In many ways, runners and particularly competitive runners, have an advantage when it comes to health monitoring. This mainly stems from the fact that our bodies need to be firing on all cylinders to achieve the adaptations we hope to achieve through training week in, week out.

This means that we tend to clock when things aren’t feeling right earlier than most. Often athletes complain of a lousy session or a few laboured recovery runs a few days prior to the onset of full blown cold symptoms, for example. 

It is because we know how important it is to be fit and healthy, that our threshold for what’s ‘okay’ and thus what we are willing to tolerate tends to be lower.

The athlete can be a little… precious

A random back twinge may be largely ignored by a non-sports person because, rightly or wrongly, they can put up with a few days rest and an extra cushion at night. The same twinge in an athlete is likely to invoke an hour-long YouTube-led self-help session of targeted stretches, foam rolling and intermittent hot and cold treatments in an effort to quickly relieve the issue.

It is not necessarily because an athlete is any more caring towards their body, it’s just that that same twinge is impeding pain-free running which for many athletes is a complete deal breaker for what they consider acceptable.  

If your normal is legging it past the Houses of Parliament with your mates, then you might need to let the doc know. Photo credit: George Russell of Up and Running, Fleet Street).

When the doctor gets involved

Some problems require some form of medical intervention. Those lingering sort of issues that make us miserable, either because of, or-in spite of their impact on our running.

The list for such ailments is of course extensive but generally includes one, two or more of a pic ‘n’ mix selection of chronic pain/discomfort, fatigue, insomnia and low mood. The kind of things that can make us miserable enough to make the hassle of booking an appointment (invariably at an inconvenient time) with a GP, physio or other health care professional seem worth it.

If your problem can be handled by a highly recommended physio or osteopath and you can afford the treatment brilliant. If, like many athletes you do not have this luxury or your issue is not soft tissue-related then you’re likely to have to roll the dice with the local GP.

It is at this point that a conflict can arise. The NHS, for all its brilliance has limited resources. Resources that, quite rightly, are skewed towards emergency treatment and chronic disease management. For the remainder of cases, the GP must make an assessment based on the perceived impact a person’s ailment has on their quality of life before recommending them for a referral to a specialist.

There are other important considerations to be made. They of course have to make a judgement call on whether they believe the patient would benefit from a course of treatment versus rest in the case of physical injuries. But all things being equal this is where athletes can lose out if they have a GP that fails to take a patient-centred approach.

Feeling exhausted but still better than most

For example, a young distance runner comes in complaining of being exhausted after every run.

On the surface, they look fine and their vitals are normal. Young, slim-build, and they say they are able to run 5 miles a day which is far more than the average Joe. Afterall, aren’t most people exhausted after jogging five miles, let alone every day? Maybe they just need to run less?

The issue is of course that they aren’t the average Joe, they are an athlete and the only point of comparison should be themselves. It is far more important to investigate the changes that have led up to this point – their so called ‘loss of function’.

A chess player that complains he can only think 5 moves ahead might sound a bit of a nonentity. But if it turns out 5 years ago they were a grand master capable of thinking 25 moves ahead then there is grounds that this deterioration represents some level of cognitive decline.

By analogy, if our young athlete 6-12 months back could comfortably run 8-10 miles carefree then this is a red flag that needs to be addressed. It could be an early sign of relative energy deficiency in sport (RED-S), anaemia, depression, Lyme disease or even autoimmune diseases like coeliac disease and diabetes that are being partially masked by a patient’s athleticism. 

Talk to and work with your local GP. The NHS is working in extreme circumstances in 2020 and the fact your 5k PB isn’t dropping as quickly as you hoped might not be an alarm bell for them.

Some general advice

I think there needs to be some level of responsibility taken by everyone involved to ensure that athletes’ problems are noted and listened to at the earliest possible stage.

Coaches, an athlete’s wider support network and the athlete themselves have just as much responsibility as the health care professionals in ensuring that appropriate interventions can be made. A doctor of course KNOWS the important of taking a patient-centred approach and should be well-versed in taking a full history from a patient in order to contextualise their problems. But they also need a bit back from the athlete. Athletes need to get across two really important things during these consultations:

1. That they are an athlete and what their baseline level of health / normality looks like. 

I.e. “I am a competitive distance runner and I would usually be running 60-70 miles a week…”

2. The impact of their current health problem on their running relative to their own baseline from point 1. It may also be good, if relevant, at this point to explain the impact this is having on your mental health too. For many of us, running is an outlet for neutralising stress and an opportunity to meet up with friends which can be compromised when we are injured or otherwise feeling unwell. 

i.e. Over the last 2 months I’ve been really struggling to summon any energy to run even 3 miles a day and when I do I’m exhausted. It’s also meant I’ve been feeling increasingly lonely as I’m no longer seeing my friends as much…

Communication can be key

Ultimately this will lead to productive discussion between an athlete and physician. It will also ensure that a good, trusting patient-doctor relationship is established from the off.

I think historically, some athletes in a bid to be heard have felt the need to exaggerate or worse invent symptoms. But this can lead to problems of its own.

Being open and honest with ourselves, our coaches and our GP at all stages has got to be the way forward and I think that’s something we can all improve upon going forwards.

Want to run faster? For just £30 per month athletes are provided with a Final Surge plan for each day of the week, coaching advice from Robbie Britton and Tom Craggs, as well as access to the unique Fast Running Performance community.

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The post What’s up doc? appeared first on Fast Running.

It was my 24th birthday recently. I spent the day hobbling around Stockholm, grimacing every time I faced a staircase, wincing at each downhill slope. This was, of course, entirely my own doing. I had run the Stockholm marathon the previous day, finishing 8th woman and 1st British lady in a time of 2:43:41.

