Episode 160: Welcome back to Real Health Radio. Today's guest is Charlotte Gibbs.
Charlotte Gibbs is an ultra-distance runner whose relationship with the sport has not always been healthy. After suffering from a succession of stress fractures and amenorrhea, she was diagnosed with RED-S in January 2019. Since then she’s been trying to learn as much as possible about RED-S in order to discover a better way of being an athlete and to try to educate others who are at risk of making the same mistakes.
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Chris Sandel: Welcome to episode 160 of Real Health Radio. You can find the show notes and links talked about as part of this episode at www.sevens-health.com/160. A couple of times a year I take on clients. Client work is the core of my business and the thing I actually enjoy the most. And after working with clients for the last decade, I feel confident in saying I’m very good at what I do.
And when I reflect on the clients I’ve worked with over the last couple of years, there’s a handful of areas that come up the most. So one of the biggest is helping women get their periods back. So recovery from hypothalamic amenorrhea or HA, and this is often a result of under-eating and over-exercising and is almost always coupled with body dissatisfaction and a fear of weight gain. So the work with these clients as is really the same with all clients is a mix of understanding physiology and how to support the body, but also being compassionate and understanding psychology and uncovering the why’s behind these client’s behaviour and figuring out how to change this.
I’ve even had a client regain her period after being absent for 20 years after being told it would never happen again. I also work to help clients who are disordered eaters or who have previously been diagnosed with an eating disorder. And with these clients, there are symptoms that are commonly occurring. So water retention, poor digestion, always cold, peeing all the time, often waking multiple times in the night and no period or bad PMS symptoms, low energy, poor sleep, low thyroid.
There’s also like mental and emotional symptoms that they have. So a compulsion to exercise, a fear of certain foods, anxiety, low mood or depression, poor body image, fear of weight gain. And with these clients, it’s using that same mix of understanding science and compassion to help them recover. And I know that for recovery as possible. And I’ve had many clients who’ve had multiple stays at inpatient facilities where nothing has worked, but they’re able to get to a place where they are now fully recovered.
The final area is helping clients transition out of dieting and learning to listen to their body. So they’ve had years or decades of dieting and nothing works. They know that it’s a failed endeavor, but they struggle to figure out how do we, without dieting, how do they listen to their body? What should they be eating? Like they are just really confused. And with this work, it’s often a combination of intuitive eating, a non-diet approach, my nutrition understanding and being able to go and being able to guide clients towards listening to their body that then helps them put an end to their dieting habits and truly understand how to nourish and look after their body.
So these are the kinds of clients that make up the bulk of my practice and I’m very good at helping them get to a place with their food and with their body and even with their life in general that they think is impossible. So if any of these scenarios sound like you and you’d like help, please get in contact. You can head over to www.seven.com/help and there you can read about how I work with clients and you can apply for a free initial chat. The address again is www.seven-health.com/help. And I’ll also include a link to that in the show notes.
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Welcome to Real Health Radio health advice that’s more than just about how you look. And here’s your host, Chris Sandal.
Chris Sandel: Hey everybody, and welcome to another episode of Real Health Radio. So this episode is actually going out a day later than usual. Ramsay was sick last weekend and then I caught what he had. I spent a good chunk of this week holed up in bed. I’m someone who gets ill probably like a couple of times a year but it’s always intense and acute when it happens. So for 24 or 36 or 72 hours, I’ll be in a bad way and then I get better and I’m all done. There then might be another day or two after that, or I’m a little tired, but it’s normally over pretty quickly, but it just really knocks me down when it is going on. So that has really messed up my schedule this week. But I’m now feeling better, so that’s good. And hopefully, I’ve now got my sickness out of the way for the next six months or so, if it follows the usual pattern.
The other bit of news on a more positive end of the spectrum is that I finally have a new website. So this has been long overdue. My old site has needed a complete overhaul for literally years, and I’ve just never seemed to be able to get round to doing it. The new site process actually started back in November time of last year.
But it was also focusing on branding as well as the site, which explains the long process. We’re now figuring out Instagram and Pinterest and Twitter. So I’m going to finally be getting across all these social media platforms properly in a way that I really never done before. This is going to be a new podcast, be a new podcast image coming to and there’s also going to be transcripts coming for the podcast. So the functionality is now in place on the site, which is awesome.
So it will initially start with the new episodes and just go forward from there. It’s not this one, but we’ll start soon and then we’ll be working back and doing all of the previous episodes. But that’s going to take some time because being at 160 episodes with each episode being an hour or more, this is a rather monumental task.
But it is something that people have asked for, for a long time. And so it is finally going to happen. Yeah, I really like the new site. There’s bound to be bugs and glitches. And I’m feeding these back to the developer as and when I find them. But I liked the branding. I like the aesthetic, I liked the functionality. So yeah, when you get a chance, please go over to the site, check it out, and let me know what you think.
So yeah, that’s it with the housekeeping part of it and let’s get on with the show. So today I’m chatting with Charlotte Gibbs. So Charlotte is an ultra-distance runner and coach whose relationship with sport has not always been healthy after suffering from a succession of stress fractures and amenorrhea. She was diagnosed with RED-S in January this year and since then she’s been trying to learn as much as possible about RED-s in order to discover a better way of being an athlete and to try and educate others who are at risk of making the same mistakes.
In addition to RED-S, her interests include sports, nutrition, athletic performance, body image, and exercise physiology and specifically the psychology of exercise compulsion and over-training. And she blogs at impossiblehighways.wordpress.com.
So Charlotte is someone I’ve had on the show before. So back on episode 94 when her surname was Goodall at the time. And I wanted to bring Charlotte back on because of the work she’s doing around RED-S, which stands for Relative Energy Deficiency in Sport. If you’ve never heard of RED-S, like don’t worry, we will cover exactly what it’s all about in the podcast. And by the end of the show you will know a lot about it. But if you are someone who has a tendency to over-train or to under-eat or to eat clean then you definitely want to give this one a listen.
And we cover a lot in the show. I think this is the longest interview I’ve done. We define what RED-S is and why it is now replaced the previous ‘female athlete triad’. We look at is there a difference between overtraining syndrome and relative energy deficiency in sport? We talk about energy availability throughout the day and how this affects health.
There are many systems of the body that are affected by relative energy deficiency. So we talk about many of them for things like reproduction and bone health and thyroid function and immune function and psychological health. We talk about the pressure on athletes to look a certain way and how disconnected this can be from actually helping their performance and about the recent Nike controversy because they have the audacity to make clothes in bigger sizes and have bigger mannequins where those sizes we go through the difficulty of overcoming RED-S in the current system because there just isn’t enough focus on the psychological component.
And Charlotte also shares her story about her own struggles with overtraining and disordered eating and RED-S she is someone who is still on the recovery journey and you can hear this in her comments and she talks about some of the places she is still struggling with.
And some parts of this are more specific for athletes or elite athletes or at least that’s how certain sections of the conversation have framed and given Charlotte lives in that world. And we’ll be sharing this with people in that world. She does talk about things through that lens and is always happy to keep it at that level. But there is nothing that we talk about that isn’t appropriate across all levels. So whether you’re training for the Olympics or you’re a person newly entered into the exercise world, RED-S can still be a thing that is important to know about. It does get a little scientific and into the weeds in parts, but hopefully it’s still easy enough to follow along with even if you have limited science or physiology background.
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It was interesting. There’s a point in the conversation where Charlotte mentioned that she thought that the most elite of athletes are probably more sheltered from succumbing to RED-S or exercise addiction because they have coaches in place and they have checks and balances in place that are on the lookout for these kinds of thing.
And I actually pushed back against this idea as I don’t think this is true and while we’re chatting, the person that actually came to my mind instantly is Amelia Boone. So Amelia is someone who I first came across and became aware of through Tim Ferriss’s podcast. It was probably two or three years ago. She does Spartan and obstacle races and has won many of the toughest and most brutal races. There are like 24-hour obstacle races. She might not be as well known around the world, but I believe she’s fairly well known in the US and when she was on Tim’s podcast, there was something about how she talked about training and her philosophies on life that just raised red flags for me. And I think she was out injured at the time and was trying to come back into the sport. So I started following her and over the last couple of years, she’s just had one injury after another.
And again, this raised red flags for me, but the reason I didn’t mention her at the stage that we were recording the podcast was that it was only speculation. I had nothing to back up my assumptions. So it didn’t seem fair to cast aspersions on someone when I had no way of knowing if I was correct.
Well after recording this podcast, Amelia’s now come out and shared that she is currently in treatment for an eating disorder. She talks about the fact that she was first diagnosed with anorexia at age 16, and she had her first hospitalization at this age and then throughout the rest of her schooling and through college, she was in and out of various treatment centres. And interestingly, whenever she was interviewed on various podcasts because she started being on many different podcasts, she always talked about picking up exercise in her mid-twenties.
Like it was something that she just wasn’t interested in until later in life. But what she didn’t mention was, and she obviously has mentioned it now in the blog post, was that the reason she didn’t exercise until then was that she was incapable of doing it. She was just too ill.
It’s a very honest article about where she’s at and it’s wonderful to hear that she’s finally getting the help that she needs and the kinds of things she talks about in that article sound very promising. And so I’m going to put a link to it in the show notes.
The article even opens up with in the second paragraph, the sentence is, “I’m not dense. I’ve known for a long time that I’m the living walking example of RED-S also known as the female athlete triad. I’ve known that probably a huge reason that my bones keep breaking is because I have a 20-year history with anorexia.” The reason I’m mentioning this is because RED-S is an issue that can affect people even up to the highest level and it can be going on even when someone is winning races and supposedly at the top of their game.
