British distance runner Jake Smith, now 28, has revealed that he suffered from Relative Energy Deficiency in Sport (REDs) for years without realising he was under-eating. Doctors told him four years ago that if he continued on this path, he would end up in a wheelchair by the age of 30.
Smith signed a professional contract with Nike at 23 and represented Great Britain on the global stage. However, he returned from a training camp in Uganda weighing just 51 kilograms despite being 1.7 metres tall. His bones were so fragile that he was told his career could be over. In a four-month period, he suffered two stress fractures, after which he sought professional help and was diagnosed with REDs.
REDs is a syndrome that can affect anyone, but due to stigma and a lack of obvious warning signs in men, it can remain undetected for longer. Men are equally susceptible to this condition, and if it is not diagnosed or treated, it can impact performance and cause serious, long-term health problems. REDs can cause stress injuries, sleep disorders, fatigue and low mood, and if left untreated, it can lead to osteoporosis, cardiovascular disease and fertility issues.
Dr Nicky Keay, a hormone health specialist, explains that many symptoms stem from hormonal disruption caused by insufficient energy intake. "Hormones go to every part of the body and need to be fed regularly to be healthy," Keay says. In an energy deficit, some hormonal systems often slow down or shut off completely. Women have a monthly barometer of hormonal health through their menstrual cycle, which Keay calls a "free monthly medical check-up". In men, the effect is more subtle – testosterone levels drop, resulting in reduced libido and fatigue.
The condition was first called the "female athletic triad" in the early 1990s, and the International Olympic Committee renamed it in 2014 to recognise the wider range of symptoms of energy deficiency and that it harms athletes. "We realised we were ignoring half the population," Keay said, adding: "It’s a strange situation because women’s health is usually ignored, but in this instance, men were not recognised or represented."
A meta-analysis published last year in the Australian journal Sports Medicine followed a study involving thousands of elite and amateur athletes worldwide. It showed that 44.2 per cent of female athletes and 49.4 per cent of male athletes had low energy availability. One reason for why REDs is so common lies in the phrase "faster is easier", which has been accepted wisdom for decades in sports such as distance running, cycling, climbing, horse riding, dance and aesthetic sports like diving and gymnastics.
Smith admits he believed in that philosophy for years. "I believed in it for years. I thought that was the way forward," he says. "I started thinking how do I improve my half marathon by 10 seconds? Is it weight loss? And then my head just went." Although the strategy may work initially, the body has evolved to prioritise movement, so athletes can lose weight and still train and achieve good results. Dr Keay calls this "fool’s gold", as the body adapts to the energy deficit, causing a drop in performance and a high risk of injury.
Olympic and world triathlon champion Jonny Brownlee, who recently announced his retirement, admits that mistakes regarding insufficient energy intake in his career contributed to serious injuries. "I didn’t see the importance of it. Training was first, and I think we weren’t educated enough on how important fuel is," Brownlee says. "Culturally, it was seen as being a bit weak if you ate on the bike." The impact, he claims, was definitely injuries, stress reactions, stress fractures, but also underperformance in races. He believes the culture of not eating on the bike has changed now.
However, the stigma remains. Brownlee says REDs is still perceived as a "women’s problem". "In women, there are more obvious signs, but in men, it can go under the radar and then a really serious injury hits you," he warns. "I think there is a stigma, or it is not seen as an obvious answer to some of your problems, and it is discovered later." He adds that men do not like to talk about insufficient energy intake because it is seen as "you probably should".
Tennis player Emma Navarro revealed her diagnosis last month and decided to withdraw from competition until 2027.
