Maximal oxygen uptake (V̇Omax), fractional utilization of V̇Omax during running, and running economy (RE) are crucial factors for running success for all endurance athletes. Although evidence is limited, investigations of these key factors indicate that East Africans' superiority in distance running is largely due to a unique combination of these factors. East African runners appear to have a very high level of RE most likely associated, at least partly, with anthropometric characteristics rather than with any specific metabolic property of the working muscle. That is, evidence suggest that anthropometrics and body composition might have important parameters as determinants of superior performance of East African distance runners. Regrettably, this role is often overlooked and mentioned as a descriptive parameter rather than an explanatory parameter in many research studies. This brief review article provides an overview of the evidence to support the critical role anthropometrics and body composition has on the distance running success of East African athletes. The structural form and shape of these athletes also has a downside, because having very low BMI or body fat increases the risk for relative energy deficiency in sport (RED-S) conditions in both male and female runners, which can have serious health consequences.