“I’d got self-destruction down to a fine art”: a qualitative exploration of relative energy deficiency in sport (RED-S) in endurance athletes

Figures & data

Table 1. Participant demographics

Participant (number)	Sex	Age	Participation level^1	Primary sport	Additional sport/exercise during RED-S experience
1	M	23	Semi-elite	Endurance running	Football
2	F	30	Sub-elite	Ultra-endurance running	Triathlon, pointe ballet, strength training
3	F	27	Sub-elite	Endurance running	Track-and-field athletics
4	F	40	Sub-elite	Endurance running	Strength training, fitness training (gym)
5	F	39	Sub-elite	Ultra-endurance running	Cycling, triathlon, football
6	F	26	Sub-elite	Endurance running	Triathlon
7	F	28	Semi-elite	Endurance running	Swimming
8	F	32	Sub-elite	Endurance running	Hiking
9	F	39	Sub-elite	Ultra-endurance running	Cycling, strength training
10	F	26	Sub-elite	Endurance running	Swimming, netball
11	F	24	Sub-elite	Endurance running	Fitness training (gym), swimming
12	M	36	Sub-elite	Endurance running	Rugby, strength training

Notes: Participants categorized based on criteria advanced by Swann et al. (2015). RED-S = relative energy deficiency in sport.

Table 2. Contexts and mechanisms influencing the onset of RED-S

Example raw data codes	Sub-theme	Theme	Category
It was really really drilled into us basically that you know if you were still getting your periods you probably weren’t training hard enough	Sporting culture	Sport-specific pressures	Onset contexts
My running training was probably absolutely fine but my problem was what I was doing in addition…so my training schedule might have been say ten hours of running over a week but you could probably double that with everything else that I was discounting	Physical demands of sport and exercise
I can really remember someone saying to me that they wanted my legs or something. And cause it had like come at a point where I’d just been like changing my diet and doing a bit more exercise, I thought “oh I can’t stop now”	Social approval	Social environment
I lost grandparents in a short space of time and although fuel-wise and all the signs in my body were pretty good I think I just started training a bit too hard to just cope	Trauma, loss and grief	Psychological health
Because I had an eating disorder before I started running, I wasn’t eating enough anyway, for just kind of like, working my body normally. just going to work and not doing any exercise	Pre-existing DE/ED
I like started trying to control what I ate and then it became a control thing like I couldn’t ever have that one chocolate bar or that one chocolate because then I might have it everyday	Perceived need for control	Psychological mechanisms	Onset mechanisms
The way I sort of dealt with my problems was very much, just kind of an all or nothing implosion. It’s like ‘that’s the bottom line, you’re not good enough, what’s the matter with you, just train harder	Low self-worth or confidence
And I suppose like I’ve always been a pretty driven perfectionist kind of person and just, and a people pleaser too so the thought that there was anything wrong with me that people didn’t like, then I had to fix that	Trait expression
I just sort of you know again quite unscientifically just ran more and didn’t stop. Eat sleep and breathe training basically in some form	Increased training load/PA	Physiological mechanisms
I think I’d read things, people talking about clean eating and things they don’t eat… so I just kind of didn’t eat puddings and sweet things, cutting them out entirely was probably quite a big change for my body	Restrictive eating practices

