Race, illness, injury, repeat: Jake Smith and the hidden burden of REDs in male athletes

"If you keep this up, you'll be in a wheelchair at 30," doctors told British long-distance runner Jake Smith four years ago, after a period of relentless race, illness and injury that culminated in two stress fractures in four months and a diagnosis of REDs (relative energy deficiency in sport).

Smith, now 28, had signed a professional contract with Nike and represented Great Britain by the age of 23, yet he returned from a running camp in Uganda weighing just eight stone (51kg) at 5ft 5in (1.7m) and was told his bones were so brittle his career could be over; REDs is a syndrome that can affect anyone and, if left untreated, can damage performance and cause long-term health problems.

REDs can produce bone stress injuries, disrupted sleep, fatigue and low mood and, over time, lead to conditions such as osteoporosis, cardiovascular disease and fertility issues; Dr Nicky Keay attributes many of these problems to hormonal disruption caused by insufficient energy intake, saying "Hormones go to every single bit in your body. So, if your hormones are not working well for you, you're going to feel it in all sorts of different areas."

Keay described the menstrual cycle as a "free monthly medical check" for women, explaining a woman with REDs will have her periods "switched off", while in men the signs are subtler with reduced testosterone producing lower libido and fatigue; the topic received recent public attention when tennis player Emma Navarro revealed her diagnosis and her decision to step away from competition until 2027.

The condition was originally labelled the "female athlete triad" in the early 1990s but the International Olympic Committee renamed it in 2014 to reflect a wider set of symptoms and to acknowledge male athletes, a change Keay summarised as: "We realised we were ignoring the other half of the population." A meta-analysis published in the Australian journal Sports Medicine last year reported low energy availability in 44.2% of female athletes and 49.4% of male athletes.

Cultural pressures such as the long-standing belief that "lighter is faster" have driven under-fuelling in endurance and aesthetic sports; Smith said: "I believed it for years. I thought that was the way forward," and added he began obsessing over small weight reductions to improve times. Keay warned this approach is "fool's gold", because the body eventually adjusts to the deficit, producing a drop in performance and a higher injury risk.

Three-time Olympic medallist Jonny Brownlee reflected on his own career, saying: "I didn't see the importance of it. Training came first and I think we weren't educated enough in how important fuelling was," and he linked under-fuelling to stress fractures and other injuries, adding that cultural stigma meant men often delayed recognising the problem. Keay's 2019 assessment of 50 male competitive cyclists found nearly half had poor bone health and 25% were suffering from REDs; after splitting the cyclists into two groups over six months, she reported: "The group that I left to their own devices unfortunately went on the default and they lost even more bone mineral density, similar to an astronaut in space… And they performed OK, but relative to their functional threshold power, they didn't get the race results that you would have expected. For the group I took under my wing, there was an improvement in their bone health and really good race results."

Support and prevention efforts range from resources such as Project REDs, set up by former GB runner Pippa Woolven, to clinical help from Keay, who said most of her patients are women but that more men are now seeking help and are often in "bad shape." Keay acknowledged a psychological element in some cases, saying: "I don't mind that though because there is definitely a psychological aspect to REDs. Why are you doing this? Why are you not eating the carbohydrates?" Former British cycling champion Brian Smith described developing bulimia during his career around his appearance at the 1996 Olympics road race for Great Britain, noting his race weight fell to about 66kg despite being "just under six foot," and only discovered he had been affected by REDs years later after developing three severe stress fractures, including one in his femur.

Governing bodies have taken different approaches: British Cycling points to education starting at academy level and annual physical and psychological screenings, with chief medical officer Dr Nigel Jones saying: "One of the big things we've done in the past 10 years is try and turn this into a performance-related conversation" and "Now, we couch the conversation with an athlete around 'if you under-fuel, you will not be able to perform at your best'"; World Climbing introduced mandatory health checks two years ago using pre-season questionnaires and "random and targeted" competition screenings, a policy drawn up by Professor Naama Constantini who said: "We are trying to educate and prevent. I'm not a policeman and we're not looking for cheaters. I'm a medical doctor and we want to make sure our athletes are healthy."

Smith has publicly shared his recovery, saying he has reversed his condition and is "10-15 kilos heavier than I've ever been" while racing better, including a personal-best Berlin marathon time of two hours, nine minutes and 24 seconds; he added: "I'd never want to see an athlete go through the years I've had... I'm heavier, I'm faster, I'm happier." The big goal is the 2028 Olympics, but he says his priority is ensuring he is healthy enough to start every race.