Mimmi Kotka (far left) at the start of the 2020 Transgrancanaria – (c)iancorless.com

Mimmi Kotka broke silence just last week after a string of below par performances and has acknowledged it is time to take a break from sport. In an open and honest post on social media, she clarifies:

“I have been suffering with my body since the end of 2018. I have finally connected the dots between my low immune system, anaemia, fatigue, stomach problems, lack of menstrual period, inability to run fast and my body always running in reserve: it is RED- S, Relative Energy Deficiency in Sport.”

Now for many, RED-S may well be a new term, however, the list of symptoms and problems Mimmi lists are not. In recent years we have witnessed the rise of many a runner, particularly in the ultra-world for them only to slowly disappear.

Caroline Chaverot at Limone Extreme, Italy – (c)iancorless.com

Recently, Caroline Chaverot, a dominant force and some would have said unbeatable in trail running, slowly removed herself from the sport with a string of below expectation performances. In an interview with Damian Hall for IRunFar, Caroline said, “…I want to be better. Everyone else is training a lot, so I will train like them.’ Maybe I did too much? Or maybe too soon? If training becomes like a competition, then you get tired. I probably trained too hard and fast.”

The story of Geoff Roes and his dominance, for a period over the 100-mile distance, who now runs for fun, forever fighting a battle with fatigue. “It seems like I take two steps forward and one step back. I can’t really do what I want physically, I still get pretty fatigued.” said Roes talking with Justin Mock in an article on IRunFar dating back to just April 2020.

To be clear, I am not saying that Caroline or Geoff had RED-S, I am merely pointing out that our sport, the challenges it brings, without close attention can be far more negative than positive. No runner or athlete intends to get RED-S or OTS, quite the contrary. As Mimmi says:

 “I never had the intention to lose weight, nor do I have an eating disorder. I ended up with RED-S by mistake.”

The great thing about trail and ultrarunning is that it is a sport for all. All body types are welcomed and RED-S can happen to anyone at anytime. It can creep up without your realising.

“But a mysterious training condition is suddenly plaguing its ranks, robbing a generation of top athletes of their talents and forcing victims to wonder: Is it possible to love this sport too much?”

Mike Wolfe at The Rut, he is co race director with Mike Foote – (c)iancorless.com

The above is from an article, “Running on Empty” by Meaghen Brown that starts with the story of Mike Wolfe at the 2012 Transvulcania. I was there, I witnessed the day unfold. The article goes on to say:

“The past seven years have seen the rise and decline of at least a dozen elite competitors, including Anna Frost, who won the women’s division of the North Face Endurance Championship in 2011; Anton Krupicka, two-time winner of the Leadville 100; Geoff Roes, who set a new record at the 2010 Western States 100; and Kyle Skaggs, who demolished the Hardrock 100 record in 2008. Each of them reached the pinnacle of the sport only to mysteriously struggle to repeat their best results. Transvulcania was the start of Wolfe’s own precipitous fall.”

Now the context of the above article was OTS, (Overtraining Syndrome,) but the similarities with RED-S are noticeable.

What is RED-S?

Relative energy deficiency in sport, known as `RED-S `is the result of insufficient caloric intake and/or excessive energy expenditure. For Mimmi, it was the latter, excessive energy expenditure. The condition can alter physiological systems such as metabolism, menstrual function, bone health, immunity, protein synthesis, and cardiovascular and psychological health.

For many, RED-S was known as the Female Athlete Triad and is often directly related to not eating appropriately for the amount of energy one extends. This can be a particular problem for the ultra-distance runner. “Furthermore, the RED-S model includes both male and female athletes – so if you are a male athlete, please do not stop reading! Low energy availability can impact male and female exercisers of all levels and of all ages.”

Food restriction is a worrying scenario, both for male and female athletes. A simple analogy is taking a car and restricting the fuel you add to the car. Do not add enough fuel and the car will eventually grind to a halt, the body is no different. While the condition was often thought to be one for female athletes, medical professionals are now seeing similarity in male athletes and the usage of the RED-S term now applies to male and female.

Mimmi continues to write, “I have plunged myself into this condition over the last few years. I have simply put in more and more hours of training without adjusting my calories accordingly, dragging me towards incredible fatigue.”

Mimmi was eating healthy and good quantities, however, the balance was off. Her training volume was too high and calorie intake insufficient. It was not an eating disorder of any sorts, more a miscalculation of energy burnt/ calories in.

Mimmi, was the winner of CCC and TDS and for a period of time, was considered unstoppable. A force to be reckoned with. But as she says, since 2018 she has continually suffered to find the same performance levels. This in turn brings a negative cycle that only perpetuates the problem.

