4.10 Disordered Eating, RED-S & Registered Dietitian Referral
Key Takeaways
- The DCO expects a TSAC-F to recognize adverse signs, symptoms, and behaviours associated with eating habits that indicate the need for referral to a registered dietitian - recognition and referral, never diagnosis or treatment.
- Relative Energy Deficiency in Sport (RED-S) arises from low energy availability and produces endocrine suppression, impaired bone health, immune dysfunction, and degraded performance in both sexes.
- Low energy availability is conventionally defined as below roughly 30 kcal per kg of fat-free mass per day after subtracting exercise energy expenditure.
- Administrative body composition standards and tape tests are a documented trigger for rapid weight manipulation, dehydration, and restrictive eating in the days before a weigh-in.
- A defensible referral is private, factual, behaviour-focused, documented, and routed through the agency's existing medical and behavioural health channels.
4.10 Disordered Eating, RED-S & Registered Dietitian Referral
Quick Summary: Body composition standards, selection courses, and weigh-in culture make tactical populations unusually exposed to disordered eating. This section covers the recognition signs a facilitator is expected to notice, relative energy deficiency and its downstream consequences, and how to make a referral to a registered dietitian without diagnosing or treating.
The Task as the Blueprint States It
The Detailed Content Outline gives this task in a single line: recognize adverse signs, symptoms, and behaviours associated with eating habits that indicate the need for referral to a registered dietitian.
Read the verbs. The facilitator recognizes and refers. The facilitator does not screen with a clinical instrument, does not diagnose an eating disorder, and does not treat one. Exam items in this area are almost always testing whether you know where that line falls.
Why Tactical Populations Are Exposed
Tactical settings contain a specific combination of pressures that sport settings mostly do not:
- Administrative body composition standards. Failing a tape test can trigger a flag, block promotion, or end a career. That is a far stronger incentive than a coach's preference.
- Scheduled weigh-ins. A known date creates a predictable window of acute weight manipulation: fluid restriction, sauna use, laxative use, and severe caloric restriction in the 48-72 hours before measurement.
- Selection courses. Prolonged high energy expenditure with restricted intake is the design of some selection pipelines, which normalizes energy deficit as a virtue.
- Occupational culture. Restriction and stoicism are read as discipline. An operator who eats little and trains hard is frequently praised rather than questioned.
- Shift work. Erratic access to food produces genuinely chaotic eating patterns that can mask or mimic disordered behaviour.
Relative Energy Deficiency and Low Energy Availability
Energy availability is the energy remaining for physiological function after exercise energy expenditure is subtracted, expressed per kilogram of fat-free mass:
Energy Availability = (Energy Intake - Exercise Energy Expenditure) / Fat-Free Mass
Values below roughly 30 kcal/kg fat-free mass per day are conventionally described as low energy availability, and sustained exposure produces Relative Energy Deficiency in Sport (RED-S). RED-S is the broader successor concept to the female athlete triad (low energy availability, menstrual dysfunction, low bone mineral density), and it affects both sexes.
Consequences that show up in tactical work
| System | Effect of sustained low energy availability | Operational consequence |
|---|---|---|
| Endocrine | Suppressed sex hormones, reduced testosterone, menstrual dysfunction | Impaired recovery and lean-mass retention |
| Skeletal | Reduced bone mineral density, impaired remodelling | Elevated stress fracture risk under load carriage |
| Immune | Impaired immune function | More lost duty days to illness |
| Metabolic | Reduced resting metabolic rate, poor glycemic control | Paradoxical resistance to further fat loss |
| Cognitive / psychological | Impaired concentration, irritability, depressed mood | Degraded decision-making and marksmanship |
| Performance | Reduced strength, endurance, and training response | Failed fitness tests despite high training volume |
Note the paradox that makes RED-S so persistent: the operator is training harder, eating less, and getting worse - which is usually interpreted as needing to train harder still.
Recognition: What a Facilitator Actually Observes
You are not administering a diagnostic instrument. You are noticing patterns across weeks of contact.
| Category | Signs a TSAC-F may observe |
|---|---|
| Behavioural | Skipping meals routinely; secrecy about eating; ritualized or rigid food rules; excessive additional training beyond the program; frequent bathroom trips immediately after meals; obsessive tracking or weighing |
| Verbal | Persistent negative body talk; fear of specific foods or entire food groups; describing food as "earned" through exercise; anxiety about upcoming weigh-ins |
| Physical | Unexplained or rapid weight change; frequent dizziness or fainting; recurrent illness; cold intolerance; poor wound healing; dental erosion; hair loss |
| Performance | Declining performance despite consistent training; repeated stress reactions or stress fractures; chronic fatigue unresponsive to deload |
| Contextual | Acute fluid and food restriction in the days before a tape test; sauna or sweat-suit use for weight manipulation; laxative or diuretic use |
One observation is not a referral. A pattern across time, or any single high-severity indicator such as syncope, purging behaviour, or diuretic use, is.
Making the Referral
The referral is a professional act with a defensible procedure:
- Choose the setting. Private, unhurried, never in front of peers, never during a group session.
- Describe behaviour, not diagnosis. "I've noticed you haven't eaten at the station in about two weeks and you've had two dizzy spells during PT" is defensible. "I think you have an eating disorder" is not - it is a diagnosis you are not licensed to make, and it usually ends the conversation.
- State the professional boundary plainly. "This is outside what I'm qualified to address, and I want you talking to someone who is."
- Name the destination. A registered dietitian is the primary referral for nutrition; a physician for medical evaluation; behavioural health when psychological features dominate. Route through the agency's existing channels - unit dietitian, flight surgeon, employee assistance program, peer support.
- Do not condition training on compliance. Withholding training as leverage damages trust and may itself be harmful.
- Document the observation and the referral. Objective, factual, dated, stored per agency confidentiality policy. An undocumented referral does not protect the athlete or you.
- Follow agency mandatory-reporting policy. Some organizations require notification of the chain of command for medical conditions affecting duty status. Know your policy before the conversation, not during it.
Language that helps and language that harms
| Say this | Not this |
|---|---|
| "I've noticed you skipping meals before weigh-ins. I'd like you to talk to the unit dietitian." | "You're not eating enough, you're going to give yourself an eating disorder." |
| "Your stress reaction and your fatigue may both be tied to fuelling. That's a dietitian's call, not mine." | "Just eat more and you'll be fine." |
| "Everything you tell me stays with me except what agency policy requires me to report, and I'll tell you if that applies." | "Don't worry, this is completely confidential." |
| "Making weight by dehydrating hurts your test score and your health. Let's plan the timeline differently." | "Everybody cuts water before a tape test." |
Over six weeks a TSAC-F observes that a soldier has stopped eating with the unit, has lost noticeable body mass without a programmed deficit, has had two episodes of dizziness during morning PT, and recently sustained a metatarsal stress reaction. What is the correct professional action?
Which statement about Relative Energy Deficiency in Sport (RED-S) is accurate and most relevant to tactical populations?