This was two minutes slower than the PB I had run in the 2018 Yorkshire Marathon. My post-race mind was struggling to decide whether or not I was delighted or disappointed with my performance. In net terms, very little has changed between my turning 23 and my turning 24. I haven’t got significantly faster or slower in terms of my PBs since I set them last September/October. My weight is very similar to 12 months ago, I still live and work in the same places with the same people.

Looking beyond the numbers

Looking at the net difference between 23 and 24 would be doing a disservice to the journey that I have been on this year. A few months ago, I wrote an article detailing my battle with anorexia nervosa as an athlete. It detailed my decision to fight and beat my eating disorder for good. At that point, I was still in a very hairy situation, with a struggling immune system, poor bone density and was only just incorporating training back into my schedule.

In the four months since writing that article, I have managed to get my weight back up to the level it was before the anorexia took hold again. More importantly I’ve been able to sustain it while increasing my weekly training load. My immune system has been holding its own. Whist my periods haven’t come back yet and I have been fighting a losing battle with my local GP practise regarding the prescription of short-term hormone replacement therapy (HRT) to help the bone density, I know I am going in the right direction.

My coach Liz Yelling has been helping me reintroduce tempo sessions into my schedule. I am now going to club track sessions once a week. This is a huge triumph for me as I missed training with Sale Harriers and being a part of the running community. Prior to Stockholm I have done two races, narrowly missing a PB and finishing as second woman in the Shakespeare Half Marathon at the end of April. I also won Hook 10 in May and set a new course record.

Marathon Motivation

Back to the here-and-now – Stockholm. The marathon will always be my preferred distance. I find 5km and 10km pace hard but have an uncanny ability to maintain a relatively fast pace for a very long time. Being given permission to do a marathon at the start of June had given me a lot of motivation. Over the last few months I’ve foused on staying strong, keeping on gaining weight, and (with a few exceptions and slip-ups) doing what I was being told in terms of training and challenging my eating behaviours.

Furthermore, it made swallowing the bitter pill of having to forgo the Manchester and London marathons, and therefore any hope of being selected for international teams this year, slightly easier. I didn’t really know what to expect in terms of performance in Stockholm. Certainly I knew I had done very little specific training for the event and was only just coming back after a reasonably long break. I only had two races in the bag this year. I didn’t have the months of double sessions, track and tempo work I had leading up to my PB race. But equally, I was heavier and healthier than I had been for a long time. Most importantly I was enjoying running again, seeing it as a fun activity rather than a chore I was compelled to do.

Mixed emotions

So, am I delighted or disappointed with how it went? I know I should be ecstatic. To quote Liz, my time was a ‘miracle’ given the circumstances. It showed just how much potential I have if I stay healthy and make my wellbeing the number one priority. To be able to run a sub-2:45 marathon (and my second fastest marathon ever) on the back of very little training with a short lead-up, proves that my talent hasn’t gone anywhere. With sustained training, proper nutrition and a more balanced outlook, I could go a long way if that is what I want in the future.

The ultra-competitive, perfectionist side of my mind, however, is gnawing away. It’s telling me that had I got a better start (rather than getting caught up in the masses in mile one and playing catch-up over the subsequent few miles) and paced the hillier sections better, I should have got a PB.

Looking ahead

As soon as I finished the race, I was already thinking ahead to the Berlin marathon this September. Berlin is my big competition goal for 2019, and focussing on going sub-2:40. But that was never the point here Stockholm was meant to be a fun birthday weekend. Enjoying a long training run to feel to set me on track for the rest of the year and remind me why I do what I do.

And I did have a lovely birthday trip. Having a good race experience has given me a lot of confidence looking ahead to Berlin. I need to relish these emotions and the good memories, while learning to deal with the perfectionism. I need to accept that I have accomplished a great deal over the last year personally and professionally, and that won’t necessarily be reflected in a running time or race performance.

So, a year of little progress? Not at all. I have learned so much about who I am, how to get a better training/work/rest/life balance, how to accept help from others and how to manage my expectations. Things aren’t perfect but then recovery isn’t like a 5km race (relatively short and uncomfortable but over quickly); recovery is a marathon (long, hard, very painful at times, but so very rewarding when you cross the finish line).

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The post A journey beyond the numbers appeared first on Fast Running.

2018 – where to start? It was a year of massive highs in terms of my running career, but I failed to take proper care of myself or to acknowledge that cracks beneath the surface were appearing. I needed help and it resulted in me crashing into 2019 in a very bad place both mentally and physically.

Let me introduce myself. My name is Katherine Wood and I’m a 23 year-old endurance runner living in Manchester and training and racing with Sale Harriers.

I moved to Manchester after studying for my undergraduate degree in Biochemistry at Oxford University in the summer of 2017 to start a PhD in the field of Genetic Medicine.

For the last 10 years, my life has been deeply intertwined with mental health issues. At the age of 13, I was hospitalised as an in-patient with anorexia nervosa.

To give some context, I had been a competitive swimmer and runner as a child and a young teenager, but as I went through puberty I struggled to balance my energy output of training with energy input. When this was combined with my perfectionist tendencies, high-achieving nature and extreme determination, I rapidly transitioned from losing some weight accidentally, to suffering from a full-blown eating disorder which was picked up too late.

My periods stopped, my bone density had plummeted and at the time of hospitalisation I had a BMI of less than 14.

While I was never treated as an in-patient again, I had several relapses over the following years requiring out-patient care, the most notable of which being when I moved to Oxford to start studying for my undergraduate degree.

During the first term, I lost a huge amount of weight and without parental nagging, I clearly wasn’t able to cope or manage myself nearly as well as I’d thought. Just before the Christmas vacation, I was told to gain weight over the holiday or I would not be able to come back for the next term and would have to take a break in my studies.

