I have never really considered myself to be a "proper" runner, still less an athlete. Don't get me wrong, I am in awe of those that have the commitment and determination to put themselves through the mill by training really hard, being strict with their diet and sacrificing a lot of their "social" life, but I see myself as more of a fun runner....running for the love of being outdoors, being fit, and discovering new cafes to run to "just to check out their cake selections". I would look at some (rather) slim runners and wonder how they had the energy to do what they did and why they didn't break. I honestly never expected to be one of those "broken" people. However, a nonhealing stress fracture, a DEXA scan showing osteopenia and a diagnosis of RED-S made me take my head out of the sand and investigate further.
I feel like I have been talking about RED-S for a while now, but I fully admit that when I first heard of it (ie when I was diagnosed with it) I did not know much about it. It is good to raise the profile of this condition as a lot more people are affected by it than realise it, so spreading the word is vital for diagnosis and treatment..
On chatting to a friend last weekend, she admitted to (very sensibly) googling RED-S when I mentioned the condition, but other people seem to think I'm talking about anaemia and red blood cells, so I thought I'd give you a little bit more information about it.
RED-S is a condition caused by low energy availability, where nutritional intake is insufficient to cover the energy demands of both exercise training and normal physiological function.
Unintentional low energy availability can arise with an increase in training load not matched with an appropriately timed increased of nutritional intake or an underestimation of energy expenditure from exercise outside of training schedule, for example active transport (eg cycling) to/from training sessions, study or work.
Intentional low energy availability is more prevalent in sport where low body weight confers a performance or aesthetic advantage, eg endurance running, cycling, dance, gymnastics.
The Relative Energy Deficiency in Sport (RED-S) model was first described by the International Olympic Committee in 2014, and published in the British Journal of Sports and Exercise Medicine. Prior to this, there had been a lot of research in female exercisers, with what was known as the female athlete triad (low energy availability, menstrual disruption and impaired bone health). It is now recognised that this triad is a clinical spectrum, reflecting varying degrees and time scales of energy availability, menstrual function and bone health.Energy availability can range from adequate, with healthy eating patterns matched to requirement, through to low due to disordered eating and severe energy deficit with an eating disorder involving a psychological aspect. Menstrual functional can vary from regular menstruation, to lack of periods (amenorrhoea) and bone health from normal for age, through to weak bones (osteoporosis). The female athlete triad model evolved into the RED-S model as growing evidence showed that the consequences of low energy availability can affect males as well as females, and at all ages and levels of exerciser from recreational to elite.
Presentation
- RED-S involves multiple systems and hence bone stress injury may not necessarily be the presentation; particularly in acute low EA and/or in non-weight bearing sports.
- Recurrent illness, fatigue, athletic underperformance and psychological issues rather than injury can be presenting features.
- In young athletes, RED-S may present as delayed puberty, fall off growth centiles for height and/or weight
- In any woman of reproductive age in the absence of pregnancy, whether exercising or not, if menstrual cycles are not regular then this requires medical investigation, as RED-S is a diagnosis of exclusion. The Royal College of Obstetrics and Gynaecology (RCOG) defines primary amenorrhoea as no menarche by 16 years of age, secondary amenorrhoea as cessation of periods for >6 months in a previously regular menstruating woman and oligomenorrhoea is defined as less than 9 cycles per calendar year. this does not include withdrawal bleeds from hormonal contraceptives.
- The equivalent of normal menstrual cycles in men, is morning erections indicating reproductive endocrine axis function with adequate testosterone levels.
- Athletes with RED-S may first present with injury to a physio, eg a bone stress response, including stress fracture typically of the lower limb/pelvis.
- Recurrent soft tissue injury could also be a presenting feature of RED-S.
Management
Drugs are not recommended as first line management in amenorrhoeic athletes. Oral contraception (OCP) masks amenorrhoea with withdrawal bleeds. OCP does not support bone health and indeed may exacerbate bone loss by suppressing further IGF-1 (a growth factor). Although transdermal oestrogen, combined with cyclic progesterone does not down regulate IGF-1, any hormonal intervention cannot be a long term solution, as bone loss will continue if energy availability is not addressed as a priority.
So clearly, the mainstay of management is to deal with the energy availability imbalance in terms of increasing the intake/type of nutrition or decreasing the expenditure, or a combination of both.
And finally, re me...
As for myself, I naively thought "it could never happen to me" as I've never restricted my diet, love my food, have a normal BMI and although I love running, I've never taken my training that seriously. Yes, I became amenorrhoeic about 6 years ago, but I hadn't lost really lost weight or increased my training. I do remember going away for a few days with a group of running friends at this time, but I wasn't actually running at the time as I had PF (I was helping time their sessions instead), but even so, after eating meals with all of them, I found I was still hungry and so I would go and eat extra food by myself in my room. I guess this shows that I wasn't getting enough nutrition, but I didn't realise what longterm damage might be occurring. I've previously had horrendous problems with my menstrual cycle, having been admitted to a gynae ward while a junior doctor due to pain and heaviness so I was actually happy when they seemed to stop. Since the stress fracture and the DEXA scan, I have done a lot more research on the matter and now realise that I need to be "healthier". I've been told that my fracture may never heal, but at least I have managed to treat the RED-S with a combination of eating (even more than before) and a total break from any exercise. I am no longer amenorrhoeic (humbug to remembering how horrendous periods can be all over again) and am now teaching myself that I am not so much "heavy" as "healthy"......onwards and upwards...and if I can help others learn more in advance of having to deal with fractures and osteopenia then I've achieved something!
http://health4performance.co.uk/
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