Why Do Some Endurance Athletes Develop RED-S?

    In a recent qualitative study, researchers interviewed athletes about their experience with relative energy deficiency in sport to determine what triggered the onset and what factored into continuation of this behavior.


    Elizabeth I. Barchi, MD  


    Langbein, RK, Martin D, Allen-Collinson J, Crust L, Jackman PC. I’d got self-destruction down to a fine art”: a qualitative exploration of relative energy deficiency in sport (RED-S) in endurance athletes. J Sports Sci. 2021 39:14, 1555-1564. doi: 10.1080/02640414.2021.1883312  Epub 2021 Feb 11.


    In a qualitative study, Langbein et al explored endurance athletes’ subjective experience of relative energy deficiency in sport (RED-S) in an effort to further understanding of the complex psychosocial mechanisms and consequences of this condition. 

    In RED-S, low energy availability (LEA) is caused by consuming too little food to support the amount of energy being expended. In 2014 the International Olympic Committee (IOC) revised their consensus statement on the Female Athlete Triad to better describe the complexity of this condition, as well as the occurrence in both male and female athletes. The IOC defines RED-S as impaired physiologic function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health changes caused by relative energy deficiency.

    For their study of RED-S, Langbein et al included 12 female and male endurance athletes, ages 23 to 40, who had been recruited through media and community outreach (informational posters, emails to coaches, social media). All study participants said that endurance running or ultra-endurance running was their primary sport. The study authors used a semi-structured, open-ended approach to the athlete interviews, focusing on their experience of RED-S from onset to present day. The data were analyzed using the 6 steps of thematic analysis and were grouped together in codes, sub-themes, themes, and categories.  

    Langbein et al found that the onset of RED-S coincided with a significant increase in training load that was not matched by adequate energy intake. Half of the participants reported that this imbalance was unintentional and that the potential consequences were not understood at the time. Across the sample, the initial LEA resulted in physiological outcomes, such as reduction in body mass and/or fat percentage and initial increased performance, that were positively appraised. This reinforced the behaviors, which eventually contributed to the development of RED-S and disordered eating.  

    The participants identified several psychosocial barriers to physiological and psychological rehabilitation, including:

    • Restrictive eating practices
    • High training load and physical activity level
    • Perceived need for control
    • Social comparison
    • Need for social approval

    Unfortunately, some participants also reported a lack of professional support and information. Several athletes reported feeling dismissed by their physicians or unworthy of support due a normal BMI, which further legitimized their unhealthy behaviors. Sport culture was also identified as an important barrier to recovery. Many athletes reported attitudes that promoted training through injury and illness, normalization of menstrual dysfunction, and restrictive eating habits.   

    Clinical Relevance 

    Sports-related injuries are common presentations to the orthopaedic clinic. Traditionally, we focus on the injury itself, with the goal of helping the athlete return to sport.

    However, psychosocial factors can significantly impact the physical recovery. Screening for psychosocial barriers such as disordered eating or unhealthy relationships with exercise, with the understanding that these barriers are often invisible on exam, can increase patient trust and improve satisfaction with their care. Early diagnosis and referral to appropriate specialists, including nutritionists, sports psychologists, and eating disorder specialists, can make a significant difference in the life and career of the athlete. 

    In addition, recognizing and addressing cultural attitudes in sports that are counterproductive to recovery is essential to safe return to sport, as well as to prevention of injury. 

    Author Information

    Elizabeth I. Barchi, MD, is with ChristianaCare in Chadds Ford, Pennsylvania, where she specializes in primary care sports medicine.

    Disclosures: Dr. Barchi has no disclosures relevant to this article.