This proved motivation enough to kick me into action and I successfully gained back the weight I had lost over the following few months, this time using my determination and general pig-headedness in a constructive manner to put my everything into recovery.

While depression and anxiety plagued me throughout my time at Oxford, my weight remained stable after this at a relatively healthy level, I was allowing myself more flexibility as to what I ate (it turned out that chocolate in moderation was a fabulous antidote to essay crises and finals’ stress!) and I was able to start running again.

My first half marathon and increased training

My first half marathon was 2015 before and completing my first marathon in October 2016, in a respectable time of 3:20. I felt in control of my eating disorder (rather than it controlling me) and I believed that I would never let myself slip back into my old ways; I had everything to gain by remaining healthy, and so much to lose if I didn’t.

I then joined Sale Harriers in October 2017, and over the next year, I really became immersed in the sport of running. My training volume increased – I was now including double sessions on some days and the purchase of an exercise bike meant I was incorporating more cross-training into my schedule – but I felt great for it.

In 2018, I lowered my marathon PB to 2:49 in Bavaria and I decided to enter the Yorkshire marathon in October, with the Scottish Half Marathon and Robin Hood Half Marathons in September as my training races in the lead-up.

The combination of increased mileage and cross-training seemed to have been successful so far so I continued to up my miles further; I was now running between 90 and 100 miles a week, with double runs every day, a 20-miler every Saturday. I was also doing at least an hour of cross-training and core strength work every day.

But beneath the surface, cracks were beginning to appear. I was aware that I had lost some weight, and that it was lower than it had been for a few years. I had tried (and failed) to come off my antidepressants over the summer, but it had thrown me out of balance and routine, and I was really struggling with my mood.

At the beginning of September, I contracted cellulitis in my lower left leg – the pain and swelling had initially led me to think this was a running injury, but a trip to the physio and then the GP confirmed it was instead an infection.

I was put on a course of antibiotics which helped to clear it, and while the pain was excruciating, I refused to stop training or miss a single run, although I had to forgo running the Scottish Half Marathon.

Winning the England Half Marathon title and a 2:41 marathon

With the clearance of the infection, I decided that I would still run the Robin Hood Half Marathon, which incorporated the England Athletics Half Marathon Championships, two weeks before the Yorkshire Marathon.

In racing terms, it was a huge success. I not only won, but I also ran 77:34 to record a two-and-a-half minute PB.

With the win at the forefront of my mind, the last fortnight of training before the Yorkshire Marathon was now underway. I was aware that my weight had dropped slightly more, but I kept telling myself that things would sort themselves out.

My performances were improving and I thought my body was coping well and responding to the amount of training I was doing; I would sort the weight out after the marathon.

Despite what my fellow runners were telling me, I decided not to bother with tapering for the marathon; I couldn’t bear the idea of lower mileage weeks and I went into the marathon on the back of an approximately 80-mile week.

As with the Robin Hood Half, things couldn’t have gone better. By mile 20, I knew I had several minutes on Julie Briscoe and although I was beginning to really feel the cold and wet, I pushed myself on to cross the finish line in a huge PB of 2:41:33. It was the biggest running victory of my life.

Soon afterwards though things would take a turn for the worse. I was on such a high that I didn’t give myself any sort of recovery or rest and I was back to a normal training week the day after the marathon.

Furthermore, Liz Yelling had also agreed to coach me remotely, something I was over the moon about.

My health was declining, but I couldn’t stop training

However, two weeks later, I found myself back at the GP being prescribed another course of antibiotics as the cellulitis had returned on the other leg. As recurrent cellulitis is quite uncommon in young, apparently healthy females, the doctor questioned why this might be happening and suggested it may be a consequence of my low weight.

After standing on the scales for her, which indicated I now had a BMI of just 16, she told me that she was referring me to the NHS eating disorders service and requested several blood tests. When these came back, they indicated that my immune system was not functioning particularly well and my creatine kinase (CK) levels were elevated, a mark that the muscles in my body were breaking down.

We were now into November, and yet again I resolved that I needed to sort myself out in order to keep training and performing to the best of my abilities. And yet, despite the racing calendar coming to an end for 2018, I continued to train – now I felt like a failure if I wasn’t running 100 miles a week, doing an hour each night on the exercise bike and at least 30 minutes of core exercises per day.

Repeated blood tests showed the CK remained high and my weight was continuing to go down. I knew my diet had become far more restrictive again and I was worrying far more both about what I ate and how my body looked than I had for many years.

When December came, my fiancée and I went on a holiday – that was booked months in advance – to New York, but the trip was dominated by running and worries about food and on my return to the UK, my weight had dropped considerably more, giving me a BMI of just 15.

Christmas 2018 has to have been one of the loneliest and most difficult periods of my life so far. Hugely worried about Christmas dinner and that I might not be able to do all my training sessions. Christmas Day was certainly no rest day – I pushed myself to run a half marathon distance in the morning just in case I ate more than I wanted to later, but halfway round I felt something twinge in my hamstring and the rest of the run was a painful hobble.

Despite this pain, I continued to run and run and run. My hamstring was now very bruised and my whole leg was swollen and painful. The pace I was able to run was getting slower and slower, and I just felt completely alone and lost.

Enough was enough

I remember so well the day I decided to make a change. It was December 29th, and I had just read an article on Fast Running about another young female suffering from RED-S, and how, with the renowned sports’ and eating disorder specialist nutritionist, and founder of the #TRAINBRAVE campaign, Renee McGregor, she had been going through a long and difficult, but ultimately successful, road to recovery.

