They were two exceptionally promising athletes, seemingly bound for track and field stardom, when their careers were derailed by a condition that doctors and researchers say they are only now beginning to understand.
Their experiences highlight the damaging expectations that can surround athletes, blurring the thin line between the discipline that allows athletes to achieve superhuman feats and the disordered patterns of behavior that can harm their health, as they push themselves, and are pushed by their coaches and trainers.
Mary Cain was the youngest ever US track and field athlete to make the World Championships team, a teenage phenomenon who held several national age-group records in middle-distance running.
Pippa Woolven was one of the UK’s best steeplechase athletes, winning British university championships, competing in the 2012 World Junior Championships and earning an athletic scholarship to Florida State University.
Then, as both women edged closer to the pinnacle of athletics, they developed Relative Energy Deficiency in Sport (REDs).
The syndrome occurs when someone of any gender has overtrained and/or undereaten for a prolonged period in an attempt to improve their athletic performance, often without knowing the dangers of failing to compensate for the energy they expend in training, racing and their daily lives.
Left untreated, medical experts say REDs can damage an athlete’s metabolism, their bone health – leading to more fractures – their immune system, their cardiovascular health, their menstrual cycle, and mental health, as well as their athletic performance.
Where training safely transforms into REDs is “different for everyone,” Dr. Farrah Jawad, a consultant at Pure Sports Medicine specializing in the condition, tells CNN Sport.
The condition can often develop unintentionally and requires individual solutions to account for different levels of physical activity and food intake, she adds.
Woolven, now 30, tells CNN Sport, that she wouldn’t be surprised “if it was the most widespread medical condition in sport.”
“It’s more prevalent in endurance sports because of the … high energy expenditure (and) an emphasis on a lean physique but … literally anybody can be affected by it.”
Uncertainty remains around the true prevalence of the condition, “with estimates ranging between 15% and 80% of elite athletes,” according to the IOC, and it varies across different sports.
“We do think the deeper you start asking these questions … the numbers seem to be pretty high,” Dr. Kathryn Ackerman, an associate professor at Harvard Medical School and director of the Female Athlete Program in the Sports Medicine Division at Boston Children’s Hospital, tells CNN Sport.
If REDs historically has suffered from a lack of awareness in sport, Cain and Woolven, alongside healthcare providers, are seeking to build a new culture and “a place to pursue peak performance in a healthy body and mind,” as the British athlete’s advocacy website says.
“Developing this negative relationship with your body where your body starts failing you … it can compound the effects of body dysmorphia because you’re not only disliking how you look, you’re disliking how it’s responding to stress,” said Cain.
‘A toxic environment’
Shortly before Cain, now 27, first publicly spoke about her experiences suffering from REDs, she says she changed from thinking “I was the failure, I couldn’t handle it,” to (it) was actually this system.”
Although many different factors can cause REDs, Cain tells CNN that for her it was due to a “toxic external environment” and “abuse” at the Nike Oregon Project that “changed (her) mindset around sport.”
Once she had come to this realization, she decided to detail those experiences at the Nike Oregon Project in a video 0p-ed for The New York Times in 2019.
In it, she said that she suffered with suicidal thoughts and self-harm, accusing her coach, famed long-distance marathoner Alberto Salazar, of publicly shaming her if she did not make her weight target. She says she broke five bones and didn’t have a period for three years while training there.
Cain also said in the op-ed that she was put on a diet that left her so hungry, she secretly stole food from her teammates which she ate in the bathroom.
“The repercussions of that are going to leak into everything,” she told CNN. “It’s just going to be horrible, especially when you’re undereating and underfueling yourself (and) your ability to just quite literally live.”
Responding to Cain’s allegations at the time, Nike told CNN that it would launch an “immediate investigation” and that “these allegations are completely inconsistent with our values.”
CNN’s multiple calls to Nike and Salazar seeking comment for this story, have not been returned.
The results of Nike’s investigation were not made public, but the company told Women’s Running that it was using its findings to identify areas, “where we can do better in supporting female athletes.”
Salazar told The Oregonian at the time that he disputed Cain’s allegations and that her father, a medical doctor, was “deeply involved in her training” and consulted on medications that she used.
He also said that he had referred Cain to a female doctor and contradicted Cain’s allegation that the Oregon Project team had not included a nutritionist and a sports psychologist.
Offered the opportunity by CNN to respond to the Smithsonian story, Cain said that she wanted to focus on spreading awareness about REDs.
Salazar further refuted Cain’s allegations in Sports Illustrated, saying at the time that his “foremost goal as a coach was to promote athletic performance in a manner that supported the good health and well-being of all my athletes.”
In November, Nike and Salazar settled a $20 million lawsuit that Cain had filed in October 2021, in which she alleged that both parties acted negligently towards her, which had been “a substantial factor in causing, aggravating and/or exacerbating” several injuries, including REDs.
Nike closed down the Oregon Project in 2019 shortly after the US Anti-Doping Agency banned Salazar for four years for “multiple anti-doping rule violations.”