But like Amelia has experienced, at some point this catches up with you and after winning everything for a number of years, her body just couldn’t take it anymore and she suffered injury after injury leading to her now finally and hopefully getting the help that she needs.
During the recording of this, Skype was not on its best form. There were times where it would drop out for long stretches and I’d have to get Charlotte to start a section again or it would drop out for a second or a couple of seconds. And if you miss a handful of words, but you could still follow along with the point that she was making. And I’ve tried to sew this back together as best I could and it’s not perfect. But that’s sometimes what happens when recording these things online. So this intro has gone on long enough. Let’s get on with the main part of the show. The show here is my conversation with Charlotte Gibbs. Hey Charlotte, thanks for joining me on the podcast again.
So we first chatted, I went back; it’s like over two years ago. You had a different surname back then, going by Goodall instead of Gibbs. And so for anyone who wants to listen to the first episode that we did and I do highly recommend it. It’s episode 94 and the reason I’ve invited you back on the show is because of a Facebook group that you recently set up on the topic of Relative Energy Deficiency in Sport which is abbreviated to RED-S. And it’s a group that I found really helpful for like as a practitioner because of the articles that have been linked to in this discussion that’s being had. And so I’ve been thinking about the structure for this conversation and what I believe could be more useful is to do it in the reverse order of what I usually do.
So I usually start with a bit of background on the guest and their story and then go to the topic at hand. But I think what might be better is to really start with some definitions and some understanding of the topic and then we can talk more about like how this is applicable to you and your experiences. And obviously like by all means, feel free to weave your own story and insights, as we go through this. But yeah, having that understanding of science and what’s going on at the bigger picture level I think will give a better groundwork for then chatting about your experiences. Like are you okay with that?
Charlotte: Yes, absolutely. That makes complete sense to me.
Chris: So I know I just said, let’s put your story to the second half, but just as a frame, can you give a short bio of yourself, like who you are, what your background is?
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Charlotte: Sure, well my name is Charlotte Gibbs. I was, as you said, Goodall before I got married about eight months ago. Which was wonderful. I am primarily a runner. I’ve had a running background from probably most of my life. I’m originally a road runner – marathoning, shorter distances, 10 Ks. And then more recently I’ve started doing a lot of ultra running and mountain running and trail running.
I had a certain amount of success over the years but as well as that I’ve also suffered on and off from various different forms of disordered eating, never to the point of an actual diagnosed eating disorder. But unfortunately, it has affected my own health. And now I was 40 last year and I’ve had six stress fractures probably over the last maybe five years.
The action of soft tissue injuries as well. And finally, in January of this year I was diagnosed with this syndrome, which is being called RED-S, Relative Energy Deficiency in Sport. And that’s what we were going to talk about today. So my situation now, I’m five months down the line, I have a slowly healing tibia stress fracture and a very slowly healing meniscus, knee injury, which has been caused by a stress response. I’m slowly trying to figure out a way of returning to my sport in a healthy form where I’m fuelling properly and not over-training and able to enjoy my sport in a way which has been denied to me for those reasons for so many years.
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Chris: So, that’s great. And I really want to dig into all that. But let’s just define a couple of terms and start to understand this better. So, Relative Energy Deficiency in Sport or RED-S is the abbreviation that people use.
As far as I understand it. I’ve heard some people say REDS and some people say RED-S. I tend to say RED-S because there is the little dash in it. But it stands for relative energy deficiency in sports. And it was a term that was used in order to come away from the traditional concept of the female athlete triad, which was the original model in which this idea of the network of symptoms including under-eating leading to bone issues in athletes. It used to be looked at through the lens of the female athlete triad and of course that for obvious reasons, excluded men who also can suffer from these problems. And it also was a bit too narrow because it ignored some of the other massive issues which can be included in this in these problems.
And so in 2014, a contestant consensus statement was published by the IOC setting out the terms under which this new concept of RED-S could be understood. And since then a lot of work has been done both scientifically looking at the actual physiology that underpins some of these problems. And also psychological assessments have started to be done underneath the umbrella of this RED-S diagnosis. And it’s been updated recently. So there’s an updated consensus statement which sets out, I think very clearly and very fluently, how this is now understood. And that this has become the standard way of looking at the concept of how under fuelling, how being energy-deficient affects people who were involved in sport.
And so there’s a lot of articles that Charlotte has linked to in the Facebook group and that I read through in prep for this. And I’m going to put a lot of them in the show notes. And there’s one in particular that we’re going to go through as part of this conversation. And you talked about it originally being the female athlete triad and that being then broadened out. I want to go through that in a bit of detail, but I guess to start with maybe other people have heard of like overtraining or overtraining syndrome.
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Chris: So what would be the difference between overtraining syndrome and then really relative energy deficiency?
Charlotte: That’s a really good question and I don’t think anybody actually knows the answer. Some people would argue, and I think probably correctly, that overtraining syndrome is itself a symptom of RED-S or is one of the branches of RED-S. I think some people would say it’s the other way round. And that RED-S is a function which when you are over-trained you fall into, I don’t actually know the answer to that question. I think that you can have RED-S without being over-trained and vice versa. But there’s definitely a subtle interplay between the two. And I don’t think that’s really been incredibly well explained in the scientific literature. But having said that, actually overtraining syndrome itself hasn’t been particularly well served by science and it’s not really entirely well understood.
And I think that because of that, the RED-S model has been quite useful because it’s allowed us a way of looking at overtraining syndrome and the symptoms that it causes. But I don’t think that RED-S explains everything about overtraining syndrome. I think there are aspects of overtraining syndrome which don’t fall under the RED-S model. And maybe that’s an area where there just needs to be a lot more work done.
Chris: Because I mean when I was going through it, I then read a fair bit on overtraining syndrome and try to work out, like conceptualize how these things could be different. And it seemed that with overtraining syndrome, the focus seemed to be what is causing it. And again, there could be multiple things that are causing it, but what is mostly causing it is the lack of rest or recovery. So in a sense, someone who’s training hard but then not having enough downtime for the repair to take place.
So that’s the component that is causing the issue. Whereas with relative energy deficiency, it’s not the lack of rest per se. It’s the lack of calories or energy coming in. In regards to the amount of training someone’s doing and all the other stuff that’s going on in their life. So in a sense, someone could be overtraining while taking in a sufficient amount of food, but it’s not the food that that person needs, it’s the rest that they need. Whereas someone with relative energy deficiency, if it’s happening just on its own outside of overtraining, they could be training only two times a week or three times a week. They are getting enough rest or they’re sleeping enough or at least in bed long enough to, to get adequate sleep. But it’s the lack of energy that would be the need to do the repair work. Does that make sense?
Charlotte: I think that does and I think that’s probably a very sensible way of looking at it. However, where it becomes a little bit more blurry is the idea that for example, the amount of training that you need to do to be overtrained is very relative. It’s relative to the context of the athlete themselves. So it is more than possible to be overtrained and only doing maybe three sessions a week. If your body is not able to cope with those three sessions a week. And one of the reasons why you might not be coping with those sessions is if you are significantly under fuelling because that’s a function of recovery. And I think that’s what I mean, where the interplay between these two ideas is, is still not really entirely well explored.
Because I think that, and some people will say there’s actually no such thing as overtraining, it’s all to do with under fuelling that you can’t actually be overtrained if you manage your fueling correctly in such a way as to maximize recovery. I don’t think that’s true. I think that it is absolutely possible to be over-trained in a way despite fuelling sufficiently.
But I do think that the level of fuelling that’s required in a lot of these cases is so much higher than what would normally be considered an eating strategy for an athlete. Particularly when we’re looking at say ultra running. And this is one of the areas where, I mean ultrarunners seem to be the most prone to the problems around over training of maybe all endurance sports, including triathletes who are also extremely prone to it, mainly because of the volume of training required on a weekly basis in order to actually do the sport that they want to do.
And I think that the mismatch between the volume of training and eating can be so huge and in a way it can be so easy to get it wrong, unintentionally. I mean this is when we come to talk about RED-S you can look at it through the lens of deliberate disordered eating where you’re deliberately restricting your calories. But I think really commonly you get people who don’t realize how much food they need to eat to support their training. And I think that it’s in that area that then the overtraining syndrome probably possibly gets more of a risk factor or much higher risk factor than otherwise it might be. Because I think it would be quite hard to train yourself into the point of severe overtraining syndrome without the added complexity of under fuelling as well. And I think that that’s where the two syndromes I think should be looked at as probably physiologically very similar.
Chris: Cool. And yeah, I agree with everything you said there. And if I’m visualizing this as a Venn diagram, they’re pretty much overlapping. I was just trying to see if there were points at the extreme where you could have one but not the other.
Charlotte: Yeah. I think you can have one without the other. But in reality, most of the time I think the two will go together, but again, how that interplay actually works is probably not very well understood as yet.
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Chris: And so there’s a couple of things I want to flag at this early stage as well. And this is stuff that you’ve also talked about, is that like, one, this can happen with all body shapes and sizes, so it’s not got to do with someone’s body composition, but to do with the energy that they’re actually taking in and what they need to manage their everyday life as well as the sport and the movement that they’re, they’re doing on top of that. So do you want to just kind of speak to that?