By this point, I knew I had to do something. My situation felt desperate and I realised that I couldn’t do this alone. Liz Yelling had some idea my weight was a bit lower than ideal and was aware of my history, but I hadn’t told her what was going on, my parents clearly didn’t know what to do (while I hadn’t owned up to how much weight I had lost, they could very clearly see how bad things were) and while extremely supportive, my partner was also at a loss.

Ultimately, I had to make the decision to change and act upon it – nobody else could recover for me. So I made contact with Renee and arranged a Skype consultation, and in the meantime, I wrote myself a 3000-calorie meal plan to follow, with the intention of continuing to train while gaining weight.

The day of my consultation with Renee finally arrived. I was anxious about talking to her, but since starting my high-calorie meal plan my weight had increased slightly and I was hoping that she would be able to provide me guidance on how to improve the meal plan while still training.

I think deep down I knew what was actually going to be said, but I was adamant I was doing the right things in terms of making positive changes towards recovery.

Of course, one of the first thing that Renee said was “I want to work with you and help me, but I will only do this if you agree to stop running or doing any exercise immediately”. I was absolutely devastated – I had put on some weight while still running, so why couldn’t I carry on this way?

Renee explained to me that I was putting myself in great danger, that my heart could give way at any moment, my bone health was probably very poor and that I was very unwell. I was so caught up in the eating disorder that I couldn’t see those home truths, but deep down I knew I had no choice; I had approached Renee for help and if I didn’t do what she asked or work with her, I probably was either going to be hospitalised or die.

Renee suggested that she and Liz work together to support me, and reminded me that I was not alone in this and that I couldn’t do this without any help and expect to recover long-term.

The day of the consultation was one of the bleakest days of my life; I cried and cried, many things were thrown across the room in anger and all I wanted to do was to curl up in a ball and hide away from the world. But it was also one of the most important days of my life. I had made the very positive step of reaching out for help and had approached arguably the most qualified professional in the field. Things could only go up from here.

It’s been a whirlwind

Over a month has passed since that initial consultation, and things have been a bit of a whirlwind. The mental effort to stop myself from training has been hugely draining, and I have found it unbelievably difficult emotionally to cope with eating a huge amount and not exercising.

On the positive side of things, I have managed to gain several kilograms of weight, and as a result, I am now allowed a couple of short runs a week, a little bit of exercise biking, and I have started doing yoga and pilates.

I am hoping that by doing things like pilates (which are extremely good for runners anyway) that when I do get back to training and racing properly, I will go into things in much better shape and come back stronger than ever.

I have also been using the extra time I now have to try new things and be more balanced – I’ve been proactive in meeting friends for coffee, finding craft projects, baking, my partner and I got a pet snake, and I even managed to brave a pub quiz.

On the more negative side, all the evidence suggests my body is really struggling, far more than it did when I first got ill a decade ago, probably to be expected given how long I have been ill and not providing it with the nourishment it needs.

My blood tests are still showing elevated CK, my lymphocyte count is very low meaning my immune system is very compromised and as a result, there are signs that I have had an acute infection in the liver. Additionally, the DEXA scan I had has shown very poor bone density, putting me well inside the osteopenic category, likely an effect of very little oestrogen production.

The likely outcome of this is that I will be going on hormone replacement therapy (HRT) to provide an oestrogen ‘boost’ until my body starts producing enough naturally due to my long history of illness and menstruation problems.

Wider problems and lack of support

One thing that has really shocked me is the availability (or lack thereof) of services in the NHS. After waiting three months for my NHS Eating Disorders Unit initial assessment, I was told that this appointment was to decide which waiting list to put me on to receive the appropriate treatment.

When I asked about the waiting times, I was told that because I had been put onto the fast track system due to my low BMI when I was referred it should be less than 12 months, but if I had been on the general waiting list the waiting time could be up to two years.

For someone with an eating disorder, two years is far, far too long – at least 20% of anorexics die prematurely, with suicide and cardiac arrest being the two highest contributors to this figure.

The lack of funding and support for people with eating disorders and mental health problems in general is shocking; I am extremely fortunate I have a family who can support me financially to see a private specialist, and while the work Renee does through TRAINBRAVE is outstanding, there simply isn’t enough money to offer help to everyone in situations like mine.

While still in an early phase of recovery and it will be a long road ahead, I am determined to succeed and overcome my eating disorder this time. I want to be the athlete I know I am capable of being without nutrition or my weight being a limiting factor.

I would not wish any of this on my worst enemy – anorexia and sports-related disordered eating has ruined the last decade of my life, I have missed out on so many things in life because I have been ill for so long, and although I know it is wrong to feel guilty or blame myself, I feel a huge burden on the people around me who have supported me and whose lives have been turned upside down because of my illness.

All I can say is that if you have even the tiniest shred of worry that a fellow athlete is over-training or under-fuelling or becoming obsessive, do not ignore it or push it under the carpet until it is too late. This is my motivation for sharing my recovery. If opening up about my own experiences with disordered eating and sports helps one other person – who might be going down a similar pathway and hasn’t yet reached out for help – then sharing my story is the right thing to do

We need to break the taboo around the subject of RED-S, anorexia and sport if we are to tackle this issue head-on.

This week is Eating Disorders Awareness Week and one charity that is doing great work to build awareness, provide resources and offer support is Beat, the UK’s leading eating disorder charity. Further information and advice can be found here.

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The post Seeking help after ignoring the signs appeared first on Fast Running.

The research led by Australian Catholic University’s Ida Heikura, and a multi-institution team of academics including Prof. Louise Burke from the Australian Institute of Sport and Dr. Trent Stellingwerff from the Canadian Sport Institute Pacific, aimed to “investigate energy availability, metabolic/reproductive function, bone mineral density, and injury/illness rates in national/world-class female and male distance athletes”.

