their coaches’ weight demands, some coaches searched luggage and rooms for food, and some gymnasts suffered and still suffer from eating disorders.^[8] She found that British Gymnastics was aware that repeated weighing was poor practice.^[8]

Aftermath

In 2023 the IOC published an updated consensus statement on REDs. It noted more than 170 original research publications since its 2018 update, including evidence on the interplay between mental health and REDs and more data on the effect of low energy availability in males. It introduced a new clinical assessment tool, outlined “guidelines for safe and effective body composition assessment,” and set out prevention and treatment principles “to encourage best practices for sports organisations and clinicians.”^[3] UK Sport and Sport England accepted the Whyte Review’s recommendations and tied gymnastics funding to change.^[7]

The core dilemma

Coaches are rewarded for performance, and some believe lighter athletes perform better. Athletes, often young, depend on coaches for selection and support and may not question them. The science now shows that under-fueling harms both health and performance, yet weight-focused cultures persisted for years. Who is responsible for preventing under-fueling: the coach, the athlete, the clinician, or the organization that sets the culture?

Competing values

• Performance vs. health: short-term results against long-term wellbeing.
• Coaching authority vs. athlete autonomy: a coach’s expertise against an athlete’s control of her body.
• Paternalism vs. protection: monitoring athletes’ bodies to keep them safe, or to control them.
• Organizational success vs. accountability: medals and funding against responsibility for culture.

Strongest arguments

For strong limits on weight-focused coaching. The evidence links under-fueling to harm in bone health, menstrual function, immunity and mental health. Young athletes are vulnerable and dependent on coaches. The Whyte Review found weighing was often unnecessary and humiliating. Organizations should restrict weighing to qualified staff and treat weight-shaming as a safeguarding issue.

For a role for body composition. In some sports body composition can affect performance, and clinicians may need to monitor it. The 2023 consensus does not ban assessment but sets guidelines for doing it safely. Blanket bans could push monitoring out of sight rather than make it safer.

For organizational responsibility. Individual coaches act within cultures shaped by governing bodies, sponsors and funders. Both the Oregon Project and British Gymnastics accounts show that people saw problems, but systems did not act. Accountability must reach the organizations, not only the coaches.

Applying the frameworks

Care ethics

Care ethics would focus on the relationship between coach and athlete and the trust it depends on. It would ask whether coaches responded to athletes’ needs, or treated them as bodies to be shaped. Cain’s statement that “nobody really did anything or said anything” when she self-harmed points to a failure of care across a whole environment.^[4]

Utilitarian

A utilitarian would weigh the possible performance gains of weight control against the harms: injuries, lost careers, eating disorders and mental health problems. The science suggests under-fueling also harms performance, so the trade-off may be false. Prevention and early detection likely produce far more good than harm.

Rights

A rights lens would protect athletes’ rights to bodily integrity, privacy and freedom from degrading treatment. Public weighing and searches for food would violate these. It would also ask about the special rights of children to protection when adults control their training.

Walk it through: the Simple Decision Model

1. Spot the issue. You are a performance director at a national federation and hear that a successful coach weighs junior athletes daily. Stakeholders include athletes, parents, coaches, medical staff, the federation and funders. The codes in play are safeguarding policy, medical guidance and the duty of care.
2. Gather facts. How is weighing done, by whom, and what happens with the results? Are athletes showing signs of low energy availability? Watch for outcome bias: a coach’s medals can make harmful practices look justified.
3. Test options. Allow the practice to continue; restrict assessment to qualified clinicians; investigate the coach; or educate staff and athletes. Run each through care, consequences and rights.
4. Check codes and law. Review safeguarding rules and the 2023 IOC guidance on body composition assessment.
5. Decide and document. Set clear rules on who may assess body composition and how, and document the reasons.
6. Communicate and follow up. Tell athletes and parents how to raise concerns safely, monitor compliance and review whether athletes’ health improves.

What’s settled and what’s contested

Settled

• The IOC introduced RED-S in 2014, describing a syndrome affecting both female and male athletes, and updated its guidance in 2023.
• Mary Cain described weight pressure at the Nike Oregon Project; Salazar denied many of her claims.
• The Whyte Review found weighing of gymnasts was often coach-led and unnecessary.

Contested

• Whether the RED-S framing helps or dilutes attention to female athletes.
• When, if ever, coaches should be involved in monitoring body weight.
• How to hold organizations, not only individual coaches, responsible for weight cultures.

Why this case matters

Under-fueling is invisible until it causes harm, and young athletes may not recognize it or feel able to speak. The science has moved faster than coaching culture. This case asks students to think about non-maleficence in coaching: whether winning methods can be justified when they risk lasting harm to the people they are meant to develop.

Key terms

Duty of care

The responsibility of coaches, organizations and institutions to protect the health, safety and well-being of those in their charge. It is not a license for total control.

Non-maleficence

The duty to avoid causing harm, often paired with care ethics when setting safety rules.

Paternalism (hard and soft)

Restricting someone’s choices for their own good. Hard paternalism overrides competent, informed adults; soft paternalism steps in when information or autonomy is compromised.

Institutional accountability

Structures that make a sport organization explain its decisions and face consequences: clear authority, transparency, appeals, independent oversight and enforcement.

Stakeholders

Everyone with something at stake in a decision: athletes, coaches, parents, officials, fans, employees, sponsors, media, communities and regulators, including the less visible ones.

Whistleblowing

Disclosure of wrongdoing in the public interest by someone inside or close to an organization: a moral safety valve.

Definitions from the Ethics Cases glossary.

Discussion questions

1. Should coaches ever weigh athletes or set weight targets?
2. Why did it take athletes going public for organizations to act?
3. Does renaming the Female Athlete Triad as RED-S help or hurt female athletes?
4. What should a governing body do when a successful coach is accused of weight-shaming?
5. How can young athletes be protected when they depend on a coach for selection?

Sources

1. The IOC consensus statement: beyond the Female Athlete Triad — Relative Energy Deficiency in Sport (RED-S) — British Journal of Sports Medicine
2. Misunderstanding the female athlete triad: refuting the IOC consensus statement on Relative Energy Deficiency in Sport (RED-S) — British Journal of Sports Medicine
3. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs) — British Journal of Sports Medicine
4. Mary Cain 'emotionally and physically abused' by Alberto Salazar's system — The Guardian
5. Nike investigates claims of 'emotional and physical abuse' at Oregon Project — The Guardian
6. Alberto Salazar weight-shaming affected athletes' mental health - Steve Magness — BBC Sport
7. 'This isn't tough coaching and slight mistreatment' - reaction to the Whyte Review — BBC Sport
8. The Whyte Review: final report — UK Sport / Sport England