Mary Cain, RED-S, and the Importance of Registered Dietitians in All Levels of Sport

By Caroline Kohler

The title was eye-catching: “I Was the Fastest Girl in America, Until I Joined Nike.” The video on the New York Times YouTube channel has been viewed almost 6 million times in less than three weeks. The story was gripping and, especially for us health professionals, horrifying.

Mary Cain rose to track and field stardom in 2012 when she won the USA Track and Field Junior 15oom race and later broke the American Junior 1500m record. At the age of 16, she was competing at the 2012 Olympic Trials. In 2013 she was recruited by the Nike Oregon Project, at the time one of the best running programs in the country. Achieving that level of success is the dream of many high school athletes, but for Mary, and so many others, it would ruin her career and damage her body.

In Mary’s op-ed video with the New York Times, she described how her Nike coaches would tell her that in order to run faster, she needed to be “thinner and thinner and thinner.” On a basic level, that seems to make sense – less weight to move would make it easier to run faster, right? But it ignores all of the other facets of speed and athleticism like muscle mass and energy availability in favor of an oversimplified number on the scale.

“This Nike team was the top running program in the country, and yet we had no certified sports psychologist. There was no certified nutritionist,” Mary said. This short statement represents an all-too-common problem in the world of sports: there is no team dietitian. Period. 

The Collegiate and Professional Sports Dietitians Association (CPSDA) lists 90 colleges and universities that have at least one full-time Registered Dietitian on their athletics staff. It’s a growing number and a sign of progress, but there are over 1,100 schools registered with the NCAA so there is still a long way to go. 

CPSDA also lists 24 full-time RDs working for NFL teams, nine for MLB teams, six for Major League Soccer, eight for the NBA, and two for the NHL. Team USA/the US Olympic Committee have six RDs total, and the Ultimate Fighting Championship (UFC) Performance Institute and US Ski and Snowboard are the only two professional sports organizations that have full time RDs. (Note: this list doesn’t count the RDs who work as consultants for sports teams.) 

Mary talked about being weighed in front of teammates and coaches and shamed for her weight, which other pro athletes have since said is a common practice in many sports. Mary said her coach set an “arbitrary” weight goal of 114 pounds for her. Mary is 5’7’’ so 114 pounds would put her at a BMI of 17.9 (and BMI is a crude calculation that actually tends to overestimate body fat in athletes). 

During her time training with the Nike Oregon Project, her coaches cooked her “meager meals” so she would often sneak energy bars while hiding in her room, fearful of her coaches hearing her open a wrapper. 

Keep in mind: Mary was 17 years old. 

This regimen not only took a toll on her mentally, but of course physically. Mary says she stopped having a period for 3 years and broke five bones.

Mary was experiencing something known as RED-S syndrome: Relative Energy Deficiency in Sport. At the time, RED-S was still a relatively new clinical concept – the International Olympic Committee first adopted RED-S as a more comprehensive view of what was previously known as the “Female Athlete Triad” in 2014. RED-S is based on the concept of energy availability, which is energy intake minus energy used for exercise. Essentially, it’s the amount of energy your body has “leftover” to accomplish all the other things it needs to do besides exercise. 

RED-S is a broader term to encompass all of the negative effects that low energy availability can have on the body. The Female Athlete Triad focused on two effects: decreased energy availability has been linked to dysfunction in hormone production and bone formation compounds, which can lead to loss of a menstrual cycle and decreased bone health, as Mary experienced. But low energy availability can affect every body system and can also occur in male athletes – so we needed a better term. 

The IOC published a consensus statement in the British Journal of Sports Medicine about RED-S in 2014, and included these interesting graphics. On the left, the wheel shows all of the body systems that can be affected by low energy availability and where the Triad fits into RED-S. This is a useful summary for us clinicians, but the information in the left wheel isn’t very easy to understand for athletes. So the IOC committee included a second graphic, on the right, showing the effects on athletic performance. This “speaks” more to athletes, who are often most concerned with their performance right now. We as clinicians can’t just tell them that they have an increased risk of osteoporosis in the future – we need to also include that the consequences also affect them right now, with, for example, increased risk of injury. 

Mary Cain’s story is one of abuse and manipulation, something no one should ever experience, but especially not a teenager pursuing a passion. It is also about distorted concepts of health: coaches and institutions that focus only on numbers and appearances and adopt a “win at all costs” mentality, often in the absence of health professionals.

It’s also the story of a role model. I was a high school track athlete when Mary Cain went viral. She’s only a year older than me. I knew that I would never, ever be as good as Mary, because I’m simply not as naturally talented as she is. But I also remember, in the back of my 15-year-old mind, thinking that I couldn’t be as good as her because I didn’t look like her. So many of my teammates talked about Mary’s record-breaking performances and looked up to her as someone who symbolized what track and field is all about: being your best and achieving your goals. 

All these years later, I now admire Mary for even more reasons. For her strength to endure a toxic and damaging culture at the Nike Oregon Project, for her passion and continued love of the sport, and for her courage to come forward and start a conversation we have to have. 

This is a conversation not only about the abuses of power and lack of health professional oversight in the world of professional sports, but also about the images and messages that all athletes receive about what health and athleticism look like. There needs to be training for coaches about recognizing the signs of RED-S at all levels, inclusive coverage of athletes of all shapes and sizes, and, most importantly, more health professionals in leadership roles on sports teams. 

RDs get trained in developing healthy meal patterns, recognizing the symptoms of disordered eating, and educating individuals and communities about the long-term effects of nutrition. But RDs also need to be ready to be advocates: advocates for the importance of our expertise, advocates for structural changes to unhealthy institutions, and above all, advocates for the health of each individual client and patient.

Watch Mary’s Story Below: