Running on Empty: The Hidden Health Crisis Facing Indian Women Runners

Introduction: A New Wave of Runners and a Silent Risk

It starts as a habit, a choice, a breath of fresh air.

At 6:00 a.m., the streets are quiet. A young woman laces up her shoes, adjusts her smartwatch, and steps into the stillness for her morning run. She’s not chasing medals or podiums. Like many Indian women today, she’s running for herself—for clarity, fitness, and a sense of freedom.

But somewhere between the endorphins and the discipline, her body starts sending quiet signals. Persistent fatigue. Irregular periods. A dull ache in her shins that lingers longer each time. She ignores them, chalking it up to overtraining or a dietary glitch.

Until the signs can’t be ignored anymore.

Few realise this could be RED-S: Relative Energy Deficiency —a condition where the body doesn't receive sufficient energy to support both daily functions and physical activity. While initially identified among elite Western athletes, RED-S is increasingly recognised among Indian women engaging in recreational sports. A 2024 cross-sectional study conducted in Karnataka assessed 120 elite female athletes aged 16–30 and found that 71% were at moderate risk of RED-S, with contributing factors including high training loads, low bone mineral density, and psychological stress.

What is RED-S?

Relative Energy Deficiency in Sport (RED-S) is a medical condition that occurs when the body doesn't get enough energy from food to meet its needs. It happens when the energy used for training leaves too little for essential functions like hormone regulation, bone health, and recovery. Originally recognised in female athletes as the Female Athlete Triad, the condition was broadened by the International Olympic Committee in 2014 to reflect its impact across multiple physiological systems.

At its core, RED-S occurs when someone is exercising more than they are fueling, either knowingly (to lose weight) or unknowingly (because they don’t realise how much energy their body actually needs).

The Female Athlete Triad: A Red Flag for Women

The Triad includes:

1. Low Energy Availability (with or without disordered eating)
2. Menstrual Dysfunction (e.g. missed or irregular periods)
3. Low Bone Density (leading to weak bones, stress fractures, or even osteoporosis)

These issues don’t always occur together. A runner could have a regular cycle but dangerously low bone mass. Or she may experience amenorrhoea without realising it’s linked to poor nutrition.

Why Indian Women Runners Are Especially Vulnerable

Running is still a relatively new activity for Indian women, but it's growing rapidly. From Pinkathons to 5Ks and weekend park runs, more women across urban India are lacing up. But with this rise comes a new set of challenges many driven by misinformation, social pressures, and gaps in awareness:

• Under-fuelling in the name of 'fitness': Many Indian runners, especially those new to the sport, adopt calorie-deficit diets without accounting for their increased energy expenditure.
  
• Cultural silence around menstruation: In many cultures, missed periods are shrouded in silence—often seen as a welcome break rather than a red flag. The stigma around menstruation makes it easier to ignore than investigate.
  
• Widespread nutritional deficiencies: Studies show that most Indian women, particularly in the 18–40 age group, consume less than the recommended calcium and protein levels. Vitamin D deficiency is rampant.
  
• Lack of coaching or structured training: Most amateur runners train without proper guidance, leading to imbalances between energy output and recovery.
  

The Science: How RED-S Impacts the Body

1. Hormonal Disruption

Chronic energy deficiency suppresses the hypothalamic-pituitary-gonadal axis. This leads to reduced oestrogen levels disrupting menstrual cycles and impairing bone health.

2. Bone Loss

Without sufficient oestrogen and calcium intake, bones become porous and weak. In young women (especially under 30), this means missing out on peak bone mass, a critical buffer against future osteoporosis.

A 2023 study in Indian Journal of Endocrinology and Metabolism found that urban Indian women with irregular cycles had significantly lower bone density scores compared to those with regular menstruation. 

3. Injuries and Fatigue

Low bone density leads to higher risk of stress fractures, especially in high-impact sports like running. Combined with low iron stores (also common in Indian women), this results in persistent fatigue and poor performance.

Common Signs of RED-S to Watch Out For

• Irregular or missed periods for 3+ months
• Repeated injuries (especially bone-related)
• Fatigue despite rest
• Hair loss or brittle nails
• Drop in running performance
• Anxiety or mood swings
• Gastrointestinal issues (bloating, constipation)

Recovery is Possible: Here's What Helps

Prioritise Fuel Over Weight

Focus on performance, not weight loss. Running well requires calories. A general guideline is to eat at least 45 kcal per kg of fat-free mass per day, adjusted for training load.

Track Your Menstrual Cycle

Your period is a vital sign, not an inconvenience. Missing it is your body’s way of signalling distress.

Get a DEXA Scan if You’re At Risk

A bone density scan is the gold standard for assessing bone health. If you’ve missed periods or had repeated injuries, this is essential.

See a Sports-Aware Nutritionist

They can help balance your intake of calories, calcium, protein, iron, and vitamin D nutrients critical for both performance and long-term health.

A Word to Coaches, Trainers, and Fitness Communities

Many running groups in India now include women of all ages and backgrounds. These communities can be powerful spaces of support but they must also be spaces of education. 

Promoting calorie deficits, pushing through missed periods, or glorifying weight loss without context can be dangerous.

Instead, let’s make strength, resilience, and long-term health the new goals.

Conclusion: Health is a Perpetual Journey

The joy of running is unmatched. It builds discipline, clarity, and confidence. But if not fuelled right, it can come at a steep cost especially for women.

RED-S and the Female Athlete Triad are not fringe conditions. They're real, science-backed risks that Indian runners must understand. Because no personal best is worth sacrificing your body’s long-term health.

If you’re a runner or know someone who is, keep an eye on the signs, fuel generously, and remember: health is not the cost of performance. It’s the foundation.

This article is reviewed by Dr. Anurag Gupta, a gold medalist in MPT-Sports Physiotherapy, has worked with elite international and national athletes across football, tennis, and badminton. His clientele includes Srikanth Kidambi (#1 Men’s Badminton Player, Arjuna Awardee, Padma Shri) and Hendra Setiawan (Olympic Gold Medalist, 4x World #1 in Men’s Badminton).

Beyond athletes, Dr. Gupta is the preferred physiotherapist for top founders, including Vivek Gupta (Licious), Rishabh Telang (Cult.fit), and Arjun Chaudhary (former MFine), helping them recover from musculoskeletal issues efficiently.