The athletes in the study were separated into groups by reproductive function, testosterone levels and energy availability. This was calculated from seven-day training and food diaries.

With many athletes continuing to open up about their experiences of the female athlete triad and RED-S, the results from the research provide alarming evidence of the link between energy availability, reproductive function, bone density and injury/illness rates in male and female athletes.

In fact, the findings reported that bone injuries were four and half times more prevalent in the amenorrheic and low testosterone groups compared with others, as well as both male and female athletes with low energy availability.

Amenorrhea

Amenorrhea is defined as the “cessation in periods for six months in a woman (whether athlete or not) with previously regular menstruation”. This was highlighted by Anna Boniface in her interview with Dr Nicky Keay on Fast Running. In Heikura’s study, they defined three consecutive missed periods as a definition.

Within elite sport, there has been a normalisation of amenorrhea, and some coaches still misinterpret amenorrhea as a (wanted) sign the athlete is training hard enough.

When both athlete and coach refuse to address the issue, the problem is only exacerbated. An athlete may fear being kicked from a team or made to reduce the training they love if they reveal that their periods have stopped.

Some coaches even cultivate the sporting environment where amenorrhea is an inevitability. The heavy pushing of the idea that ‘light is fast’ above all else, including the importance of health and consistency in training, is part of the problem.

RELATED: Female athlete health: conversation is only the start

Stress fractures, illness and long-term health complications are the consequences and certainly shouldn’t be seen as normal.

Alongside this, the team looked at the robustness of diagnostic criteria from tools used to diagnose low energy availability in athletes, including tools that help identify possible contributors to the female athlete triad and RED-S.

Looking at the results from the research it highlighted that bone injuries were ∼4.5 fold more prevalent in amenorrheic and low testosterone groups. So if a female athlete has stopped having periods then she is four and a half times more likely to suffer bone injuries. That’s a huge number.

The study also discovered that current reproductive function tests (questionnaires/blood hormone concentrations) appear to provide a more objective and accurate marker of optimal energy for health than the more error-prone and time-consuming dietary and training estimation of Energy Availability (EA).

Simply if an athlete is experiencing menstrual dysfunction, it is a very good indicator that they do not have optimal energy for health, are more at risk of bone injuries and it should not be seen as simply part of being an elite athlete.

Male athletes are also susceptible to the risk of RED-s, bone injuries and long-term consequences. But there is not as clear an indicator as the menstrual dysfunction and one wonders if the sporting world appreciates the problem is there for both genders?

Yet Heikura states that there was a “relatively high prevalence of physiological symptoms of low energy availability in both elite female (37%) and elite male (40%) middle/distance athletes”. The ~4.5 fold prevalence in bone injuries was found in both male and female athletes with low energy availability.

If RED-s is a contributing factor to bone injury then treating just the bone injury could be ignoring the underlying major issue. When complete rest is needed but ignored, then in some athletes we only see a cycle of injury, recovery, injury, recovery. Without looking at the cause, an athlete may never solve the problem.

What can we do?

As a male coach and athlete, it still feels strange to write about this subject and I am far from knowledgeable on amenorrhea, RED-s and even how to discuss the topic with female athletes. Often I will wait for an athlete to bring up the subject rather than put it forward or just awkwardly do so, probably making things worse.

Yet we all just need to talk. Talk to female athletes, coaches, researchers, doctors, anyone who might know more than yourself. I even had a great conversation with my mum about the menopause and how it might affect someone’s life, running and training. I figured if I can chat to her about it then it might be easier elsewhere.

Athlete, coach and parent education is something that Boniface herself has advocated and Heikura also realises that “educating not just the athletes, but also coaches, other team members (physios, physicians, etc) and parents, is crucial”.

The researcher added: “The athletes tend to listen to their coach more so than, say, a dietitian. Coaches can also make a massive difference in the way they talk to their athletes about nutrition, body weight/composition management, etc.”

Ideas such as athlete mentoring for those going through puberty and improved access to medical support are other key developments suggested by Boniface on in a recent post on Twitter.

In the same way that a coach should never ignore the physical impact of an athlete’s job or mental stress of family relationships, a coach shouldn’t be ignoring a major factor in female energy levels every month.

Research in the field is still young, but academics like Heikura and the rest of the team behind this study are doing excellent work. She said: “While our findings are certainly interesting and unique in this athlete population (largest cohort to date with truly high calibre athletes), similar outcomes have been reported previously with smaller sample sizes, younger athletes, and sub-elite cohorts.”

Information from apps like FitrWoman can help athletes, coaches and parents too. The app lets users track their menstrual cycle and provides personalised training and nutritional suggestions tailored to the changing hormone levels. Co-founder of the app, Georgie Bruinvels, a research Scientist at Orreco, who recently completed her PhD at UCL, is passionate about the app and said: “I really want to empower women by helping them train smarter.”

From my discussion with Bruinvels, it soon became clear that knowledge and education about the menstrual cycle can also be seen as an opportunity to really optimise your training.

“It’s not just training stress that can cause the hormonal imbalance that leads to amenorrhea, but all types of stress,” said the academic, who has run a 2:37 marathon. “Understanding the best way to train alongside your menstrual cycle is one way to reduce this and FitrWoman can help you track your period and train smarter.”

With indications from research like this that show a strong correlation between amenorrhea and the likelihood of bone injuries, as well as menstrual dysfunction being an objective and accurate measure for athlete health we cannot afford to ignore the subject.

It doesn’t need to be rocket science or something we only talk to females about. Heikura said: “When it comes to athlete education, I believe explaining (in simple terms) the importance of adequate energy availability would be more useful than just telling the athlete to eat enough.”

