RED-S Syndrome – What Athletes Need to Know

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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RUNNING and INJURY

Humans are designed to move, there is no question about it and moving by putting one foot ahead of the other is a rewarding exercise that can be done anywhere at any time. Walking in itself, is an essential part of day-to-day life as it allows us to just function and get around. Running, allows us to cover more ground quickly and it is here that we progress to exploring, racing and seeking to improve.

Improving in anything requires training, you need to train to be a doctor, you need to train to be an artist and in sport, no matter what sport, training is required to improve and progress. By definition, *’Training allows the body to gradually build up strength and endurance, improve skill levels and build motivation, ambition and confidence. Training also allows athletes to gain more knowledge of their sport as well as enabling them to learn about the importance of having a healthy mind and body.’

In running, it has often been said, there are three types of runner:

  • The runner recovering from injury.
  • The runner that is injured.
  • The runner that is about to be injured.

The above is a pessimistic look at a runner, but there is some truth. You see, runners get injured because our bodies are only capable of so many miles or hours. Push too much, too hard, too often and the body breaks.

Sports injuries are commonly caused by overuse, direct impact, or the application of force that is greater than the body part can structurally withstand. Common injuries include bruises, sprains, strains and joint injuries. ******

Training in itself is designed to stress the body so that it adapts. The body breaks down on a cellular level (bone cells and networks of cells deform) with long-running, fast-running, climbing, descending, whatever it may be specific to your chosen discipline. The magic happens when we rest. So, the first lesson is to embrace rest. Rest is not a dirty word; rest is essential to make the training stimulus work.

’Experts recommend training is varied and tailored to specific individual needs; this helps keep motivation and establish individual goals. Athletes should take care to rest fully between training sessions; this will help to prevent overtraining, which can have negative effects on performance and contribute to injuries… Sessions should not be too easy or too demanding; they should be pitched at the appropriate level to facilitate improvement but prevent injury and a lack of self-confidence.’ **

Finding the balance is hard. The stress-v-rest equation is a tough one and difficult to get right. You see, running, and most sports in all honesty are addictive.

‘Sports addiction sounds paradoxical, because we usually reserve the word ‘addiction’ for things that are recognizably bad for us, such as illicit-drug use or alcoholism, but there really is a sense in which you can become addicted to exercise. Even modest athletes can relate to the famous ‘high’ after exercising, triggered by the release of ‘happiness hormones’ such as dopamine and endorphins, which have mood-altering effects.’ ***

It makes sense, just as a drug addict needs a fix of ‘x,’ we as runners need a run to get that kick of endorphins. When we don’t run, we get low, our mood changes and well, we can be a little difficult to be around. But, let’s be clear, the positive and psychological effects of an active lifestyle are proven. Improved fitness, stronger heart, better weight management, increased life expectancy, clearer mind, stronger bones and the list goes on. But like in all things, we need balance.

Irrespective of ability, runners need balance. If you are new to running the balance will be different to the experienced runner who is maybe looking to run a personal best. One thing is common though, all training places stress on the body.

Let’s say you are new to running and looking to go from the Couch to 5km. A week may look like this:

  • Monday – 30 min walk
  • Tuesday – Rest
  • Wednesday – 30 min alternating between 5min walk/ 5 min jog
  • Thursday – Rest
  • Friday – Gym working on strength and core
  • Saturday – 30min walk
  • Sunday – 45 min broken down as 5min walk/ 10 min run and repeat

By contrast, an experienced runner looking to break 3-hours in a marathon, may have a week that looks like the following:

  • Monday – 40 min easy run at 90 secs per mile slower than MP
  • Tuesday – 50 min run as 10 min easy, 30min at Marathon Pace, 10 min cool down
  • Wednesday – 90 min endurance run, 1min slower per mile than MP
  • Thursday – 15min war up, hill reps 10 x 2min efforts (85%) on 90 sec recovery, 15 min cool down
  • Friday – Rest
  • Saturday – Park Run
  • Sunday – 2hr 15min run as 90min 1min per mile slower than MP, then 30min at MP followed by 15 min easy to cool down

There is a huge difference between the training plans above. Each applies stress in its own way, and both require rest or easier days to allow the body the strength to train hard when required.

Read about OVERREACHING HERE

So, planning is key in a training plan. Runners require a rest day and easier days in a training week, and importantly, they need easier weeks in let’s say, monthly training blocks. A good strategy is building for 3-weeks and dropping down on week 4, so, 8-weeks training in hours (just for illustration) could  look like:

  • Week 1 : 6 hours
  • Week 2 : 8 hours
  • Week 3 : 10 hours
  • Week 4 : 6 hours

 

  • Week 5 : 8 hours
  • Week 6 : 10 hours
  • Week 7 : 12 hours
  • Week 8 : 6 hours

If a runner never gets injured, one could arguably say that they fall in one of two categories:

  1. They have a superb training plan that balances stress, stimulus and rest.
  2. They are not training hard enough and not adding any stress.

