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Prevalence of Triad–RED–S symptoms in high-level Kenyan male and female distance runners and corresponding control groups

A Correction to this article was published on 24 October 2021

This article has been updated



This study examined and compared select Triad–RED–S components/risk factors in high-level Kenyan male and female distance runners to corresponding control groups; focusing on examining energy intake (EI), bone indices, and hormonal markers.


A cross-sectional, observational design was used in which Kenyan male and female (n = 30 and n = 26, respectively) middle- and long-distance runners and corresponding male and female control groups (n = 29 and n = 29, respectively) were examined.

The participant’s bone mineral density (BMD) at the lumbar spine, right femur, and total body were measured using a dual-energy X-ray absorptiometry analysis. Complete blood counts (CBC) were done on the whole blood specimens and hormonal measurements were performed on plasma specimens. In addition, athletes completed metabolic testing to determine maximal oxygen uptakes and 7-day dietary diaries.


Overall daily EI across runners and controls within each sex were low, but not significantly different (p > 0.05). Prevalence of low BMD values (Z score < − 2.0) was comparable across groups in each sex (p > 0.05). CBC measures suggested that both runners and controls were healthy. Finally, slight hormonal differences between runners and their respective controls existed (p < 0.05), but were not clinically meaningful or observed in typical Triad–RED–S-related parameters.


High-level Kenyan male and female runners had low daily EI, but no tendency toward a higher prevalence of low BMD, or Triad–RED–S–related hormonal abnormalities. The occurrence of low EI was not a major risk factor in our athletes; this calls into question whether the current criteria for Triad–RED–S are entirely applicable for athletes of African ethnicity.

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The data that support the findings of this study are available from the corresponding author, upon reasonable request.

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Change history



Bone mineral density


Body mass index


Complete blood count




Dual-energy X-ray absorptiometry

E2 :



Energy availability


Energy Intake


Follicle-stimulating hormone


Growth hormone






International Association of Athletics Federations (world athletics since October 2019)


Insulin like growth factor-1




International Olympic Committee


Lean body mass


Low energy availability


Luteinizing hormone


Lumbar spine bone mineral density




Red blood cells


Relative energy deficiency in sport


Right femur bone mineral density

T3 :


T4 :



Total body bone mineral density.




Female athlete triad


Thyroid-stimulating hormone

VO2 :

Oxygen consumption

VO2max :

Maximal oxygen consumption


White blood cells


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This study was funded by International Association of Athletics Federations.

Author information




MM and ACH conceived and designed research. MM, SS, DWH, RO, ACH and ARL conducted experiments. ACH and LÕ analyzed data and wrote the manuscript. All authors read and approved the manuscript.

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Correspondence to Lauri Õnnik.

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Communicated by Kirsty Elliott-Sale.

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Õnnik, L., Mooses, M., Suvi, S. et al. Prevalence of Triad–RED–S symptoms in high-level Kenyan male and female distance runners and corresponding control groups. Eur J Appl Physiol (2021).

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  • East Africa
  • Elite athletes
  • Energy intake
  • Bone mineral density
  • Hormones