RED-S: One Athlete’s Story

March 5, 2021

LAST UPDATED March 4, 2021

The words no athlete ever wants to hear: “Indefinite leave from racing and training…”

Disordered eating and eating disorders in sport have alway been a problem, but shame and stigma means they are rarely discussed. The global pandemic has unfortunately led to an increase in the number of children and adults struggling with their eating, because as the surrounding world has seemingly spiraled out of control, what we are putting into our bodies is one thing we do retain control over.

As cyclists, we like to push ourselves hard, to eek out every extra watt, and with that comes a desire to seek improvement any way we can, to constantly strive to be better and better, to find new ways to make marginal gains. This leaves us more vulnerable to developing unhealthy habits around our eating.

Zwift racing has been an absolutely fantastic tool for cyclists around the world during the pandemic, but sharing my story in my club WhatsApp group brought home the stark reality that it’s not only those of us competing in the premier league who are acutely feeling the pressure surrounding our weight on the platform. This prompted me to want to share my experiences here in the hope that it may help others from becoming as ill as I have in the past.

Struggling Again

A link to the first article in the recent Zwift insider series ‘Extreme dieting in virtual cycling’ dropped into my messenger inbox just as I was about to get on the bike to start my warm up for the final round of ZRL Premier League Season 2. The race should have been one of excitement and celebration for me, with my team set to complete a remarkable second clean sweep of team wins in the series. The perfect score!

But just like the previous weeks, I was struggling to get myself on the trainer. The enthusiasm I had felt in the first 6 weeks of ZRL season 2 had totally vanished, and unusually for me I was longing for time away from the bike. The red flags were there and I knew I was now in the crucial window to act before I became very ill again, a fact confirmed by a blood test result I received the following day. The intensity of Zwift racing and the pressures to constantly live up to expectations had seen me slip into unhelpful eating and training habits again, and it was time to reassess if I wanted to avoid repeating history and instead be able to participate in Season 3.

RED-S and Running

RED-S stands for ‘Relative Energy Deficiency in Sport’. In short, you are not replacing the calories that you are expending during exercise. RED-S can be caused by intentionally restricting calories, but crucially it can also be caused by not eating the right foods or at the right times.

I’ve had knowledge of RED-S for a long time. I was first diagnosed with it as a 20-year-old runner, except then it was known as ‘the female athlete triad’. I was competing at international level and thought I was eating well, but my judgment was clouded by my recent recovery from severe anorexia. Overtraining combined with under-fuelling had led to amenhorhea, putting me on the brink of osteoporosis in my early 20s. A series of stress fractures and other joint injuries rapidly ensued, and my elite sporting career was over before it had barely started.

Misunderstanding and poor knowledge around the condition led to several years of me battling to return to running, only for my body to break down every time I got close to being ready to race again. Eventually I had to accept my bones were not going to let me run fast anymore and I switched to cycling.

Spinning Up, Spinning Out

Similar to in my running career, it wasn’t long before I was competing at a National level in cycling, and in 2017, 3 years after I’d started racing, I broke the National 100 mile and 12 hour records, and won multiple national time trialling medals. As the season ended, time and time again, I was told that it would be impossible to better what I’d achieved that year. I was determined to prove the doubters wrong though, and buried myself in training that winter.

Meanwhile, I was undergoing huge upheaval in my personal life and also facing an incredibly stressful and challenging time at work. My training, though, was the one constant and it was where I could escape. It became the one thing I prioritised above everything else, and that’s where I fell into the trap once more.

Fast forward to March 2019, and if I’m honest with myself, I knew I’d been on borrowed time for months; cycling had become a chore rather than a passion. I resented having to get up at 5am to fit training in before work, and all my enthusiasm for racing had gone. I was training harder than ever, but my weight was creeping up and my power was dropping. I was constantly tired and I’d grown to hate the sport I used to love. My performance was dropping off a cliff edge and I didn’t know what to do, so I took a biomarker test which revealed a very disordered hormone profile.

