Objective To determine whether diet and risk of disordered eating contribute to risk of running-related injury in adult (= 18years) distance runners. Design Systematic review and meta-analysis. Methods Random effects meta-analyses were conducted on prospective cohort studies comparing dietary intake and risk of disordered eating in distance runners with and without running-related injury. Quality of evidence was assessed using an adapted GRADE approach. Results Fifteen studies involving 5942 distance runners (n = 2364 female) were identified. Nine studies were included in meta-analysis. Sex differences were observed for total energy and total fat intake (both p = 0.01). Moderate certainty of evidence suggested female runners who sustained a running-related injury had lower intake of total energy and fat compared to uninjured runners (mean difference [95% confidence interval] = - 449kcal/day [- 696, - 202] and - 20g/day [- 31, 9], respectively, both p < 0.001). Moderate certainty of evidence suggested runners (combined sexes) who sustained a running-related injury had lower dietary fibre intake compared to uninjured runners (-3g/day [- 5, - 0], p = 0.04). However, most dietary factors (protein, carbohydrate, calcium, alcohol intake or risk of disordered eating) did not influence injury risk (low-moderate certainty of evidence). Conclusions There is moderate certainty evidence that adult female distance runners with lower energy and total fat intakes have increased risk of running-related injury, as do runners (combined sexes) who have a lower dietary fibre intake. Future research should include long duration, high quality prospective cohort studies in male and female runners with clearly defined athletic abilities and consistency in running-related injury definition and statistical analyses. Review registration PROSPERO # CRD42022323627. Practical Implications • Few prospective studies of risk for running injury have comprehensively evaluated dietary intake and risk of disordered eating, with no consistent definition of running-related injury. • Lower total energy and fat intake increase the risk of general running-related injuries and bone stress injuries in female distance runners, while low fibre intake heightens bone stress injury risk (both sexes). • There is low-moderate certainty of evidence that most dietary factors (protein, carbohydrates, alcohol, calcium, and risk of disordered eating) did not influence the risk of running-related injury. • The role of disordered eating risk in running-related injuries is underexplored in male athletes.
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