Having open discussion and education is the biggest step we need to take. Heikura felt very strongly that if an athlete understands the signs and consequences of low energy availability and “how this chain of events eventually has an influence on bone injury risk and training ability, they may be more motivated to pay attention to adequate energy availability”.

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The theme for the ‘ECN 6’ event on Saturday, April 21 at Athlone IT, is keeping athletes healthy and injury free.

Since bravely speaking out about her osteoporosis, European U20 Championships gold medallist Clay, who was Great Britain’s top-ranked 1500m junior in 2015 and 2016, has helped create awareness around the issue of RED-s (Relative Energy Deficiency in Sport).

Clay is determined to help other young athletes in similar situations. She is equally motivated to steadily build back her fitness and run once again, and she will tell of her experience in an interactive Q&A session.

Also speaking on April 21 are Sharan Madigan, Head of Performance Nutrition Sport Ireland Institute, Sarah Jane McDonnell, Head of Rehabilitation Sport Ireland Institute and David Harmer, National Performance Institute Endurance Coach at British Athletics.

This event is open to all event group athletes, coaches and parents and promises to be an event not to miss.

It is not solely applicable to those focused on endurance, and Athletics Ireland encourages all coaches & parents from sprints, jumps, throws and endurance to attend.

RELATED: Broken dreams: why we need to break the cycle

There are only 150 places available once full there will be a waiting list in operation.

“We are incredibly excited with the line up for ECN 6 which is generic in nature and relevant to athletes, coaches & parents in all event groups,” said Athletics Ireland’s National Endurance Coach, Steve Macklin. “Keeping athletes healthy and injury free is a priority for coaches and extremely difficult to master.

“The experts speaking at ECN 6 will help share from their experiences working in development and high-performance sport. I would encourage every athlete, parent and coach to attend this event and really gain an understanding of what it takes to keep an athlete healthy & injury free.”

A timetable for the ECN 6 can found here, and further information on speakers here. To book your place follow this link.

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Dr Nicky Keay is no stranger to Relative Energy Deficiency in Sport (RED-S). The sports endocrinologist has extensive clinical expertise in RED-S and worked as a research fellow investigating anti-doping of the human growth hormone.

A regular contributor to the British Journal of Sports Medicine, Dr Keay has talked about her own experience with RED-S. A background in ballet, she didn’t start her periods until 32 years old. This was following the birth of her two children where she finally learnt how to relax.

From both her clinical, research and personal experience, Dr Keay enlightened to me the importance of hormones for both female and male athletes.

What is the difference between the Female Athlete Triad and RED-S?

The female athlete triad is part of the RED-S continuum. RED-S highlights that there is a broader spectrum of symptoms, affecting multiple systems.

These directly impact performance. Further research is ongoing to elucidate the details in some areas, as RED-S is a relatively new concept.

However, the crucial importance of RED-S, beyond the established female athlete triad, is that by highlighting these other elements, it helps detect those without stress fractures and includes male athletes. Using the triad alone, these athletes can slip under the radar.

Potential performance effects of RED-S

Not having periods. Sounds like an advantage? Why are periods important and how can they help performance?

What makes you run faster? Training hard. We train to gain physiological adaptations. Better VO2 max, shifting the lactate curve to the right. Stronger, more efficient muscles. But what drives these adaptations? Hormones.

Abuse and manipulation of hormones are a frequent method of doping. Performance is enhanced and dependent on hormone levels. They are stimulated during sleep and recovery, which are essential for the adaptation process.

Hormones are anabolic. They are responsible for bone health, protein synthesis, tissue repair and muscle growth.

Key players include:
– Human growth hormone (IGF1)
– Oestrogen
– Testosterone

This does not advocate using performance-enhancing drugs but highlights why it is important to have healthy hormone levels.

Periods are a barometer of hormonal health

This is dependent on the balance of training, nutrition and rest.

Men have no obvious indicator of their hormonal health. This makes problems difficult to detect, although regular morning erections is usually a sign.

Careful monitoring of frequency of colds, fatigue and “not feeling right” despite rest is often a sign of hormonal upset in both men and women.

The hypothalamic–pituitary–adrenal axis (HPA axis)

The hypothalamus is your neuroendocrine gatekeeper. Integrating internal and external inputs.

It interacts with the pituitary influencing our hormones, which is essential in the body’s homeostasis regulation.

The HPA axis works on a feedback loop. Chronic stress through overtraining, under fuelling, poor sleep and excessive anxiety can desensitise the HPA axis. The stress hormones cortisol and noradrenaline cause the body to interpret a constant “flight or fight” response.

The body’s perception of safety is threatened and amenorrhea occurs.

The oral conceptive pill. Is this the answer to amenorrhoea?

The oral conceptive pill gives you a withdrawal bleed.

This is NOT a period.

Athletes are often given a false sense of security taking the pill. Essentially it is reinforcing a medical menopause and masking amenorrhoea.

Does this pill protect bones?

Oestrogen is not the only influencer on bone health. IGF1, Ferritin and Testosterone are also involved.

Research is now indicating that the pill can increase binding protein globulins which reduces IGF1 and testosterone levels, therefore impacts bone health.

It advised not to be given the oral conceptive pill for the treatment of amenorrhoea.

Amenorrhoea – what actions should an athlete take?

Primary amenorrhoea is not starting your period by 16. Secondary amenorrhea is cessation in periods for six months in a woman (whether athlete or not!) with previously regular menstruation.

Either one of these is not normal.

It firstly requires further investigation for a diagnosis of exclusion. Could there be a medical cause for the amenorrhoea?