I was offered a private consultation with one of the doctors who analysed the samples, and keen not to lose the hard work I’d put in over winter, headed off to an appointment. Despite knowing I wasn’t right, the verdict was not what I expected to hear. “Indefinite leave from racing and training. You are in a state of RED-S and your body needs to heal.”

As I sat across the table from two experts in the field, tears streaming down my face, I struggled to comprehend how I was back in the same place I’d been nearly 15 years earlier. I wasn’t underweight and I wasn’t consciously dieting so this time it didn’t make any sense to me!

How It Happened

In 2018, I was so focussed on fitting my training in and living up to (unrealistic) expectations at work that I was forgetting to refuel properly after training or racing. I’d be up at 4:30 or 5 am to train, have 15 minutes to shower and change, rush into work and then due to being called in all directions at once, often not eat anything substantial until I got home over 12 hours later. Many days I was so tired when I got home that instead of cooking I would substitute healthy, nutritious meals with a bowl of cereal or a sandwich.

For months I sustained an elite training regime on this. I even broke 3 more national records and defended both my national titles, but the cracks were appearing and crucially I ignored the warning sign that my periods had become very irregular again. I just didn’t want to admit anything was wrong.

Sharing My Story

When I finally crumbled in spring 2019 and received that second diagnosis of RED-S, a cloak of shame enshrouded me. I remember saying to the doctors “But I can’t talk to the people I’ve been riding with, they won’t get it.” I was taken aback by the reply: “You may be surprised to hear this, but the majority of my patients are male cyclists. It’s hugely prevalent in the sport.”

As I started to process my diagnosis, I realised I now had a choice: disappear from the sport and hide away whilst I recovered, or speak up about my struggles, and perhaps help others from slipping into a similar hole.

In the following days I shared my story to social media, and was contacted by numerous riders who were seeing similar warning signs in their own lives. Some were doing too many fasted sessions like me, others were training in the evening after a busy day at work where they’d skipped lunch, or forgotten to consider how much energy the commute would consume. Sharing my story had now prompted them to be more mindful of how important a part of training nutrition is.

Enter Zwift

When I first joined Zwift shortly after the COVID lockdown hit, my body had finally started to recover and for the first time in 2 years I was feeling energetic and healthy. It was only a week before the impact of my weight on race results was jumping out at me though, and I’d be lying if I didn’t say there were immediate thoughts of decreasing my weight. The chronically-elevated cortisol from the RED-S had seen me gain weight and now every time I raced on Zwift, I was reminded of this and how much bigger than most of the other riders in my category I seemed to be.

But I’d just spent the last 12 months working really hard to get the condition under control, and I didn’t want to break my body again as my metabolism was just starting to reset. My weight did drop slightly in my first few months on the platform, but having spoken openly to my coach, I had things under control and the weight loss was underpinned by healthy eating and the benefits of working from home allowing my body to finally reach a stable point and recover from the RED-S.

High-Pressure Zwifting

Before long I was ‘picked up’ by a team and thrown into a higher level of Zwift racing. Other riders immediately began sharing the strategies they would use ahead of a race series and to ‘get their weight down’ prior to the video submission on race day. I’d convinced myself I was strong enough not to give into the pressures, but that all evaporated with my first ‘pro-am’ race series in August 2020.

Race 1 went brilliantly but in race 2 I was dropped on the steep climb in New York and I couldn’t help but notice that I was one of the heavier riders in the race. I restricted my eating, shifted some weight, and got better results in the last two races; destructive positive reinforcement at its best. I didn’t feel good in myself though, and luckily there were no more invitational races on the horizon so I was able to reset and stabilise.

Both ZRL seasons have seen me slip again though as the weeks progressed and this week it hit home that I need to be more honest with myself and my support network in the sport if I want to succeed long term. There’s no getting away from the fact that w/kg are important on Zwift and ultimately what wins most races. The weekly weigh-ins, though necessary for validity, also create stress for riders. I know I’m not alone in my double takes about my food choices during the premier league race season, and whilst I am not calorie counting or intentionally trying to lose weight, I am spending the weekend being over-mindful of what I eat in case it makes my weight go up. That has been enough to result in unintentional under-fuelling and a drop in my performance, but also more crucially it destroyed my ability to enjoy racing.