I will train more.

I will lose weight.

Two common scenarios that gradually add more issues and one cannot ignore pressure from peers, fans and sponsors. In the case of Mimmi, she trained more to get better. She had no intention to lose weight.

While eating habits are an indicator of RED-S, the overall picture is much more complex and of course, the differences between male and female are marked.

The BMJ (British Medical Journal) list several key notable factors as an indicator, the first is missed periods or no menstrual cycle. Now of course, this is specific to women, but what other factors should be considered?

Stress Fractures.

Low BMI.

Strange eating habits.

Increase training.

Inability to recover.

The long-term impact if unchecked can be devastating with affects on the health system staying with the body for the rest of the athletes life.

When hormone levels are altered, the impact is potentially far reaching and why it may be common to know and understand that immunity is impacted, recovery, growth, concentration and an impact on endurance, the cardio vascular system can also be impacted which could lead to heart disease.

This is not a condition just for the “elite” of the sport, quite the opposite. We look up to our idols and we copy them. We hear stories of mega training sessions, we hear about fasted runs and we hear stories of specific diets to maintain race weight… A picture builds and is one that many try to copy and emulate. For some and in the case of Mimmi, it was about being fitter, therefore adding more training. But for others, the pressure to be thin is very real and fad diets contribute leaving a myriad of question marks that few find the answer to.

Going back to the car analogy, sports people need energy and that energy comes from food full of nutrients and variety. One should not have a troublesome relationship with food but unfortunately, sport is littered with athletes who do. How often have you heard someone say, “I need to run to earn my calories!” 

This mindset is the start of a potential problem and it needs checking.

As Mimmi says in her honest post:

“…I’ve dragged myself deeper and deeper into this condition during the last years. Just loaded on more training hours, not adjusting my calories accordingly and slugged through incredible fatigue. Being able to ignore the physical body is what makes a good ultra runner but it’s also what brought me down.”

Nutrition specialist, Dr Nicky Keay confirms in an article, “Fundamentally there is a mismatch between food intake (in terms of both energy and micronutrients) and the demand for nutrition required to cover expenditure, both of exercise training and for basic “housekeeping” tasks in the body to maintain health. If there is insufficient energy availability, then the body switches into an energy saving mode. This “go slow” mode has implications for hormone production and metabolic processes, which impacts all systems throughout the body.”

We train to get fitter, faster and stronger. But a complete athlete should look at all aspects to make a perfect picture. Food and nutrition is a key building block and without it there will be an inability to improve as expected in response to training and the risk of injury will increase. It´s a downward spiral we have seen all too often in the sport of ultra-running.

Counting calories rarely has a benefit in the long-term, however, in the short term, keeping a training diary that records food intake v expenditure can be useful. If an athlete consumes fewer than 2500/2000 calories (male/female) after taking energy expenditure in to account, your intake is likely to be inadequate

There are many fad diets out there but find a balance with nutritious food that has plenty of variety. Periodise food intake to coincide with training. For example, there is a time and a place for carbohydrate. Equally protein and fats. Eat fresh, minimally processed foods that include plenty of servings of vegetables and fresh fruit. Try not to avoid certain food groups unless advised otherwise by a medical professional and if vegan or vegetarian make sure you understand how to maximise calories paying attention to Protein, Fat, B12, Iron, Zinc, Calcium, Iodine and D Vitamin. “The No Meat Athlete Cookbook” by Matt Frazier is a great resource for all sports people

Post exercise, make sure you replenish your body with protein and carbohydrate. Protein will help repair lean muscle and carbohydrate will help restore glycogen for the next training session. How much carbohydrate you eat depends on what training you have coming up… This is where the help of a coach and nutritionist will help keep you honest.

Be sensible with training volume, less is sometime more!

To conclude, who is at risk of RED-S?

The reality is, RED-S can occur in any age or level of athlete but the greatest risk comes for those who are involved in sports that require high power. Power to weight ratio is a fickle beast and those most at risk are cyclists, climbers, triathletes, runners – yes, runners!

Ultimately, find a healthy balance between training, nutrition and rest. Go through the warning signs below and be honest with yourself. If in doubt, ease back, eat healthy and seek the advice of professionals who can help get you back on the correct path.

Warning signs:

1. Fatigue
2. Illness
3. Repeated injury
4. Mood changes
5. Broken sleep
6. Below par performances
7. and of course, an unhealthy relationship with food.

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References:

• UW Health
• BMJ
• endurancesportsnutritionist.co.uk
• health4performance here
• Sports Injury Bulletin here
• Outside Online here
• OTS here
• IRUNFAR here and here

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