Salazar said he was “shocked” by the ban, claiming he was treated “unjustly” and “unethically” by the USADA.
The New York Times reported, at the time, that it had received an email from Salazar denying many of Cain’s claims and saying, “he had supported her health and welfare.”
Cain’s op-ed, however, did more than just detail her own allegations. It helped to spotlight the damaging effects of REDs and how its development can be influenced by the expectations and culture that surround an athlete.
“The environment was such a win at all costs mindset … and so I think because I was so passionate about it, it was easy for me to get sucked into a different type of obsession with it, because that was the sort of obsession that people around me had,” she said.
‘A slow unraveling’
Initially, success for Woolven was as simple as getting a personal best or making a team for an event so that she could enjoy the “cool experience” of competing there, but that changed once she accepted a scholarship to attend Florida State in Tallahassee.
“I moved to America, and I lost other aspects of my identity because it was so serious and it was so running-focused, I started to rely more and more on … the success – I needed to do well in running,” she says.
In the intensity of a high-performance sporting environment, Woolven never “really recognized that I was becoming … a bit obsessive about exercise, a bit intense about my nutrition.”
She says her period stopped – though at the time she didn’t realize as she was on birth control pills – and experienced problems with her digestive system as her mental health deteriorated.
“It was like this slow unraveling into a really poor state of mental and physical health … I just couldn’t keep going,” she recalls.
Eventually, Woolven stopped competing for about a year while recovering before returning to athletics, after which she competed at the international level again “in a healthy way.”
She took time off for a second time when she got “swept up in the unintentional side of REDs again,” accidently overtraining and becoming fatigued, but returned once more before retiring for a third and final time.
‘Instituional buy-in’
REDs’ symptoms can affect anyone, particularly athletes training in a culture that celebrates overtraining and undereating – or that has an unhealthy relationship with weight.
Even without explicit abuse like Cain alleges she experienced, Woolven says she absorbed the expectations of the culture around her, contributing to her downward spiral.
“These subtle changes were encouraged by the coaches,” she says, like “a competitiveness towards leaving the gym last” or “doing little extras … on top of your training” or cutting out food “deemed non-essential.”
The potential dangers of overtraining and undereating can still be brushed aside – more than a third of female athletes have ignored missed periods, thinking that it was either normal or even beneficial, a UK Athlete Health survey found in May.
“It’s our job as the professionals around them to really help athletes recognize when they’re pushing themselves too much or they’re not recovering enough. It’s important to sleep, it’s important to fuel, it’s important to have a rest day,” Dr. Ackerman says.
There’s greater awareness about REDs thanks to the efforts of athletes like Woolven and Cain, as well as Dr. Ackerman whose research has helped to spotlight the adverse health effects of the condition.
While on furlough from her job at the National Trust during lockdown, Woolven began blogging about her experiences, prompting a slew of responses from people around the world. Eventually, her blog morphed into Project RED-S – a site filled with resources for athletes, coaches and supporters.
Meanwhile, Cain established the Atalanta NYC, employing professional female runners to mentor girls in the community alongside their training and racing, and also coaches at New York Road Runners.
“If institutions aren’t going to change, can I at least make an institution that I know will be a safe space for people and will do some of the work that I really want to happen?” said Cain.
And without “institutional buy-in,” she observes, facilitating widespread culture change in sport remains difficult for individuals.
‘Not all doom and gloom’
Obtaining a diagnosis of REDs was a long, difficult process for Woolven, beginning at Florida State where she says she underwent numerous tests and was infused with iron via a drip on a cancer ward.
“Nobody was able to look at the holistic health picture … zoom out and say: ‘This girl has lost a significant amount of weight, she’s increased her training load, she’s experiencing all of these symptoms,’” she says.
There isn’t a single diagnostic test for REDs, Dr. Jawad says, adding that a diagnosis is instead based on “how they present to you and you connect all the clues together.”
In September, an IOC Consensus Statement written by a panel of experts, including Dr. Ackerman, was published and included new resources to improve the process of diagnosing and preventing REDs.
Using this system, doctors will be able to look for “more than just one thing,” Dr.
Ackerman says, removing the importance of one symptom such as periods stopping.
It also lays out recommendations for preventing REDs such as prescreening an elite athlete’s disposition to disordered eating before implementing a plan to reduce body weight.
Access to “dietician input … and appropriate psychological support if it’s needed,” can also help prevent and treat REDs, Dr. Jawad says.
Once REDs has been identified “it’s not all doom and gloom,” she adds. “It is possible to reverse some of the negative effects of REDs. It can take a bit of time because there’s so many different components.”
Treating the energy deficiency created in REDs ultimately involves some combination of eating more and training less though, Dr. Ackerman says, “treatment really depends on where you’re starting from” and may also require addressing “other health consequences” too.
Woolven’s Project RED-S aims to provide that support she lacked and initiatives like this allow Cain to envision a future that “looks really bright.”
“I’m hopeful,” Cain says. “But I don’t think we can rest on our laurels yet.”
