Race, illness, injury, repeat – RED‑S and why men stay silent
By Sarah Dawkins, BBC Sport senior journalist
Warning: this article discusses eating disorders.
Four years ago doctors warned British long‑distance runner Jake Smith that he could be confined to a wheelchair by the age of 30. At the time his career seemed to be taking off. By 23 he had secured a professional deal with Nike and was representing Great Britain on the world stage. Yet his body was paying a heavy price, caught in a relentless cycle of racing, illness and injury.
Trying to juggle a demanding training schedule with disordered eating left the 28‑year‑old returning from a running camp in Uganda at just eight stone (51 kg) and 5 ft 5 in (1.7 m). His bones were so fragile that doctors warned his career might end. After two stress fractures within four months, Smith finally sought help and was diagnosed with RED‑S – relative energy deficiency in sport.
RED‑S can affect any athlete, and if it goes unnoticed or untreated it can damage performance and cause long‑lasting health problems. The condition is better documented in women; last month tennis player Emma Navarro revealed her own diagnosis and her decision to step away from competition until 2027. Men are equally vulnerable, but stigma and the lack of obvious warning signs often keep the problem hidden, leaving athletes like Smith to suffer in silence.
BBC Sport outlines what RED‑S is, how it impacts both sexes, and why, despite its prevalence, it remains an under‑reported area of sports science. The syndrome can lead to bone stress injuries, disrupted sleep, fatigue and low mood. If left untreated it may result in osteoporosis, cardiovascular disease and fertility issues.
Dr Nicky Keay, a hormone‑health specialist, explains that many of these symptoms stem from hormonal disruption caused by insufficient energy intake. “Hormones affect every part of the body,” she says. “If they are not functioning properly you will feel it in many different ways. To keep hormones healthy they need regular fuel. When there is an energy deficit some hormone systems slow down or shut down completely.”
Women have a monthly indicator of hormonal health – the menstrual cycle – which Keay describes as a “free monthly medical check”. In simple terms, a woman with RED‑S may have her periods switch off. For men the signs are subtler; testosterone levels drop, leading to reduced libido and fatigue.
The condition was originally called the “female athlete triad” in the early 1990s because of its impact on menstrual health. The International Olympic Committee renamed it RED‑S in 2014 to acknowledge the broader range of symptoms and to include male athletes. “We realized we were ignoring the other half of the population,” Keay says. “It’s a strange situation because normally women’s health is the one being overlooked, but in this case it was men who were not being recognised or represented.”
A meta‑analysis published in the Australian journal Sports Medicine last year, based on a study of thousands of elite and amateur athletes worldwide, found that 44.2 % of female athletes and 49.4 % of male athletes had low energy availability.
Why is RED‑S so common? One answer lies in the long‑standing belief that “lighter is faster”. For decades athletes in endurance running, cycling, climbing, horse riding, dancing and aesthetic sports such as diving and gymnastics have been told that shedding weight improves performance. Smith fell into that trap.
“I believed it for years. I thought that was the way forward,” he recalls. “I started wondering how I could improve my half‑marathon by ten seconds – is it a drop in weight? That’s when my head completely went.”
Initially, losing weight can produce short‑term gains. Evolution has taught the body to prioritise movement over other needs when energy is scarce, allowing athletes to train and still see results. But the strategy eventually backfires. Keay calls it “fool’s gold”. The body adjusts to the deficit, performance drops and the risk of injury rises sharply.
Olympic and world champion Jonny Brownlee admits that under‑fueling contributed to serious injuries in his triathlon career. “I didn’t see the importance of it. Training came first and we weren’t educated enough about how crucial fueling is,” he told BBC Sport. “Culturally we were seen as weak if we ate on the bike. The result was injuries – stress fractures, poor recovery and probably under‑performance in races as well.”
Brownlee, who recently announced his retirement, says the culture around fueling on the bike is changing, but a stigma surrounding RED‑S and the perception that it is a “female issue” persists. “In females the signs are more obvious, but in males it can slip under the radar until a serious injury hits,” he explains. “There’s still a stigma, or it’s not looked at as a problem for men.”
The growing awareness of RED‑S among male athletes highlights the need for better education, open discussion and timely medical support, so that more runners, cyclists and others can break the cycle of race, illness, injury and repeat.