Relative energy deficiency in sport (REDs) in women’s soccer: a scoping review mapped to the REDs health and performance models

Women’s soccer has seen a large increase in popularity with 16.6 million women and girls playing organised soccer, a 24% growth since 2019 (1). Although research in women’s soccer is expanding, it remains heavily skewed toward injury-medicine (N = 521 studies), while interdisciplinary areas such as nutrition/hydration (n = 51), illness-medicine (n = 29), and integrated performance analysis, such as single skill/drill (n = 65) and match play (n = 89) are comparatively under-represented (2). Consequently, key physiological and performance-related mechanisms underpinning injury, illness risk and impaired health and performance – such as relative energy deficiency in sport (REDs) and low energy availability (LEA) have received limited attention. This gap is especially important given the increasing professionalism of women’s soccer, characterised by greater weekly match exposure (3) and physical demands (4,5). Adverse health outcomes may emerge as training and competition demands increase (6), often simultaneous with rising performance expectations (7,8). The structure and logistics of travel may further compound energy availability challenges and recovery deficits, particularly during congested competition schedules (9). All of these scenarios can lead to problematic LEA, leading to greater and potentially persistent disruption of various bodily systems (10), which can result in a syndrome of negative health and performance effects known as REDs. The effects of LEA are also time-dependent, short-term energy deficits may acutely impair performance and recovery, whereas chronic or repeated LEA can result in the broader constellation of REDs with long-term consequences for health and sustained performance. There remains limited clarity regarding how REDs manifests within specific training structures, competition cycles, and developmental pathways of female soccer players. Beyond physiological demands, professionalisation has introduced occupational and psychosocial stressors, including short-term contracts, financial insecurity, limited post-career support, congested schedules and long-distance travel, all of which have been linked to poorer mental health and performance outcomes (9,11–19). Qualitative reflections from elite female players suggests that professional demands have often outpaced the development of holistic support systems, contributing to cumulative physical and psychological strain (19). Players also report pressure to conform to sport-specific and societal body image ideals, influencing eating behaviours and exacerbating psychological stress (11). These pressures are closely linked to disordered eating behaviours and are reinforced by performance culture, societal expectations, and occupational precarity (20). Food insecurity represents an additional and under-recognised risk factor. Food insecurity refers to the inability to consistently access adequate, safe, and appropriate food, either due to limited availability (e.g., living in food-scarce environments) or insufficient financial resources to obtain sufficient quantity and quality of food. Nevertheless, such psychosocial and contextual determinants are rarely integrated into contemporary player support systems, which continue to prioritise biological outcomes of REDs and menstrual dysfunction (3–5). Addressing this gap is critical to enabling athlete-centred, sustainable performance and health support across all stages of the women’s soccer pathway. Compounding these challenges, female athletes and their support network demonstrate low baseline health knowledge, limited communication pathways and reliance on external recognition for identifying health risks (21–23). While REDs encompass multiple interrelated physiological systems, menstrual health remains a highly visible and sensitive indicator of LEA in female athletes. It is often highlighted as disruptions in the menstrual cycle can provide an early, easily observable sign of energy deficiency (24), are closely linked to downstream consequences such as reduced bone density (25–27), altered metabolic function (28), impaired cardiovascular and immune responses (29), changes in mood and cognition (30), and can signal risks that may otherwise go unnoticed in contexts with limited health literacy or diagnostic resources. However, it continues to be highly stigmatised and poorly understood across diverse contexts, with players, coaches, and medical personnel often holding incomplete or unsupported beliefs regarding the menstrual cycle and injury risk (31–33). In low- and middle-income country (LMIC) contexts, barriers such as poor knowledge translation, limited communication, and restricted access to resources further constrain health-seeking behaviours (23,31,32). For example, in sub-Saharan Africa, approximately 65% of women and girls are unable to afford adequate menstrual hygiene products (23). Menstrual health challenges within LMIC soccer contexts are driven by structural constraints, gender norms, and resource limitations (23,31,32), factors that are closely linked to energy availability, nutritional practices, and broader REDs risk. Similarly, although disability soccer is growing (34) and supported by initiatives such as Football Without Limits, the representation of female disability soccer players within REDs research remains unclear. These intersectional challenges, spanning socioeconomic status, cultural expectations, gendered norms, and resource availability, may exacerbate vulnerability to REDs through constrained dietary intake, disrupted training engagement, heightened psychological stress, and limited access to medical and performance support (35–38). Importantly, LEA may also arise in the absence of overt societal pressure or food insecurity, due simply to insufficient knowledge regarding appropriate fuelling strategies, specifically what, how much, and when to eat in relation to training and competition. Thus, making it important to synthesise research on a global and inclusive scale. Collectively, these findings highlight a growing but disjointed body of evidence that has yet to be systematically mapped or integrated within a women’s soccer-specific performance and health framework. In response to growing recognition of women-specific health in soccer, several educational and capacity-building initiatives have emerged, including FIFA’s Women’s Health, Well-being and Performance project, the FIFA Nurse programme in LMIC settings, and applied education–research initiatives such as Project ACL and the FUEL programme. While these initiatives underscore the importance of education, awareness, and communication in mitigating REDs risk, they also reflect the absence of a consolidated evidence base to inform consistent, context-sensitive implementation. The diversity of initiative aims, target populations, and underlying assumptions highlights the fragmented nature of current knowledge and reinforces the need for a comprehensive synthesis of existing evidence to support effective, interdisciplinary practice. REDs and LEA can undermine performance and heighten vulnerability to a range of health disturbances, including menstrual dysfunction, impaired bone health, reduced immunity, altered metabolism, and cardiovascular complications (8,39), with both long and short-term consequences for athlete health and performance (40). The REDs Performance Conceptual Model provides a comprehensive framework for understanding how REDs may interact with and impair multiple domains of performance (e.g. recovery capacity, muscle strength and adaptation). Specifically, the model integrates physiological, psychological, and training-related factors that collectively influence performance outcomes, thereby offering a structured lens through which the multifactorial consequences of REDs can be examined. Despite its relevance to interdisciplinary performance teams within women soccer environments, no review to date has synthesised the existing evidence on REDs through the lens of this model at each performance level. In conclusion, despite the global growth of women’s soccer, evidence relating to REDs remains limited in scope, population diversity, and contextual relevance. With prevalence estimates of LEA in elite women’s soccer ranging from 20–80% (36,41,42), the absence of an integrated synthesis represents a significant gap for both practitioners and researchers. Therefore, the purpose of this scoping review is to comprehensively map and synthesise the existing literature on REDs in women’s soccer using an interdisciplinary lens that encompasses physiological, psychosocial, educational, and environmental dimensions, and examine how these conditions relate to key domains of the Health and Performance Conceptual Models. Lastly, to identify critical gaps and priorities to guide future interdisciplinary research.