When I reflect on my recent race results, the stand-out ride of this season for me was in race one, off the back of a period of not worrying about my weight, eating better, and at my highest weight of the series.

Moving Forward

So how do we move forward in the world of Zwift racing? I fully understand that Zwift started life as a computer game, but the success of the platform means that it is rapidly developing into a bona fide sporting discipline. It would not be fair to say that Zwift causes disordered eating; not everyone on the platform develops issues surrounding food and their weight. But there are aspects of the way competition is run that definitely contribute to such problems.

If Zwift wants to continue to develop as a sporting platform, I’d like to see them take some more proactive steps towards supporting healthy eating:

They already run several excellent event series where pro athletes and experts in the sport share their training advice, so let’s see some on nutrition.
Providing educational resources for team managers and athletes to enable them to spot the early warning signs would be incredibly helpful too.
I’d also like to see the weight column removed from Zwift Power. I don’t understand why it is there, and to me, it only serves a purpose to allow riders to compare themselves to each other in an unhealthy manner. Yes, weight could still be calculated from the race data, but it wouldn’t be so obvious. For sure, the highlighting of the lowest and highest weights on the startsheets and results definitely needs to go.

We also need to take more responsibility ourselves as riders and not be tempted to succumb to the entirely permitted measurements of weight cutting ahead of races, or in the community leagues, the widely-adopted practices of intentional weight-doping. If we are struggling we need to reach out to our friends and family for support. Each and everyone of us can play a role in combating this growing crisis in the sport.

Are you suffering from RED-S?

It’s far easier to spot an energy deficiency arising in women than it is in men, as a irregular or absent periods are a key sign that your body is not functioning properly. There are many other warning signs that appear in both men and women too, though:

Increased fatigue
Tendency to overtrain or difficulties taking rest days. This can include preoccupation with targets such as power, duration or speed.
Recurrent injuries or poor healing from injuries. Bone health is particularly at risk so stress fractures or ‘easy’ breaking are coming
Poor thermoregulation e.g. feeling cold on warm days or ‘overheating’ very easily
Disrupted sleep patterns
Fear of food and weight gain including anxiety around meals and/or irrational, restrictive, or obsessive behaviours
Weight loss
A sluggish digestive system including constipation and bloating
Poor performance and difficulty adapting to increased training load
Very low or high resting heart rate
Morning erectile dysfunction
Changes in mood including increased anxiety and depression

The long term consequence can include osteoporosis, permanent infertility, cardiac arrhythmia, or even heart attack.

Some practical advice:

Be honest with yourself. It’s extremely easy to make ‘excuses’ in our sport: ‘But it’s a hilly course, I need to lose weight…’ / ‘I’m training for a long distance event so I need to do those extra miles…’ / ‘I got home from work too late and had to train late so I didn’t have time for proper dinner…’ / ‘My dietary requirements mean I can’t eat here, I’ll get something later…’, etc.
Don’t be fooled by your own body – notice and recognise changes in your physical and mental health. My body ‘coped’ for a long time. I’m pretty sure I spent most of 2017 in this state. I KNOW I spent all of 2018 not fuelling or recovering right and I was still able to excel for a long time. It all unraveled catastrophically in the end though.
Look out for each other. If you’re worried about someone, have a conversation and just generally check in to see if they are okay. Try to avoid talking about the benefits of weight loss and focus instead on the benefits of health.
Avoid preoccupation and frequent discussions about weight and body composition. We’re all unique. The only ‘right weight’ is the weight your body wants to be. Everyone’s weight fluctuates naturally, even more so if you’re female.
Reduce levels of expectation and pressure where possible. Try to focus less on race results or power numbers and more on enjoyment. That doesn’t just apply to our personal goals but what we project onto others.
Stop obsessing over the numbers – kilograms, watts, miles, minutes, hours, seconds. They don’t define who you are or act as a measure of your worth.
If you’re worried, speak to your GP or other medical professional, but don’t panic or be dismissive if they don’t get it. Take a read of the websites below and take a listen to the podcasts (you may be surprised to hear pro cyclist Charlie Tanfield suffered too).