Charlotte: Absolutely. So the primary driver for reds and probably for overtraining syndrome as we’ve just been discussing is something called low energy availability. So that’s the concept of energy availability, which is really the idea that underpins all of this discourse. Energy availability is the amount of energy that you have available to your body to use. And so it’s calculated essentially as the energy expended above that of daily living.
And the way they describe it as the overall result is expressed relative to your fat-free mass. So it’s a slightly complicated mathematical equation, but essentially the way it works out and this has been shown in laboratory testing. Most people for healthy functions need to have an energy availability of 45 kilo calories per kilogram of fat-free mass per day.
So if you drop below 45 calories per kilogram of fat-free mass per day, you technically are coming into a low energy availability condition. Now obviously that requires, first of all, you to know what you’re fat-free mass is, which has to be done using a dexa scan or some other form of testing. So it’s not something which is available to most people. You can quite easily figure it out as an approximate number. And you can have a vague idea of where you might stand on that spectrum. But I think if you’re an athlete and if you’re an elite athlete, you certainly have access to the laboratory testing, which would allow you to figure out exactly what your energy availability is. And the rest of us, I think we can have a fairly well-educated guess of where it should be.
The point is that if it falls below that level and they’ve shown that you can get into substantial trouble if it falls below 30 calories per kilogram of fat-free mass then you are very, very much at risk of RED-S. And interestingly on some of the studies done specifically on male cyclists, elite male cyclists. So we’re talking sort of Tour de France level cyclists. They were having energy availability of eight calories per kilogram of fat-free mass, eight when below 45 would be considered dysfunctional. So that shows how incredibly dysfunctional some of their eating habits were and how dangerous that could be for their bodies.
Chris: Definitely. And I do want to just say if we’re talking to a broader audience who isn’t just athletes or elite athletes, like you don’t need to know that level of detail around what your fat-free mass is. Like, there are going to be other ways that you can start to figure this stuff out by using symptoms, by using different testing. Really just by having good body awareness and stuff that we can touch on as we go through this.
Charlotte: Oh, absolutely. I mean this is looking at it from very much a sort of scientific perspective. They needed to put a definition on where they think this comes from. BMI is not a way of approaching it because anybody can suffer from this. So it doesn’t matter whether your BMI is low or high or in the middle. It’s to do with how many calories you have coming in at any given time in relation to how many calories you have going out. And that’s why I quite like the model because in a way, it’s a very positive model because it moves away from looking at it in terms of body size or even body fat percentage, which is another way that is possible for it to be looked at us.
But by looking at it in terms of a very relatively simple equation which is to do with energy in and energy out, I think that allows the model to importantly not be tied down to ideas of certain body shapes or certain body types, which may or may not suffer from this, from this issue because it can affect everybody.
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Chris: And when they’re working out the energy availability, are they doing it well over the space of a day, over a week? How long are they looking at, in terms of balancing that out?
Charlotte: So it’s looked at on a daily basis. So the energy availability calculation is per day. I know, and I can’t give you a citation off the top of my head, but I know that there’s been work on energy availability on a much shorter periods of time. So looking at hours and there’s been some evidence to show that falling into a state of low energy availability, even for the space of an hour or two, in the course of a day is enough to give poor outcomes, in terms of certain hormonal responses. And I think that’s a very interesting piece of research, which I will find the reference to and you can add it to the show notes.
Chris: Yeah, I’ve got that. I mean, part of the reason I was asking is I read the research in advance of this – it was Nicola Rinaldi who I’ve had on the podcast a couple of times before talked about this as part of her blog posts. There was some research done in Sweden where they looked at on an hour by hour basis and then made some recommendations based on that in terms of the number of hours per day that you could be below a certain figure. But yeah, I will link to that in the show notes as well.
Charlotte: Yeah, that’s the piece of research I was thinking of here. It’s a very, very important piece of research. And I think that comes back to one of the things that, you know, a lot of athletes and regular people who exercise do is a lot of people will do like a fasted cardio as they call it. So, you know, go for a run in the morning before having breakfast and things like that. Now that in itself, I think there’s nothing necessarily wrong with that, but if you look at it through the lens of energy availability that is forcing your body into a state of low energy availability from the very start of the day. And if you then don’t recover sufficiently from that bout of exercise, you will be playing catch up for the rest of the day in terms of your energy availability. And I think that that can be, and there’s some of the research has shown that that can be, particularly for women really quite dangerous in terms of their hormonal responses. And that’s something that I wish that people would actually know a bit more about before they start thinking, oh well I’ll do my run in the morning before eating anything because a lot of people have this idea that, oh, it’ll make me burn more fat, which it doesn’t, frankly.
Chris: Totally and I think obviously with intermittent fasting becoming such a craze and everyone getting behind it and seemingly or people talk about so much research supporting its health benefits, I think this bit of research that we’re talking about really pointed to how that can be problematic because obviously overnight you fall into sort of energy deficit. And so if you’re then going for a fasted run and then you have a smallish breakfast and you don’t have that much for lunch cause you had a salad and then you have your main meal in the evening time, that is a really long part of the day where you’re in that low energy availability state. And as you say, from a hormone perspective it seems to have a really negative impact.
And it probably has an impact on lots of other functions that just hasn’t been studied to the degree that it needs to. And I don’t want to get too far ahead with this piece of research because it’s one piece of research. And so there needs to be more to really back it up. But yeah, it does start to point towards things that I’ve seen in my clinical practice as well of once people are eating more consistently throughout the day time things can start to improve even when calories are kept equal.
Charlotte: That’s really interesting that that’s something you’ve seen in your own practice because I think that’s something that I’ve experienced myself definitely in terms of the way my own body reacts. And I notice that now that I’m recovering from having been in a state of low energy availability for a long enough period of time that it has impacted on my health. I can’t go for a long time anymore without eating. My body just rebels completely now. I don’t deal with it well at all. And I used to be one of those people who would quite happily go hours and hours and hours without eating and never particularly feel hungry. But now, I think my body has learnt enough to say, uh-uh, can’t do that anymore, or give me some food.
Chris: Yeah, I think that’s a very common thing with clients is that once they start to eat more, once they make improvements, it just, it becomes very difficult to go back. And it’s not to say that people can’t relapse, but it becomes often when someone’s relapsing it’s because it’s something very unintentional. Either I had to finish this project at work or there was this big family stressor that was going on, like something that inadvertently blotted their hunger or really became all-encompassing. But outside of those kinds of factors, it becomes very difficult for them to intentionally do what they did before because they just, yeah. As you say, you start getting very different feedback from what used to happen.
Charlotte: Now that’s really interesting. That’s very, very true.
Chris: So I want to go, I mentioned about an article that I wanted to use as, as a point of reference. And this is an article that was in the BMJ. And the reason that I want to go through this is, as we talked about before, the relative energy deficiency normally was talked about in terms of the female athlete triad. And as part of the female athlete triad, you would have these triad of conditions which were menstrual cycles that were irregular or had stopped. You had issues around eating. So whether that’s a diagnosed eating disorder or just not eating enough because you were under the misunderstanding of how much you needed. And then also changes even in terms of bone health. So that could be osteopenia or osteoporosis, which is looking at the level at which the bone is being broken down or the level of which degradation has taken place. And so it was just those, those couple of areas.
But what this article points towards is lots of different systems within their body that can be affected by not having enough energy available. So I want to go through all of these different areas and we can both then speak to what we’ve noticed and you can talk about personally or what you’ve noticed with other athletes or what you’ve noticed from people committing in the group. And I can then also talk about from my own perspective with clients that I’ve worked with.
00:41:40
So, in terms of menstruation, like let’s start with this stuff from the female athlete, try to, in terms of menstruation, is there anything you want to comment on that?
Charlotte: Yeah, sure. So I think menstruation is quite an interesting one because I mean, that was one of the legs of that female athlete triad, which was the original way of describing these symptoms. And I think the best way to look at the menstruation is that it’s a sign in a woman if she’s menstruating regularly, that everything is working as normal in terms of her hormonal responses and her endocrine system.
Now obviously in women, that’s a really strong sign that doesn’t exist in men. So in some ways that was used as a way of approaching this in women. So you could see very clearly that if a period of her period had stopped for whatever reason for however long that there was obviously something wrong, there was a disruption to some degree and that needed to be investigated.
Now since the expansion of this model to under the umbrella of RED-S it has now included men, which is very important and obviously men don’t get periods. So we’ve got to look at it more widely, I think in terms of a hormonal response rather than actually the menstrual function itself. And it’s very similar in men and women. Essentially when your energy availability drops below the level which is considered healthy, or the minimum for health, which is around 45 calories per kilogram of fat-free, mass your body starts to preserve what it sees as the essential functions. And one of the interesting evolutionary functions of the human body is that actually your body thinks that movement is more important than reproduction. So it will prioritize movements. So if you’re training really hard in the gym or as a runner or as a triathlete or cyclist, and you’re not fueling sufficiently and your body’s in a state of stress or low energy availability, it will prioritize the movement. It will keep you going, but it’ll shut down other the functions. And one of the first functions that’ll shut down is your reproductive function. And in order to do that, it essentially just stops creating the hormones which drive your reproductive system. And that’s why women, you stop getting periods. And in men they show that levels of testosterone become very low. And in both men and women, this leads directly to impaired bone health.
And that’s, I think one of the reasons why in athletes we get so obsessed about this is because while not getting your periods itself is a sign of ill health, when it leads directly to stress fractures and poor bone turnover, that’s when we start realizing that something is seriously wrong.
And the studies have shown that in men and in women who have low energy availability have very decreased bone mineral density across the board. And this is particularly bad in people who don’t do weight bearing sports. So for example, in cyclists who aren’t doing anything weight-bearing. So cycling isn’t weight bearing, it’s very cardiovascular intense, but it’s not weight bearing at all.
And studies showing that in young male cyclists who have low energy availability, their bone mineral density is so poor that often it would be comparable to that of an 80-year-old person. So it’s really shocking actually how quickly low energy availability can lead to these hormonal issues directly to significantly impaired bone mineral density.
Chris: So there’s a couple of things I want to touch on based on what you’ve said there. So one of them in terms of the body prioritizes movement over getting your period. I mean from an evolutionary perspective, that just makes sense. Like we didn’t always live in a time where there was going to be abundant food and so it made sense for a women to get pregnant at the point in which they’d have the best opportunity to be able to feed themselves and feed the growing baby. And so throughout history, if you look at different tribes, if you look at sort of ancestral health, women would have periods of like not getting periods at all. They’d have periods of having their period but not actually ovulating and then have periods where they’re getting their period and it’s because of oscillation. So from an evolutionary perspective, that definitely makes sense.
00:46:55
I would also just add that because so many women are on the contraceptive pill, you don’t get that feedback. Like you still often get a monthly bleed caused by the hormones in the pill. If you stop taking that pill, you would realize that you’re actually not getting your period. So I think that can often be a problem because you don’t get that feedback if you’re on the pill.
And then the other one I would say that often getting your period is seen as this sign of like your health is doing really well. But I don’t think that’s always necessarily the case. I’ve definitely had clients who have been able to keep their period or get their period back very easily when there are a lot of other issues going on. So it can often be talked about as if it’s the first thing to go because it’s so low on the pole of important things for like survival. But I don’t think that that’s always the case. And I know like, I’m going to throw one from the eating disorder institute, which used to be my utopia. She talks about the fact that not having your period is a really bad sign. Having your period doesn’t necessarily prove a good sign.
Charlotte: Yeah, that’s a really interesting point. I think that’s quite important. It does disturb me slightly that the period thing gets jumped on a little bit and I think that is simply because it’s a really easy sign in a model which can be quite subtle to test for.
So if you think about some of the other issues that come up around the question of RED-S, there’s not that many which are really that easily seen without doing some fairly sophisticated medical testing. Whereas having a period or not having a period in a woman is one of those few things which, which technically is quite obvious. And I think that has been jumped on a little bit. I mean for me, I had a few times where I’d missed a period, but other than that I pretty much had a regular period and was still getting stress fractures and it was only when I obviously pushed it way too far that my period stopped completely. But I think that I definitely had RED-S before my period stopped. The problem is I think also as I’ve, something I’ve learnt is that once it does stop, it can be really, really hard to get it back. And I know that lot of the work that Nicola Rinaldi has done is just been amazing. And I’m in the process myself at the moment of trying to get my period back. It’s sort of come back and then it sort of hasn’t. And it’s really frustrating because you feel like you’re doing everything “right”. You know, you’re eating the food and you’ve cut down the exercise. Why isn’t it here? Argh! And it’s just a question of I think allowing the body to recover sufficiently to then trust that the energy availability is there and that it’s safe to restore those hormonal functions.
I think the question of the pill is a really important one. So in the past if a doctor was presented with a female athlete or exerciser who was amenorrheic, quite often they would put them on the pill because there was a thought that that might be protective for their bones. But that’s been shown to be false. It isn’t. The synthetic hormones that are released by the pill do not have the protective function that normal production of estrogen and progesterone would do and all the pill does then is cover up the dysfunction that might be present. So I think increasingly now it’s understood that it is poor practice for a woman who is at risk of low energy availability to be on the pill at all. Full Stop.
Chris: I would say that that hasn’t disseminated as well as you may be thinking. I have a lot of clients, who suffer with hypothalamic amenorrhea, and yeah, the typical response they get is let’s just go on the pill and then at the point in which you want to have kids, then we can deal with it.
And I also just want to echo something that you said as well in terms of, you can keep your period while doing things that are not so great for the body, but once you lose it, it takes a much more of an effort to then get it back.
Charlotte: Oh, absolutely. And also, I mean, I’m of a generation where, I mean, I had a coach, I was a runner at school and I had a coach who said, and I remember this vividly, “if my distance girls are getting their periods, they’re not training hard enough.” And that was was normal attitudes. This was in the 90s and I’m sure I’ve heard a lot younger athletes quite recently say that they’d come across coaches still who have a similar attitude.
And I think that it’s that sort of thing, which is almost why we are suffering in the way we are from so many people who are suffering from these problems. These attitudes still exist. And the understanding of the processes that lie beneath these issues is still so poor in the wider population.
Chris: Definitely. Well, hopefully the fact that this has been an IOC consensus statement and they’ve now been talking about this for quite a while. Hopefully that starts to make its way through and trickle down to those coaches.
Charlotte: Oh, I hope so. Interestingly enough, and this makes me raise my eyebrows a little bit, but I think the inclusion of men in this model probably has focused minds a little bit better.
Chris: Yes, I really agree with that. And in terms of the comment you made before about bone health – I think people often think of bone as this very inert substance and actually bone is incredibly active and it has a lot of nutrients and that there’s so much interchange with it that it makes sense why if someone’s under-fueling why they could get issues with their bones, because things are being pulled out of the bone to be used for other processes within the bodies. So it’s not like bone just gets formed and then that’s it. It just sits there like cement or sits there, it is something that is constantly being thrown over, broke it. Like even when it’s healthy, it’s being broken down so they’re putting in newer bits of bone. And so I think if you can start to think of it that way, you can understand why bone health can be so impacted when not enough energy is coming in.
Charlotte: Absolutely, and also it’s well known that estrogen, progesterone, and testosterone are major drivers in bone turnover and in the absorption of vitamin D. So if those are not present because of amenorrhea in women low energy availability leading low testosterone in men. Then for various reasons, your bone health is going to be severely impacted.
Chris: Yep. So I know we chatted a lot about reproductive hormones, but are there other hormones that you want to talk about because the next bubble that is listed as part of this is the endocrine system?
00:55:10
Charlotte: Yes. So without getting too complicated, it has been shown that the effects of low energy availability are quite severe on various parts of the endocrine system. So it’s been shown that they’ve been impacts on leptin and ghrelin, which are the hunger hormones. So changes in your appetite regulation and your hormones. Changes in insulin and causing insulin resistance potentially.
Very interestingly, it’s been shown to have quite significant alterations in your thyroid function. And I think that’s an area of research which has been worked on a little bit at the moment where they’re looking at how it can impact your thyroid, and what that means for recovery and how you can recover your thyroid function if you suffer from these problems.
So there has been quite a lot of work done by a British doctor called Dr. Nikki Ki who’s a consultant endocrinologist and she’s really spearheaded the research in this particular area and she’s written some really in-depth studies I think mainly on male cyclists actually. And she’s looked at dancers as well, female dancers and she’s done some quite detailed analysis on the endocrine system and how it’s been really quite severely impacted by the existence of low energy availability in these in subjects.
Chris: And so with a couple of the ones that you touched there in terms of things like leptin and ghrelin, while I think the feeling would be that it would make those hormones in a certain alignment that make you more hungry and kind of drive you towards food, that’s not always what necessarily happens. It’s almost like your body’s trying to push you towards food up unto a point, and then after a while it almost feels like it’s not worth it creating these hormones to make you hungry because you’re just not listening.
And so you get into a situation where someone can be potentially so depleted that they’re actually not actually not noticing hunger or the point at which they noticed hunger is when they’re like at a 10 out of 10 and then the rest of the time it’s just like nothingness or it’s a blur.
Charlotte: Yeah, absolutely. And also I think what’s quite interesting is that if you look at the concept of RED-S through the lens of the endocrine impacts that it has, you can see the real interrelation because, so as you were just saying about leptin and ghrelin and your perception of your own hunger cues and fullness cues, that then blurs into the more psychological side of things.
So you start questioning your own hunger signals. Why do I feel so hungry? Why am I not feeling hungry? And that’s driven by the endocrinology. But it becomes psychological as it’s experienced by the sufferer. And I think that’s what makes this model so interesting is that it allows for these interconnections to be expressed.
Chris: Definitely and just on that, I mean, a lot of some of the research around say, anorexia, looks at the point that when you get into a low energy state, that’s what then flicks that switch that then drives someone to continue to eat less, to feel better from eating, less, to want to continue to move.
And so you get into a bit of a chicken and egg scenario with it. It’s like, is it someone’s desire to be thin or their desire to control the outside world by controlling food or all of the other reasons for why people talk about eating disorders happening? Or is it because for whatever reason, you’ve gone past a certain level of energy deficiency and that then just changes the processes within the brain and how you then think about food and movement.
Charlotte: Absolutely. And the way that it impacts the processes in the brain as you say, is definitely a part of this whole scenario, which it’s not been incredibly well looked at. So one of the bubbles around the RED-S model is psychological. But in a way that’s the bubble which is the least explored. For example, in this IOC consensus statement that we’re looking at the moment. And that’s probably the bubble that needs the most work, to be honest.
Chris: No, I would agree with you on that and it’s something I want to chat with you about in a little bit more detail. But just going back to the other, one of the things you mentioned with the endocrine is thyroid hormones. And it is really common for clients that I see where they then get their thyroid panel done and it comes back pointing towards the fact that they’re hypothyroid. So low thyroid function.
And what I often see with this is then the doctors saying cool, we want to put you on thyroid medication or this is why this is going on because you’ve got poor thyroid. And kind of the way that I’m conceptualizing it is the reason the thyroid is in that alignment in terms of the amount of T3 or T4 or TSH is because of the feedback it’s getting in terms of the energy coming in. Like he does not want to turn up the function of the body so that you’re using more calories, because it’s like we don’t have the energy coming in. So I think sometimes it can be a little bit of a trap where you get really focused on, okay this is being driven by the thyroid when actually the thyroid is more secondary because of the environment that someone’s created, in terms of the exercise and the energy intake.
Charlotte: It’s a bit like going on the pill in a way. You know, you can throw artificial thyroid medication at somebody who has this problem and you can boost their thyroid function, but you’re not actually looking at the underlying reason why their thyroid function is impaired in the first place.
01:02:00
Chris: Yeah. So one of the other bubbles, and I don’t think we’re going to have time to go through all of these different bubbles cause there’s other stuff that I really want to talk to them. But one of the other ones that I wanted to talk about was the immune bubble. So do you want to give your thoughts around this and what you’ve seen in the research?
Charlotte: So, well as I understand it, one of the things that happens when you are in a state of low energy availability is that your immune system can be significantly altered and suppressed. Again, it becomes one of these bodily functions that gets downgraded when the body is in a state of low energy availability. So the immune system just stops being quite so important to your body.
And it just means that you’re more likely to get things like upper respiratory tract infections, colds, flus, coughs, that sort of thing. And for athletes, obviously, that’s a massive problem because they need to perform. And for example, you know, you get athletes who are going to the Olympics and they’ve trained for this for four years and they turn up at Tokyo in 2020 and they have a stonking cold that’s really not going to be a good thing.
And the statistics for the number of athletes who actually get these kind of upper respiratory tract infections and also gastrointestinal tract issues as well, would fall into the same category, is really quite high. And I don’t think that again, has been particularly well understood until it’s been looked at more closely through this RED-S model where they realize the link between low energy availability and the immune system.
Chris: And part of the reason I’m bringing this up is I wanted to talk about the opposite side of that. And what I mean is I will have clients who will go through this and they’re like, yup, I’ve lost my period. Yeah, I’ve had a dexa scan and I’ve got osteopenia. Yes, I’m having terrible digestive issues. And then I say, so what about immune function? Are you getting coughs or colds? Are you getting other recurrent infections? And they’re like, no, I’ve got a really healthy immune system. I haven’t been sick in years. And I want to bring this up because I think sometimes people can then view this through the lens of, I must be doing things right because my immune function is really good. And what I’ve noticed is actually what happens when people start to recover – so they finally take that time off. They finally start to eat more; they finally do the things that are supporting their body.
It’s at that point that they’re suddenly like, oh my God, I just had the worst cold that I’ve ever had. Or I just suddenly broke out in cold sores. I haven’t had these since I was a teenager. Or it’s basically like you’ve now given your body enough of a rest. So that your immune system comes online and then it notices all of the things that it hasn’t dealt with. So I just want to flag that because it is something that comes up a lot and can be a barrier for why people don’t get help because they think if this was really a problem, I’d have immune issues.
Charlotte: Oh, that’s really interesting. Yeah, I can sort of understand that. And I don’t really know the physiological mechanisms that would underlie that, but I do kind of recognize that in myself. It’s almost like when you go on holiday, you’ve been working really hard and then you go away on holiday and inevitably the second day of your holiday you get sick.
For some reason, it feels like your body just as relaxed enough to allow you to feel the symptoms. Maybe something like that. I don’t really know the exact physiological reason. I’m sure there probably is one in detail there. But it has definitely been shown in terms of RED-S studies that low energy availability does alter your immune response.
Chris: And that’s often the question that I ask people is what happens when you go on holiday? And what you’ve described is often a common response.
01:06:25
Charlotte: Yeah, that’s really that, that is quite interesting. One of the other things just very quickly that I would like to touch on because I think it’s something that people don’t realize is that another thing that they’ve shown is that low energy availability is correlated with a decreased resting metabolic rate.
So for example, athletes and people in general who are suffering from low energy availability they might find because their metabolic rate is suppressed, they might find that they actually start putting on weight. And it’s something that I’ve heard quite a few people I’ve spoken to describe where they say, oh, I’m exercising so hard and I’m doing all of this stuff, but I’m putting this fat on around my stomach and I’m putting weight on, and I don’t understand why. And this is, I think one of the really cruel ironies of this entire thing is that you can actually be causing yourself to get heavier when you’re trying so hard to not be so heavy because you have suppressed your metabolic rate, to such a degree. And that this is a recognized response to low energy availability and RED-S.
Chris: And then that just feeds into the fears because it’s like if I’m doing all this and I’m putting on weight, what’s going to happen when I do start to eat more or what’s going to happen when I do start to exercise less.
Charlotte: Oh, exactly. It just causes people to double down. And actually that possibly is another driver of the over-training issue is if you’re suffering from this lower metabolic rate and you feel like you’re not getting the same results from your training and you end up training more, then you are more likely to fall into a state of over-training.
Chris: I agree. Because you, you’re not seeing the returns that you used to. And the idea is well I just need to ramp it up a little bit and that’ll fix everything.
Charlotte: And it’s such a dangerous, dangerous perspective to have. And I think that if you are the sort of person who’s fallen into this problem through an approach to your eating, which is disordered to begin with, then this is simply fuel to that fire and it pushes you even deeper into disorder.
01:08:55
Chris: Definitely, and I think especially within the athlete world, a lot of the people who are most susceptible to this, which you talked about in terms of long, long-distance running, the kind of personality traits that someone who is an ultra-marathoner, have this like perfectionist tendencies or you have this really type-A driven tendencies. And if you mix that within the message that is often coming out, which is like no pain, no gain, like relishing through agony, and that that’s a really good sign. It becomes a really dangerous mix.
Charlotte: Yes it does. It’s probably the most toxic mix of issues which has come together in this perfect storm to affect endurance athletes in particular. And that’s something which I think isn’t entirely understood. I think in the nuance, and again, I think this comes back to our original conversation. We were talking about the interplay between overtraining and RED-S and it’s very much the sort of athlete’s perspective and the athletic identity of the individual who has self-identified as this person who runs further and longer than everybody else and who is super tough and who relishes the existence of these really hard races that they want to do and put themselves into these extreme environments that a lot of these races take place in. And that’s exactly the type of mentality who will be able to push their bodies into a state of dysfunction, which then completes in the suffering from the various problems that we’ve discussed under the umbrella of RED-S.
Chris: Yeah, definitely. I mean, on the previous podcast I talked about how identity as the healthy one or the fit one can be such a straight jacket. And I’d say this is that on steroids where it is really ramped up where your identity isn’t just as the fit one. It’s like the identity as the marathon runner or the person who has to do 50 miles a week or 80 miles a week or whatever it then becomes as part of that pursuit in your sport and when you’re at a position where you’re like, I need to now walk away from this, or at least temporarily walk away from this or be side-lined and that’s who you are as a person, I think that is very difficult.
01:11:25
Charlotte: Yes, absolutely. And I think again, that’s where some of these position papers which have come out from the IOC fall down because again, they’re looking at this from the perspective of elite sports where an athlete who is in a coaching program can be benched. And you know, they have these athlete contracts where an athlete will sign a contract to say I will not train until such a point. Well normal recreational athletes, people who go to the gym, all of whom are susceptible to these problems. We don’t have access to that kind of coaching. We don’t have a coach watching our every move telling us, no, you stay on the couch for the rest of this month/six months or however long it’s going to take. We have to make our own decisions about whether we go for a run today or not or whether we go to the gym today or not.
And I think that is where it becomes really, really difficult, probably a lot more difficult for the recreational athlete than it is actually for the elite athlete who has that level of support behind them. The rest of us, normal human beings, we don’t, and we do have to make our own decisions. I mean, admittedly, some of us might have the support of doctors or nutritionists or other professionals behind us, but not in the same way as a professional athlete on a national coaching program for example.
And that I think isn’t as well recognized as it probably ought to be. And exactly as you say, this question of your athletic identity, if suddenly you are told that you’re suffering from a syndrome which is causing you significant harm and in order to recover from that, you have to stop doing the things that have made you feel like you for very long time.
You’re not given any support with that. You know, you don’t have the psychological support that you might require. You’re just told by a doctor, oh, you better stop running, you know, don’t run for a while and they send you away. And that’s really, really difficult to deal with and I think there needs to be a lot more understanding from medical professionals around the psychological impact of people having their sports and their coping mechanisms taken away from them in that way.
Chris: Definitely, and that was one of the things and that was one of the things when I was doing the research for this and reading different blogs that people had written about overtraining syndrome and RED-S is them talking about, oh, I kind of identified with this. And so I’ve taken two weeks off and now I’m feeling a lot better. And there’s just this part of me that’s like two weeks is going to barely scratch the surface on this stuff.
And so even if you’re feeling a little better after having that break, you’re just going straight back into the fire and in some short amount of time, you’re going to be just as bad as you are now, if not worse. And as you say, it’s because there isn’t all of those other support pieces in place, but I think it’s often missing the bigger core issue, which is, as we kind of briefly talked about, like that psychological bubble that hasn’t been really addressed. Like for me, when I look at all of those things, that psychological bubble could almost be in the middle driving all of the others, not just the energy deficiency.