Some coaches actually say, that injury is just part of the process and we need to be prepared for it. In a way, I agree, but that does not mean we must not try to avoid injury… On the contrary.

NSMI provide the following information to avoid injury:

  • Warm Up
  • Use the correct equipment (in our scenario, appropriate footwear)
  • Use the correct technique (run style and technique for gym/ weight training)
  • Do not over-reach (Listen to your body, know your limits)
  • Remain hydrated
  • Cool down

The above is a simple bullet list of points that provides a great starting point. But running is a harsh sport that creates great impact and stress, so, maybe we can be a little more creative.

Diet – Food is fuel and it provides us with energy to undertake training and importantly it allows us to recover. So, think about the food you eat and consume good quality calories from a variety of sources.

Cross-Train – Just because you are a runner, you don’t need to run every day. In all honesty, a good cross -training regimen is essential in my opinion to keep the body healthy and the mind healthy. One or two sessions per week in a gym on a stepper, elliptical or rower all increases fitness and gives the ‘running’ body a break. Weight training, core training and yoga are all positives to running.

Treatments – Having a massage every week or every month is a great way to have an overhaul of the body. It’s like taking your car to the garage to make sure that everything is working okay… A good sports therapist seen on a regular basis is a great way of nipping potential niggles before they become injuries.

Get a coach – A good coach will take into consideration your targets, available time, family and life stresses and provide you with a plan that balances stress and rest. In addition, they are a sounding board for your concerns, and they will keep you honest. They will push you when you need it and they will tell you to rest.

Variety – Don’t always run on the same routes. Mix up terrain so that it provides not only physical stimulus but mental stimulus. However, don’t lose sight of the reason why you are running. For example, if your target is a road marathon, you need specific road training. Equally, if you are running a trail 100-miler with loads of vertical, don’t do too much running on the road.

WHAT IF YOU GET INJURED?

The secret is noticing injury early and doing something about it. Runners are historically bad at this and I get it. We all have runs with some level of pain or discomfort and the secret is, in time, understanding what is just training discomfort (stress) or an injury waiting to happen. Simply. When in doubt, do not run.

RICE has often been used as an option in the 24/48-hour window:

  • Rest – At least 48 hours of rest for the injured area
  • Ice – Apply ice packs to the affected area for period of between 10 and 30 minutes. Be sure to place a towel over the injured area before applying the ice pack as direct contact with the skin can cause an ice burn.
  • Compression – In order to reduce swelling and also to restrict movement, compression bandages can be used.
  • Elevation – By raising the injured limb to a comfortable and elevated position, swelling can be reduced, and the limb will be at full rest.

As mentioned above, having a coach or getting regular treatment will help here, as you have at least two avenues to explore and discuss your problem with.

But shit happens and that ‘one extra run’ or not listening to your body is when the scales tip over and injury occurs.

See a professional. Don’t guess, do not go on social media and ask your peers what is wrong. Pick up the phone, get an appointment and start on the right path to a healthy body from the beginning.

There is no one type of injury and of course some injuries can be resolved in a week with some RnR and treatment, whilst others may see you sidelined for weeks, or months.

This is where cross-training in a training plan may well have been a god send. Remember we said early on, runners (all sports people) are addicted to an endorphin kick; we are addicts. So, while you may not be able to do the thing that you really, really want to do. Doing something is always better than nothing! Cross training is almost always given by a sports professional to help you on the road to recovery, so, embrace it.

Rest. Yes, if you have not already realized it. Rest is one of the key disciplines of any training plan. Embrace the rest days.

As an injury progresses and heals, be sensible. The urge to rush out the door and pick up where you left off is not a good idea. Ease the body back in, start slow, be progressive. Add stress, rest a great deal and slowly but surely increase time on feet and avoid any hard sessions. Once the body starts to feel good again, you can start to introduce other training stimulus such as speed and hill work.

Naturally, prevention is better than cure and there are many things that should be advised to professional and amateur athletes alike in order to avoid chronic muscle pain and injuries. Proper alimentation and stretching are key. A diet rich in proteins, vitamin C and A, and zinc, will help rejuvenate muscle tissues and prevent any damage and long-term injury. Making sure enough calories are consumed on a daily basis is also crucial to help maintain the body’s ability to repair itself. Perhaps also counterintuitively, the athlete also has to consume enough fat: an optimal level of fat has been proven to help reduce the inflammation process. Finally, it is recommended to eat within two hours after a workout, as it has been demonstrated that muscle tissue heals faster during these 2 hours-window frames. Stretching exercises are equally recommended by sports specialists in order to help increase flexibility and avoid muscle sprains. Warm-up stretches in particular serve to increase body temperature and prep the body to perform each activity. *****

Finally, learn from the process. Sit down and look at the training that lead to the injury. Try to see markers or key points that you can pinpoint and then moving forward, plan accordingly.

References:

* Here – ** Here – *** Here – **** Here – ***** NSMI – ****** Better Health

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