Science Mama

My vein ripples out like a mountain thrusting itself through the earth. Bold and readied as the needle slips its way in, a secret tunnel where the secrets of my blood lie in wait. The phlebotomist, Joseph, jokes to me, “Your left arm is always a winner.” He quickly fills the six color-coded test tubes on the sterile metal tray. I’ve seen Joseph eight times in the past year. A series of tests following a year of having my hormones plummet and losing my period all together. My weight has dropped with pace. 120 lbs..115 lbs..110 lbs. It wasn’t until I recently shared my condition with my local running group that I began to have answers.

RED-S (Relative Energy Deficiency in Sport) was previously known as the Female Athlete Triad— a condition in female athletes marked by three specific disorders— disordered eating, amenorrhea (loss of menstrual cycle), and osteoporosis. Over the years, though, experts expanded the definition to include males as well as more factors than just bone and reproductive health. Under the RED-S definition, an athlete who is overworking and under fueling can succumb to various deleterious health outcomes such as excessive fatigue, reduced performance, metabolic rate, immunity, protein synthesis, cardiovascular health, and gut issues (IBS), musculoskeletal injuries, and mental health changes.

It’s been a numbers game. Daily workouts lasting 2-3 hours. Striving for 800 calories per day. This has been my regime since the pandemic. In a time when I lost control of my world, I obsessively started to control my body. Silently counting the calories before each meal, a hushed prayer I would deliver under my breath to keep faith when the world was falling apart. I’m not alone; a team of researchers at Oxford recently revealed that eating disorders have increased by 15% since the onset of the pandemic. Though, many times the patient is unaware that they are under fueling to compensate for lost calories. Undereating is not always on purpose, but rather a result from increased exercise.

           I recently reached out to one of the leading experts in the field, Dr. Madhusmita Misra, chief of pediatric endocrine at Mass General Hospital and professor of pediatrics at Harvard Medical School. Dr. Misra explains that one of the reasons she became interested in the field was that her prior research in anorexia nervosa hinted that many females who suffer from eating disorders also tend to be athletes.

            I can attest to this. In my early twenties, I was a competitive cyclist. There was a massive emphasis on “race weight”. Cyclists would do anything to shave off a few grams from their bike. Young cyclists, stretched in bright Lycra, swearing that even those few last grams will make or break your ride. In my late twenties, I transitioned to running where a similar mindset echoed. As I became more serious about my race time, I took a deep dive into prevailing theories. 

Given the emphasis on younger females and stress fractures, I couldn’t conceive the idea that I could be suffering from the Female Athlete Triad. Most research has focused on a younger demographic, and thus there isn’t a ton of material that is geared toward women past their teens. I’m a 34-year-old female that looks to be at an average weight. The first few physicians I saw didn’t even think to ask me about my physical activity and eating patterns when my hormone levels went awry, and menstrual cycles ceased. It was only after digging into the RED-S diagnostic criteria and voluntarily offering up the tidbits about my lifestyle that the pieces came together, and my doctors traced the symptoms to be due from under fueling and over exercising. “Oh sure, lots of running and a limited diet would explain your test results,” my endocrinologist now tells me. My general practitioner and gynecologist echoed the same sentiments. Despite visiting their offices about the issue for the past year, none had taken the initiative to ask about my diet and exercise. It wasn’t that I was deliberately withholding information— I had up until that point just considered my training and diet normal.

Intermitting fasting has been all the rage for the past few years. Arguably, for good reason. As someone who had a background in health science, I appreciated the data on what periods of fasting can do for the body. Unfortunately, most human trials have yet to be conducted on athletes. Despite this, health fanatics have been hyping the results and taking it to the extreme. Ultra-runners now swear by running 30-40 miles while in a fasted state. Many influential researchers from Stanford, Harvard, and other prestigious universities are touting their fasted workouts all over social media. Pair the fasted idea with a ban on gluten, dairy, and an overall highly restrictive diet, and calories start to diminish quickly. I began intermittent fasting on top of a loaded workout. Often, I would come back from a 12-mile run and eat a bowl of kale with some tofu thrown on top and call it a day.

                I’m not the only RED-S case to be overlooked. There is no current diagnostic criteria or guidelines around screening. A physician must suspect energy deficiency in the patient to even consider RED-S. The issue is that most assume that one would need to be an athlete or appear underweight, but research has shown that RED-S occurs in those with a normal BMI as well as the recreational athlete. Dr. Misra emphasizes this point, “Low body weight is not necessarily an indicator. Because, as we know, women can be very athletic and then have a calorie deficit and still hold or have a normalized body weight.” The only issue that needs to be present is for the scales to be tipped; significantly more calories (energy) are burned up than replaced in the body. In this scenario, the body shut down non-essential functions to conserve energy. In women, this process typically begins with the reproductive system. 

            Once a diagnosis of RED-S is reached, it is paramount that recovery begins promptly and in the right hands. I reached out to Kylee Van Horn, RDN, and founder of FlyNutrition, to understand what recovery looks like. “The interesting part about red s is that no one’s journey is going to look the same because of how complex it is. [We] need to figure out number one, what systems of the body are being affected? Then, what are the main factors contributing to RED-S, because it could also be stress related. When I say stress, it could be exercise, but also outside life stresses too. Lastly, The relationship to exercise, such as over-exercise or using exercise as a coping mechanism.” Without intervention, RED-S can cause low bone density, early onset osteoporosis, decreased immunity, GI disturbances, and cardiovascular issues. Even with help, recovery is slow. The only indication that my efforts have been paying off are from blood tests indicating I’m trending in the right direction. Van Horn echoes the importance of not losing hope. “Being in close communication with an endocrinologist is helpful because you can do regular hormonal tests to see where you’re at in the process.”

               The lab results from my latest blood draw come back and I can feel my muscles tense in my neck as I log in to see the numbers. As they load, I feel a wave of desperation roll over me. My hands twist over one another, rippled skin that has leathered with too many years out running under the sun. The numbers pop up, and once again, there I am, points on a graph. After reducing my workout load for the past few months, my results are beginning to trend in the right direction.

Maybe we’ve relied too much on numbers. Or maybe, numbers have become our only guarantee of safety, of resolution. Where qualitative data has left us searching for answers, quantitative data began to fill the void. If we could just know the percent of positive covid cases in our community, we can begin to resume normal life. If we could only reach that targeted BMI, we would surely avoid our early demise. So, we monitor. We attach trackers to tell us how much progress we’ve made towards a magic number that promises security. There isn’t a magic number here for the perfect amount of energy in vs. energy out. Dr. Misra reminds me of the high amount of variation between people. “My own feeling about this is that everybody has their own setp oint and that you need to meet your set point for energy availability.”