DE = disordered eating; ED = eating disorder; PA = physical activity

Table 3. The subjective experience of RED-S

Example raw data codes	Sub-theme	Theme
We are all veterans of the MRI machine and DEXA scan; I got a metatarsal stress fracture and then the tibial stress fractures started, of which I’ve had three	Bony stress injuries	A body thrown into disarray
I hadn’t been having those [periods] for years; I stopped getting my period and it scared me; periods were out of whack	Menstrual dysfunction
I felt really slow and lacking energy; there could be days where I’d go out the door and feel I’m sprinting, but I’m barely running anywhere because I’d just run out of energy really	Fatigue, weakness, reduced energy
My guts were a complete and utter disaster; I’d get the worst stomach cramps and vomiting and bloody diarrhoea	Gastrointestinal health
I became anaemic; seriously low ferritin levels; took iron tablets and performance improved	Haematological health
I can feel shaky and cold and sweaty; I was cold all the time	Thermoregulatory issues
I had really low oestrogen … well literally no oestradiol; my thyroid hormone levels were dire	Endocrine dysfunction
My immune system is shocking; I think I’ve had every disease or illness going	Immunological health
A lurking panic; constantly anxious of further injury;	Anxiety, worry, and fear	A psychological warzone
Going down the anxiety/depression spiral; something weighing me down	Depression
Complete and utter desperation; I was at breaking point;	Vulnerability
When people would kind of, try to force me to do something that I didn’t want to do, especially around food I would get very irritable … I just wasn’t a very nice person	Irritability
Withdrawn from a lot of social situations; feeling detached and different to others	Withdrawal
Right “I won’t eat carbs”; only eating what I thought was healthy; intermittent fasting; scheduling a run deliberately over lunchtime so that I wouldn’t want then to have lunch	Restrictive eating	A vicious cycle of disordered eating and compulsive exercise
I had to rest but I just cross-trained like a demon; on the elliptical for hours every day in the gym, weightlifting, swimming; sweat dripping off; going in harder to hurt yourself;	Exercising through injury or illness
Running to control calorie intake; compensating with exercise if planning to eat more; I purge sometimes after a session if not feeling great physically or annoyed at the session	Compensatory behaviours to counter EI
I was greedy so I couldn’t eat; two hours on the elliptical it’s not the same as running so you don’t deserve the recovery food	Transactional relationship with food
Couldn’t go a day without running; I’d ride in the morning, gym at lunchtime, run in the evening; going to the gym every single day; an unhealthy relationship with exercise	A compulsion to exercise

EEE = exercise energy expenditure; EI = energy intake

Table 4. Contexts and mechanisms influencing “recovery” from RED-S

Example raw data codes	Sub-theme	Theme	Category
I was really open with my husband about what was going on in my head because he just initially thought I was like really healthy	Personal relationships	Significant others	“Recovery” contexts
My nutritionist has encouraged me to eat more, being put in touch with her [dietician] was the impetus to change	Professional support
In that community especially where there’s a lot of like pride with people saying “well I did my twenty-mile training run on only water” … so then me *laughs* being me, I went and I ran the marathon and literally just drank water	Sporting culture and demands	Sporting context
I ended up with a metatarsal stress fracture by July and that was when I really realized that things had to change	Motivation to improve physical health	Health as wealth
You have to reach rock bottom before you get better I think, to force change	Motivation to improve psychological health
I’d kind of looked at slowly increasing my portion sizes and trying new foods	Increasing EI to account for EEE	Physiological mechanisms	Facilitative “recovery” mechanisms
So now I actually tell myself “right, you’re not going to go for a run today because you just need to rest, because work’s been so stressful	Decreased training load/PA
I worked with a dietician to actually understand, well “what do I eat?”. Because, I think the biggest struggle in recovery is like “how do I eat?” … we don’t know how to eat	Improved nutritional knowledge	Psychological mechanisms
Okay, I’m running further, and I’m eating more, and I’m enjoying it, so trying to mentally get in my head that this is a good thing	Challenging ED/DE attitudes
Mum has never been on a diet she’s the most chilled person around food, she has cake every single day, she’s a normal weight because she exercises, but not because she’s crazy, like me	Positive role models
I had to train every single day and I wasn’t refuelling after each session	Restrictive eating practices	Perpetuation of onset mechanisms	Inhibitive “recovery” mechanisms
I had to I had to rest but I just cross-trained like a demon	High training load/PA
I’m so scared of losing control and looking normal. It sounds so weird, but yeah looking and being normal even though that’s a fear, It’s a want too … I don’t know it’s so weird	Perceived need for control
It feels like it’s decisions that I made at 16 or 17 that I’m sticking by you know and why am I still doing that? It feels ingrained … very hard to change	Trait expression
So the Doctor I went to see I just don’t think he took it very seriously … he actually, kind of made me feel like I was kind of making stuff up	Lack of professional support and information

DE = disordered eating; ED = eating disorder; PA = physical activity; EEE = exercise energy expenditure; EI = energy intake

Swann, C., Moran, A., & Piggott, D. (2015). Defining elite athletes: Issues in the study of expert performance in sport psychology. Psychology of Sport and Exercise, 16, 3–14. https://doi.org/10.1016/j.psychsport.2014.07.004

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