RELATED: Anna Boniface: the “P” word

Sinister pathology must be ruled out before confidently saying its functional hypothalamic amenorrhoea. A medic should only give the RED-S diagnosis once all else has been excluded.

When seeing a GP, be insistent on further investigation or specialist opinion. Not having periods should never be brushed off as just exercising too much.

Getting periods back

Fuel in the tank – never run empty: Energy deficits for the smallest amount of time will cause problems. Restrictions within diets can play havoc with hormones even if meeting caloric demands.

– Fuel immediately on wakening and regularly through the day.
– Nail the 30-minute window for post-training replacement.
– Top up during training.
– To run fast, don’t fast. Always eat before training.
– Carbs, protein, dairy, fats – keep them good quality and don’t exclude them.

Temporary taper: During recovery of RED-S scaling back the training will help bring the body back into balance. Some even remove themselves from training completely.

– Regular rest days.
– Plan training around life commitments.
– Monitor metrics such as heart rate and fatigue scores.
– Ensure any training limitations are clearly set and are reviewed regularly.
– Avoid double days.

Destress: RELAX. This will be specific for individuals. Learning how to switch off is paramount for happy hormones and reducing cortisol levels.

Medication
– Not the oral conceptive pill!
– Hormone replacement therapy may be required.

Keeping periods whilst keeping training load

As it’s been highlighted, calories in must be equal to calories out. If this achieved, training load should not impact menstruation.

A great example is triathlete Gwen Jorgensen posting her training metrics. She demonstrates that you can be a world-class athlete AND have periods (and a child!).

– Prioritise sleep and recovery. That’s where your hormones have the greatest impact. Don’t let your training go to waste by neglecting it.
– The pill is a FAKE period. It is not bone protective and could even be destructive.
– Never run on empty. Don’t restrict, don’t fast, eat regularly and eat balanced.
– Relax – protecting the body from the flight or fight response and feel in a safe place.

Track and record menstruation like any other training metric. It’s the barometer to your hormones!

Dr Keay is chairing the British Association of Sports and Exercise Medicine Spring Conference with world-renowned speakers in the field of sports endocrinology. Athletes, coaches and health care professionals are all welcome. Further information can be found here.

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Conversations about female reproductive health in sport have definitely started – that’s for sure. Athletes, coaches and governing bodies are getting involved in raising awareness of the risks of under eating, eating disorders and prolonged amenorrhoea.

What has become apparent is that it’s not just the occasional athlete who suffers the short and long-term effects of prolonged amenorrhoea on bone health; numerous athletic careers are being hijacked by repeated stress fractures.

But we need more than just conversations and awareness. The message is definitely getting out, but it’s not necessarily getting through.

Earlier this year, body shaming was again a feature of BBC athletics commentary; inappropriate race kit continues to make more than the occasional appearance; and, if social media is anything to go by, additional ‘punishment’ miles were yet again on the menu following Christmas indulgences.

If we are to truly get on top of the issues at hand, and break the cycle of energy deficit, amenorrhoea and bone injury, we absolutely need a cultural change. The solutions are both complex and difficult to implement. There is certainly no quick fix.

What follows are some ideas on where change can be implemented to improve prevention, diagnosis and treatment.

Remove barriers in the diagnosis and treatment of eating disorders

Imagine having severe insulin and blood sugar issues, but being told that you will only be diagnosed with diabetes once your foot needs to be amputated.

Imagine having coronary heart disease, but being told that you can only be treated once you’ve had your first heart attack.

Imagine suffering debilitating depression and anxiety and being told you don’t have an issue unless you’ve made at least one serious attempt on your life.

Now imagine having such a dysfunctional relationship with food, your body and your emotions, that you have essentially stopped eating. That you no longer feel hungry. That you have become obsessed with calories and ensuring that energy output is always higher than energy intake.

That even a single slice of bread means a punishing extra hour on the cross trainer. That you’ve got so used to lying about how much you’re eating (or not eating) that you don’t even notice you’re lying anymore.

That you’ve become skeletally thin, but keep thinking that you need to lose more weight. And then imagine being told that your BMI needs to fall even further for you to receive the medical attention you need.

Eating disorders are complex mental illnesses – albeit ones which are compounded by the physiological and biochemical effects of starvation – requiring psychological treatment, and not simply solved by a visit to the nutritionist.

With denial a major feature of anorexia in particular, each and every individual who seeks help for their eating disorder, must be treated with urgency, irrespective of whether or not their current weight places them in the ‘severe’ category, or whether or not their weight loss has been drastic enough to tick all boxes for diagnosis.

Diagnosis of anorexia, in the past, depended on weight loss leading to body weight at least 15% below that expected. That has changed in recent years, and there is no set weight listed in the most recent DSM criteria for anorexia, though BMI is still often used to classify severity.

Extreme weight loss should be considered a consequence rather than a cause or characteristic feature of the illness. A mental illness shouldn’t depend on a physical outcome for treatment to begin, particularly when early intervention greatly improves the prognosis. An individual should never be told that they need to be thinner or weigh less in order to receive treatment.

Not all athletes at risk of menstrual dysfunction or bone loss have an eating disorder. And those with an eating disorder are not the only ones that require help. But until eating disorders are treated with some level of urgency – and until we stop justifying disordered eating as a normal feature of endurance running – we have very little hope of treatment in other cases.

Downgrade the role of cross training

Your life is an imbalance… you’re not eating enough… your endocrine system is under so much pressure that your periods have stopped… your bones are breaking down… your body has had enough… you’ve just been diagnosed with yet another stress fracture.

Why then is your first thought to start twice-a-day, soul-destroying, time-consuming cross training in an attempt to maintain fitness, and then to adjust your eating patterns to ensure you don’t put on a single ounce of ‘unwanted’ weight during your injury ‘layoff’.