Charlotte: Yeah, I agree completely. I think that without the psychological reasons that push you to do the sports and the behaviours in the first place, you wouldn’t suffer from the rest of the issues that come with RED-S. I completely agree that I think the psychological etiology is the driver
01:15:40
However, I understand why they haven’t put it there because, (a) it’s really difficult to screen for and (b) I think again, because this defects elite sportspeople in a very different way from the way it affects recreational sportspeople. Because elite sportspeople are not likely to suffer (a) from exercise addiction and (b) well not necessarily from over-training, particularly not elite sportspeople who are in traditional sporting programs, they’re not overtrained because they are coached by professional coaches. They’re not allowed to be over trained. They can’t be over trained.
And they don’t suffer from exercise addiction because again, they’re managed and their sport is managed in a way that prevents them from having the problems that the recreational athlete probably has to struggle with on their own. So I think that the fact that this model has been written by people who have come directly from the world of, and when I say elite sport, I mean these are people who work with Olympians, the absolute pinnacle of sporting practice. It’s probably skewed the model away from actually being more applicable to the people who, the broader number of people who actually suffer from it, which are the more recreational athletes.
Chris: I don’t know if I would, I mean maybe it does skew more towards the recreational athletes, but the idea that as a high-level athlete you couldn’t suffer from exercise addiction or as a higher level athlete, you couldn’t be having, I don’t know, an eating disorder that’s pushing you towards overtraining syndrome. My sense is that isn’t necessarily true, but I think that’s probably there and that could be why certain people fade off into the background and don’t do as well and it’s just chalked up to all they’ve had; some niggling injuries or they’d been having relationship issues or there’s something that is a given as a reason for it when actually it is really going, it is really going on.
Charlotte: Yeah, I think you’re right actually. Yeah. Maybe I think of it in terms of the ones who succeed, the ones who survive the system and who do make it to the very top of their sport are not likely to be. It’s a huge attrition rate and the people who fall off and fall away and who don’t make it are the people who are suffering from exactly these problems. I, yeah, I completely agree with you on that.
Chris: Because you’d even posted, I, remember, I’m trying to remember who it was, one of the Paralympians who spoke out about her struggles around food that you would never have guessed and has obviously has won medals on the world stage and yet she has issues around food.
Charlotte: Oh, It was absolutely heart-breaking. So it’s a Paralympian called Kadina Cox and she’s one of the few people ever to have won Olympic medals in both athletics and in cycling. So she’s a sprinter and a track cyclist and she’s won medals in both and she’s an amazing athlete, obviously at the very, very top of her powers as a Paralympic athlete. And she came out recently in the last and how she’s struggled hugely with her perception of the way she looks and fuelling her body sufficiently. And I mean, I found that heartbreaking to read because she’s such an incredible athlete, but also I was so grateful to her for coming out and speaking about this openly because I think it’s really important that there are role models like that, that are being open about their own struggles in this way and that we can learn from how they’re dealing with them.
And she’s been really open about how it’s impacted on her training and her performance and how difficult she’s found things. And she’s not the only one. There have been quite a few other athletes who’ve come out and started speaking about this more openly, but I think she’s probably the highest level in terms of Olympic medals earned, who has actually talked about their experience with these issues.
01:20:20
Chris: Eating or eating disorders obviously aren’t simply about vanity, but one of the things I kept reading about in terms of different stories is how athletes are pushed to look a certain way and how this can be possibly a factor in this. It’s like the pressure to look like an athlete, whatever that means, or to have the body that is meant to be associated with that sport.
So you’re talking about distance runners needing to be sort of a lower weight and just how those pressures can then impact on the thoughts around how much food I should be eating and what I should be looking like and how disconnected that can really be to athletic performance where it isn’t about getting better times. It’s simply about matching up to some standard.
Charlotte: Yeah, it’s amazing how damaging these ideas can be and how prevalent they are and they affect men and women. The idea that, you know, the distance athlete has to be thin and with a very low body fat percentage and has to look in a certain way.
And I’ve heard comments on the start line of races where people have said, oh, so and so doesn’t look like an athlete or so-and-so doesn’t look like the kind of person who would win a race like this. And you just think, well, what do you mean how should this person look? What do you know about their body that their body should be in a certain way? Actually, I think that I’ve noticed recently that there has been a little bit of an attitude shift on social media and other places where I think there’s been much more of an acceptance recently that bodies don’t always look the way social media thinks that they ought to look or has wanted them to look in the past.
And I think there have been a bit more of a shift towards an appreciation of the functionality of bodies which is much to be admired. However, I do think there’s still this sort of issue that yes, it’s all right, we can accept you up to a certain point so you don’t have to be stick thin, but just make sure you’re not too big.
And I think that’s in itself very little actual true acceptance of all body shapes and sizes.
01:22:50
I mean, look at the outcry around these Nike mannequins which were used in their store and they happened to be of a larger size than normal, and there was a horrible article written in the Telegraph that this was somehow glamorizing obesity and it was just disgusting frankly, when all they were doing was showing activewear on bodies, which are slightly larger than what would normally be considered athletic bodies.
Horrible. Absolutely horrible attitudes. And I was quite shocked actually that the attitudes like that are still promulgated in the national press.
Chris: I was actually reading that article before we jumped on this call and I read the original piece and I read someone else’s sort of takedown or rebuttal to that piece and then foolishly read the comments below that article. And there’s this complete disconnect where the mantra is why don’t people in larger bodies or why don’t these fat people just eat less and do more exercise.
And then there’s a situation where Nike made clothes that are for people who are then in those bigger bodies. And the point is then now you’re glorifying obesity. And so I’m like, I don’t understand it. How does this then work? That you’re saying people should exercise and if they just exercise, they’d be able to lose the weight. But then you’re saying we can’t allow clothes to be sold to those people for exercise because otherwise that is endorsing obesity and I can’t get my head around it.
Charlotte: I think that they have no problem with the larger people exercising so long as they’re not doing it visibly. I think that it’s the visibility of larger bodies that is being objected to here, isn’t it? And that’s what makes it so upsetting.
01:24:45
Actually one of the things that just made me think, one of the things that’s quite interesting about the whole discussion around energy availability and it hasn’t quite percolated through I don’t think, but I think it will soon enough is that it definitely puts a question mark around the whole calorie counting thing that is used, especially sort of in gym culture where people are encouraged to use like My Fitness Pal and other apps to think that they’re being very accurate in counting their calories.
And actually, when you look at it through the lens of this energy availability model, you realize, well, first of all, the calories that people think they’re counting is so inaccurate that they have absolutely no idea of what they’re actually taking in. The way their body uses those calories is going to be incredibly complicated and a lot more complicated than just “I eat X calorie and my body uses Y calorie.”
And also when you think about what we were talking about before about energy availability over the course of the day and how that’s going to affect your metabolic rate and if your metabolic rate is suppressed because of low energy availability and how that’s going to affect the way your body processes calories, it just shows how much more complicated this really is than it’s been let on and the people who just say, oh well eat less and move more, clearly, that isn’t going to be as simple as that for the majority of people.
Chris: Definitely. No, I completely agree. I’ve done quite a detailed, I think it was as part of the podcast idea about my overeating experiment and I’ve done it somewhere else as well where I’ve talked about calories in versus calories out and all the components that go into that and why. Yeah, you have a lot less control over that as you think and the body really wants to try and balance things out and do things that it’s going to be helpful to preserve it as much as possible. So yeah, I completely agree with you on that. I would say at the other end of the spectrum where people get into the idea of calories don’t matter, that also irks me because I think that’s also not true, but it is way more nuanced than most people are having a conversation around this.
Charlotte: Oh yeah, it is. It’s so nuanced. And I think the nuance comes because it’s so difficult to actually calculate how many calories you are using and how many calories you are burning without access to a laboratory and using things like My Fitness Pal or a sports watch and a heart rate monitor. Yeah, it’s going to approximate, but it’s not going to be anywhere near accurate. And the margins of error can be large enough to cause serious harm.
01:27:50
Chris: Totally, and even, I think at the laboratory level, you’re not getting a proper perspective on what’s happened previously. So for example, if you’ve been under eating for 10 years and overtraining for 10 years? And then you go into a laboratory, it’s telling you, okay, what’s going on today? It’s not telling you about all the debt that you’re into to rebuild all of those barriers systems. So you get into this idea of, oh, I just need a couple of extra hundred calories, so I just need a little bit extra based on what the lab is telling me and you’re really missing the forest for the trees.
Charlotte: Oh, that’s a really important point. Really, really important point. And I don’t think that’s always very well understood actually. Yeah, really, really important. Very interestingly, one of the things that I was told by my sports medicine practitioner who’s been overseeing my own recovery when we talked about my nutrition, he said to me, would it just always give yourself a buffer? He said, eat what you think feels like you’re eating plenty, and then eat some more. He said your body just needs that buffer. And I remember kind of sitting there thinking, wow, nobody’s ever said anything like that to be before. Usually, it’s make sure you don’t eat too much and you never want to, you know, you never want to go over that level. And you always be careful that you’re not taking into much for the first time in my life ever, somebody said to me, eat loads and then more and it was an incredibly liberating thing to hear from a medical practitioner.
Chris: Yep. I mean that’s the feedback I’ve been given by a number of clients of like; you don’t know how refreshing it is. You don’t know how helpful it is to be told that there is no maximum that they are allowed to eat as much food as they need as part of their recovery and the body needs to be able to do what it needs to do. Because even when people have attempted to get better, there’s an, okay, you can have more of it, please don’t overdo it. And so to be really given that, that freedom to be even that permission can be really helpful because it’s hard to do that for yourself.