Listening to your body? If you can’t hear its desperate screams for help, how are you ever going to learn to answer its subtle warning whispers?

Anna Boniface is one athlete who has shared her story about amenorrhoea, overtraining, under fuelling and the resulting stress fracture. Now she is progressing with her comeback and recently wrote specifically about cross-training saying: “retrospectively, I should have taken this initial period not training completely. My body was screaming for some R & R. Continuing to plough away, I was still in that energy deficit, stalling my recovery.”

This is not to say that cross training doesn’t have its place.

In fact, it could play a much bigger role than it does in adding variety and reducing impact in the regular training programme. It is vital in the return to training after injury, and, in some cases, it can allow individuals to overcome a badly timed injury and keep dreams on target.

It can allow athletes to keep their head ‘in the game’ during times of injury, and some level of maintenance is good. But, as Katie Kirk, among other athletes, has recently discovered, it’s not the be all and end all!

In fact, you may later come to resent all that extra time you’re spending in the pool and on the cross trainer. And this can leave you more likely to throw in the towel altogether the next time you get injured.

Perhaps it’s not just your bones that need a rest – your mind may benefit from some downtime too. Use your injury time to do the things that you never have time to do. And if you get some space away from running and gain a little bit of weight along the way, then maybe that’s a good thing. Listen to your body!

Ensure that there is a structured referral process

Even if you’re really clued up on the causes and consequences of undereating and menstrual dysfunction. Even if you can spot and raise issues, and even if you have an open relationship with your athletes.

You can still feel desperately hopeless when faced with an athlete who reports that they have not yet started their periods or are having real issues with food and body image.

That is not your fault. I did a PhD on the subject, know pretty much all I ever want to know about the endocrinology of the female reproductive cycle and the biochemistry of the bone remodelling process. And even I’m still not sure what the next steps are when faced with an athlete suffering from some or all the elements of the Female Athlete Triad/RED-S. We are all hopelessly unsure what to do. That, above all else, needs to change.

The issues leading to our communal sense of hopelessness are multifactorial. The logical next step with primary amenorrhoea, for example, is to send the athlete in question to see their GP where underlying issues can be ruled out.

But in many cases, the doctor will then say that there is nothing physically wrong; that the lack of periods is due to their training load, and that amenorrhoea is ‘normal’ for athletes.

Common, it may well be, but healthy it definitely is not. Worst case scenario, the athlete is sent away and told not to worry about it.

The best case scenario is they are prescribed the pill – a bit like sticking a small plaster on a 6-inch laceration – told to consider calcium supplements, and possibly sent for a DEXA scan.

In this situation, and especially if it’s a whole body scan, the results may be normal, not just because the issue hasn’t got that far yet, but because whole body scans can mask underlying issues in trabecular bone (the spongy bone where the real problems lie).

Addressing the cause

Treatment needs to start addressing the causes, not just deal with the consequences. Whether or not low body mass is considered an inevitable feature of the endurance athletes, the energy imbalance should be addressed. Menstrual function should be restored. And every effort should be made to increase bone mineral density to normal age-matched levels. But all this takes time. Time which an athlete doesn’t ever believe they have. But the alternative is far bleaker.

When an athlete seeks medical help, they shouldn’t accept a quick, sticky-plaster, solution. They shouldn’t be told that what they are going through is a normal consequence of sports participation.

They may well have to fight for the support they need. And in many cases, the medical support required may lie outside of the public health service. Their fight would be immeasurably easier if a list of suitable practitioners was available, and not just of NGB sports medics which a select number of high-performance athletes have access too. But also other practitioners – dietitians, nutritionists, psychologists and counsellors – who will help in their return to help.

Education and research have improved greatly in recent years, and a lot more is known about treatment than a decade or two ago. It’s time now to put the final jigsaw pieces in place.

RELATED: Broken dreams: why we need to break the cycle

Make Long Term Athlete Development something more than a romantic ideal

We talk about Long Term Athlete Development. We know what it is, we understand the importance of it, and we like the idea of it in theory.

In practice, however, we continue to push athletes too young, entertain their ideas of trying to qualify for every international championship going, and cut the end of season break short to get ready for the next major championship, which is only ever a few weeks away.

We’ve become obsessed with endurance, without any consideration for age appropriateness, and uncovering the next child star. We behave like the next big competition is the only one left in the life of young athletes, and we are so desperate for success that we attach the same glory to underage medals as we do to senior success.

Then we place clearly unhealthy young athletes on the front covers of our athletics magazines, where the image a lot of their aspiring peers see, is that in order to win, you need to be thin too.

That’s not to say that we shouldn’t encourage competition at a junior level, that we don’t get excited about junior records, nor that we discourage aspiration. But underage success should never come at the expense of developing the skills and capacity for success later in life, or, more importantly, at the expense of future health.

Junior competition should ultimately be a stepping stone along the way, not a destination in itself. It should be about getting an athlete to the best possible position to train at a senior level, without draining them of their physical and psychological reserves. Athletes should be gliding into senior competition, ready to up the ante, not reaching 20 already drained of their physical and psychological reserves.

There’s no doubt but that Olympic champions are constantly pushing the limits of human health and performance. But in most cases, they are fully grown adults who have a sound training base, built over a long period of time.

Their health matters too, of course, but there’s a big difference in pushing the limits for a few years in your twenties and depriving a teenager of reaching peak maturation.

In many ways applying long-term athlete development requires guts.

It definitely won’t make you popular in the short term. But taking a long-term approach will, absolutely, help prevent many of the health issues faced by young endurance athletes. It’s time to start putting ideology into practice.

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