Charlotte: It really is. It’s incredibly hard to do it for yourself and particularly in combination with say being told that you can’t do your sport or you can’t exercise. So suddenly you’re in this situation where you’re being told you’ve got to eat a lot more to support your body, but you also can’t do the exercise that you’ve been used to doing. And that’s a really, really scary scenario to be in for anybody. I mean, even somebody who’s pretty healthy around their food habits, if they were put into that situation, they probably would find that quite hard to deal with and they were talking about people who were probably are coming from a history of disordered eating, if not actual eating disorders and they’re suffering from RED-S or related problems. They’re told to eat more as I was which is a good thing to hear.
But that’s kind of where the support ends and this is the problem, I think everybody I’ve spoken to who has had this diagnosis come up against is that they’re supported to some degree, they’re supported through the diagnosis, there’s a lot more awareness in the medical community if you have access to a sports medicine department through the NHS in the UK and I really cannot praise them more, but they’ll look after you in terms of your hormones and they’ll look after your orthopedics. And I’ll talk to a little bit about your eating habits, but then you’re sort of on your own and that is a huge, huge problem.
Chris: Definitely. And I think that’s the issue with health very broadly as well is that it feels like what is deemed as the missing link is that people just don’t have enough information and then if you give them more information, then they will get on with this and just do it themselves. And I don’t think that that’s necessarily the missing link for a lot of people. Like yes, there are people who were like, Oh wow; I didn’t know I was under-eating. And thanks for that. I’m now able to just eat more and I’ve noticed my performances got better and like end of. But for the majority of people, that psychological component is there and it’s then less about the information because a lot of people know all of this information.
It’s about how do you actually change behaviour? How do you put in other coping mechanisms? How do you actually make this work for yourself as opposed to just I’ve read all the research?
01:32:45
Charlotte: Yes, and that’s the question to which there isn’t an answer as yet. I think a change in culture is really important. Coming back to the discussion about the Nike mannequins, just normalizing different sizes of bodies in athletic culture I think would go a long way, I really do.
Also, things like providing support to people who need that support through say the National Health Service. So at the moment, for example, you either have the eating disorder support, which is available and which you can only access if you have a diagnosed eating disorder. So if you fall under certain level of BMI, you can be diagnosed with anorexia, you can access those eating disorder support services or, but they are very separate from the services who are supporting people who come through the athletic side of things so with this RED-S who come to the sports medicine or the orthopaedics area and lots of people will enter the system because they’ve had stress fractures or they’ll come into the system through the hormonal endocrinology side of things.
So they’ll have presented to their GPs with having not had a period or related symptoms like that and they get into the system that way. So you have this sort of atomized service provision, all of which are working in their own little silos and then once you are discharged from that silo, there is no more support for you full stop. And I think that’s a real problem.
01:34:45
And at the moment and the way our health system in the UK is structured, and I don’t think this is different a lot from other countries, there just isn’t really a solution. Having said that, there are a few fantastic practitioners who are working in the private sector, so Renni McGregor and who is a fabulous sports nutritionist, probably one of the best around in the entire world. She and Nicola Ki who I mentioned previously have set up a clinic, a private practice clinic, I think in London and Bristol specifically for people who are suffering from RED-S from the perspective of eating disorder therapy, but also looking at the symptoms that we’ve discussed, which come under the RED-S umbrella and specifically aimed at athletes or exercising people who are suffering from these problems. But again, that’s only accessible to those who are capable of paying for it. Which can be, you know, it can be very expensive and it can be quite difficult to access.
So at the moment that is, that’s the only private clinic which is specifically looking at this problem. There is an NHS consultant and so Dr. Nicola Ki has set up a clinic in London. It’s an NHS clinic and it is possible to request a referral to that clinic. And I will give the details of that for the show notes. So it is possible for a GP to request a patient to be referred to that clinic, however, again, the waiting lists are very long. And that is a very small clinic which is catering to quite a large population.
01:36:35
Chris: So I know we’ve chatted a lot, in part, about your story or how this has affected you, but do you want to kind of just go into that in a little bit more detail about your experience?
Charlotte: I will. It’s a bit of a sad story really. And it’s interesting to kind of look back on it now that I’ve almost come out the other side. Well, hoping to come out the other side. The last time we spoke I’d spoken quite a bit of detail at that time about my own experiences of a certain level of disordered eating and the tendency towards over-exercise.
And I recognized in myself that I had these problems. Unfortunately and rather embarrassingly, I didn’t really get a hold of them. And I think, and this is something that happens to a lot of people, as I got more successful, the problems got worse and it culminated last year and I was quite successful in some of the races that I did and I won quite a big ultra marathon in the summer.
And then I threw myself into training and I was incredibly fit and I was working my way through the winter just getting fitter and fitter and I was running very well and actually felt great. But I was aware that I wasn’t following the most healthy practices in terms of my eating. For whatever psychological reasons as we’ve discussed, I wasn’t able to get out of this feedback of undereating and overexercising. I think a lot of it had to do with the normalization of extreme exercise in a lot of the circles I was in. So I was surrounded by a lot of other people who do ultra marathons. Where running a lot of volume every week was pretty normal and in my mind, you know, running 10 miles was nothing. So I didn’t really need to think about eating anymore. It wasn’t an issue and I was just caught in quite a bad trap and I was able to sustain it for a few months and then slowly but surely the symptoms started to creep in.
And I’ve spoken elsewhere about the symptoms of overtraining syndrome. And I think it’s interesting that some people recognize these symptoms but won’t have put together the jigsaw which shows that these actually are symptoms of overtraining.
So for example, I started getting terrible night sweats and this is something I remember vividly where I would wake up every morning without fail at three in the morning, absolutely soaked through with sweat. It was horrible. And I would have very bad leg pains at night in particular, I would get aching legs or twitching legs and that sort of thing, muscle aches. Then I started getting a numb foot. And this was when I think I realized, okay, something is quite significantly not right here. I would be out for a run and my right foot would randomly go completely numb and it could last hours and I would just run on a numb foot.
And then probably a couple of weeks after the numb foot, I started getting bone pain and I knew immediately because I’ve had so many stress fractures, I knew immediately I had a stress fracture and I did, I had a tibial stress fracture. But annoyingly, it was in exactly the same place on the bone that I had had a stress fracture the previous year. So the bone had just basically re-fractured in the same place, which means it’s a lot worse than it was.
And that’s when finally I went through the orthopaedic system and I got referred to the sports medicine specialist here where I live in Oxford. And that’s where the diagnosis of RED-S was finally brought on board. And that’s where I was encouraged to really assess my habits and my eating in a more constructive way than I think has ever been done before.
And actually I think I’ve been relatively successful in doing that. I have been able to be more reflective about the way I eat and the way I have been eating. And I’ve definitely been able to improve my eating habits and I’m quite proud of myself for that.
In terms of the exercise, I’ve had to address my tendency to over-train. Every time I’ve gotten fit, I’ve pushed it too far and I have pushed myself into a state of overtraining. And I have very much been forced to reflect on that quite significantly. And now that I’m at the point where I can just about start training again, I am running a little bit again, I’m very conscious of my own tendencies to overtrain and very conscious of the importance of not allowing myself to do that again.
And at the end of the day, I’m 40 years old and I’m not going to have too many more chances. I would very much love to never have another stress fracture and that’s my aim in life at the moment.
01:42:20
Chris: And so something you said at the beginning of that, which was you were pushing really hard and then you were seeing really good results even though something was kind of off or at least you recognized something was kind of off. And my sense with that is probably because this isn’t like your first rodeo; you’ve been doing this for a really long time. But my sense with the other clients and with other people who are maybe younger who haven’t had the stress fractures you’ve had who haven’t owned up to some of the issues around food that you have is that they will see that performance getting better and better as an indication of, okay, I found this winning formula.
Because when I look through the list of like potential performance indicators that can happen as, as part of RED-S, a lot of them are like further on down the road where you start kind of falling off that cliff where you’ve gone past the point. And so it’s interesting to hear you kind of talk about at the point in which you were essentially winning things and for all intents and purposes, you are at your “fittest” this was also when things were really going awry.
01:43:45
Charlotte: It’s true and I think it’s really important to separate the concepts of being physically fit or fit for a sport and being healthy. I was incredibly fit in December 2018. I was running, you know, easily 80, 90 miles a week over mountains. I was cardiovascular extremely fit, I was strong, muscular. I could lift weights.
I was deeply unhealthy, deeply unhealthy. But if you looked at me, I looked like the, you know, the pinnacle of what Instagram considers fit. I had visible abs, which seems to be what it comes down to these days. But I was deeply unhealthy and I would really like that to be a message that is better understood more widely is that the concepts of fitness and of health are not synonymous. In fact, they can be extremely oppositional in certain circumstances.
Chris: Definitely, and I think part of that’s just a function of how we define fitness. If you define it in a narrow enough band, you can say you’re fit. But if you actually broaden that out and look at, okay, what does fitness mean in terms of your whole life? And then that starts to fall down a little bit.
Charlotte: Yes, and we should absolutely make sure that people understand that the concept of fitness needs to include the fact that their body is in a functional state. So being able to run x number of miles but not having a period means that you’re unhealthy, full stop. And this needs to be better understood.
And it’s actually something that I’ve been doing a little bit of work with a friend of mine who’s a personal trainer. And we’re thinking about the gym-going population who haven’t really been included in a lot of this discourse, which has been very much based around endurance athletes and maybe to some degree dancers and people like that or people in weight-related sports.
But we haven’t really talked about the general gym-going public who sometimes don’t have very good guidance, who might be really susceptible to some of the more toxic messages coming out of social media around nutrition and body image. And getting the message out there about the dangers around low energy availability I think is really important that people who are working out in gyms who also can be putting themselves in low energy availability very easily need to better understand the dangers of some of the practices which are very common in a lot of gyms.
Chris: And so, how are you going about disseminating this? What are you doing in terms of on the ground?
Charlotte: So at the moment this is very much just starting out. So, first of all, I’ve set up a Facebook group, which has been incredibly supportive and open and I think a really good model of the dissemination of information. So I would love anybody who is interested in this topic to come and join us on our Facebook group and join in on the conversation.
The other thing that I’m trying to do and trying to get off the ground at the moment is as well as a few articles. So I’ve got an article forthcoming in Ultra Magazine, which is very specialized for ultra runners but it will be available on their website at some point in the future. And it does look at all the things that we’ve talked about today, but through the perspective of ultra running in particular.
I’m trying to broaden that out more widely and I’ve put together a worksheet which I’m piloting with a few running clubs in my area, specifically looking at people who are new to running, to go through the coaching apparatus in the clubs so that the coaches are aware of this issue and are able to communicate it in an understandable way to people who are new to the sport.
And we’re hoping to roll that out to cycling clubs and triathlon clubs as well. And then with the gym system, as I say, I’ve been working with a friend who’s a personal trainer to do something similar for gyms in terms of like gym inductions and getting personal trainers more aware of these issues. And maybe including it in some of the personal training qualification courses which are available out there. But again, it’s very, very much early days at the moment, but I’m hoping over the next few months these ideas will become further evolved.
The other thing that’s worth saying is that Rennie McGregor, who I mentioned previously has a fantastic campaign called #TRAINBRAVE and they run regular-ish free sessions around the country. There’s one in Oxford in June, I think the 23rd of June is the most recent one coming up. I don’t know when you’re going to put this podcast out so it might be too late to that. But there will be others.
These are probably aimed at a higher level. So it’s aimed at athletes who would probably already be aware of this, maybe already had a diagnosis and are probably coming out of the sort of sub-elite running culture for whom for a lot of what we were talking about is relatively familiar already.
Where I’m trying to come in is at a lower level than that and reach the people who will have never heard of RED-S with a female athlete triad. And for whom this is all very new and won’t have access to the source of information that, for example, Rennie McGregor quite widely is disseminating at the moment.
So I think we’re all trying really hard to reach our various audiences. And I’m just trying to fill in some of the gaps which have been left because the work that Rennie and others have done has been just amazing and I would never want to overshadow the stuff that they’ve done already.
01:50:35
Chris: She’s someone I really want to now get on the podcast. I know she’s written a book also on Orthorexia and so I think it would be a really interesting conversation to have with her. I mean, if I’m thinking of things to be telling people at the lower end of things or just getting into gyms or even starting to, I’m just doing my first 5K or I’m just doing my first triathlon and this is stuff that I would have liked to have thought about when I was doing those kinds of things is like, hey, it’s better to be undertrained than over trained, like way better.
I think I did much better in any events that I did. If I turned up and I thought, Oh God, I probably should have trained a little harder for this. Then when I turned up and I’m like, Oh God, I wish I just had a little bit more downtime. So being undertrained is much better than being over-trained, but the other one when sort of thinking about that when trying to work out what a schedule would be, is really thinking about the other stresses that are going on in your life and thinking about exercise as a stress.
Like yes, it has benefits to the body, but that benefit comes through hormesis, that benefit comes about because of the adaptions that happen as part of eating more and resting more, et cetera. And so rather than thinking like exercise is always this healthy endeavour, and if I just put in some more, it’s going to be doing better things for my health is okay, exercise is a stress on the body.
It doesn’t necessarily make it bad, but let’s look at all of the other buckets in which I’m adding stress to the system to work out what would be the appropriate style of exercise, what would be the appropriate amount of exercise so I can actually benefit from this as opposed to it just being something that pushes me further down.
Charlotte: Absolutely. And of course, you know, this has been standard in sports science, exercise science, exercise field in physiology forever. But the problem is that none of that has really been expressed in ways which can be easily accessible to people who are new to the concepts of exercising.
And I think under the influence of social media and certain Instagram posts and all of that sort of thing, the ideas around moderation and rest and recovery are just drowned out by the noise of do more, push harder, no pain, no gain. If you’re not sweating, you’re not burning and all of this. And then there’s just this lack of education around the reality of how you train your body and even those people who should know better frankly, often don’t.
Chris: There was a great quote from Mary Kay and I can’t remember, it was an article by her or she was just quoted in it and she’s an American runner and she said that she’s learned that running is truly a sport when 90% of the time you are injuring yourself rather than being injured. And I, yeah, I think that really kind of spoke to a lot of what we’ve covered today.
Charlotte: Absolutely. Yeah. It really does. And if anything can be expressed through our conversation today, I just want people to realize that you don’t have to force yourself to train. You don’t have to force it. I had a coach who was really, really good and one of the things he said was, you want to run. You love running. You enjoy it. If you don’t want to go for your run, there’s probably a reason why you shouldn’t go for the run and we just don’t trust ourselves enough I think. And the whole culture of using watches and tracking our steps and tracking our calories and posting our runs on Strava and posting our workouts on Instagram, it’s just removed us so much from actually tuning in to the way our body is functioning and feeling the things that we want our bodies to achieve.
One of the things that I’m trying really hard to do is to just tune in to what signals that my body is telling me. And to actually trust those signals more, down to the idea of running without a watch and figuring out the pace that feels comfortable to me, that isn’t being dictated by the pace I feel like I ought to be going or figuring out, thinking to myself actually I am hungry. So I will therefore go and eat something instead of second-guessing those hunger signals all the time, the way I used to. And I think if we can help people to tune in and trust their own body’s feedback better, they go a long way to recovering or not developing these problems in the first place, definitely.
01:55:45
Chris: And I really like your coach’s advice. I would also say the inverse is true. Like if you have a problem not exercising and struggle to take time off even if you like, no, but I really love doing this. I think that’s also problematic. Like if you have a situation where if you’re trying to go on holiday for a week or two weeks and you can’t exercise and that is a real issue for you, I think that’s as much a warning sign as well.
Charlotte: Oh yes it is. And that’s me. I still can’t, I have to admit. I still can’t go on holiday without it having something to do with my exercise regime. And it’s a problem. And I’m probably for the first time in my life actually admitting that it’s a problem. And maybe admitting the problem is the first step to addressing the problem. I don’t know. Hopefully, it is. And hopefully at some point in the future, I’ll be able to take that next step. At the moment, I’m still very much caught, I think in the wanting to exercise for things where I can exercise within the constraints of my own issues around my body.
But, and I do think that it is a problem, isn’t it? Because we know that exercising is genuinely good for you, within reason. And some of us go overboard with it and some of us are unhealthy in our approach to it. But equally, some people are unhealthy in their approach to never exercising at all.
And so yes, again, it all becomes this question of moderation and finding the happy medium around doing just the right amount of movement that is healthy for your body and finding that comfort zone and that area where if you’re training for sport that you’re training in just the right way for that particular sport and if you’re training for health, that you’re training in just the right way to optimize your health.
But I do think that it’s really, really difficult to find that place and having resources available to allow people to figure out where that place is for them is really important. And that’s one of the things I think that we’re trying to do here with this RED-S campaign is to try and at least raise awareness enough so that people understand the dangers that come with access on that particular side of the exercise spectrum.
Chris: Definitely. So look, Charlotte, we’ve covered a lot. Is there anything that we haven’t gone through that you wanted to mention or any resources that you haven’t mentioned? I know that you’ve touched on a lot of people and different sources you think is valuable, but yes, anything final?
Charlotte: I don’t think so, I think as I said I really would love to encourage people to come and join our Facebook group. I hope you’ll put a link to that on the notes and to read through some of the papers on the notes that we provide and to get in touch.
So, I mean I would be more than happy if people wanted to get in touch with me directly, I can point them in various directions as well. I’ve got a few contacts with people who are capable of giving professional help so one person in particular who I’ve found incredibly useful, is a woman called Jill Pouliot and who is a qualified counsellor and she specializes in over-exercising and amenorrhea and she has been incredibly helpful to me in particular and she has a lot of knowledge and resources in the area. So I would highly recommend people either contact her if they were suffering from these things.
Chris: And just so people know, is her website “A Case of The Jills”?
Charlotte: It’s A Case of the Jill’s, that’s right. acaseofthejills.com and she’s got a quite a lot of YouTube videos where she discusses in a very entertaining and informative fashion, various ideas around this area. So I would highly recommend looking at her material. And there’s just a lot of other material out there which we can link to both very scientific and also some of the less scientific articles which are available and some from some other magazines. And hopefully my own article in Ultra Magazine, which will be another voice in this increasingly vocal area.
Chris: Perfect. Well look, I will, as I said, put all that in the show notes and I hope people can explore it. Thanks once again for coming on the show and talking both about your experience, and all the knowledge in this area that you have and yeah, I wish you the best in terms of your recovery and getting back to being able to do the sport that you love a but in a way that is helpful both for the physical body and for mental health as well.
Charlotte: Thank you so much. It’s been an absolute honour and thank you so much for the work you’ve done and for your amazing podcast.
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