2 What is the problem?

RED-S occurs for several reasons as you shall see, but central to its development is an intentional or unintentional restriction of sufficient energy to effectively fuel training, recovery and health. For some athletes this stems from a belief that restricting the diet and losing weight will improve performance, while for others it is about conforming to socially constructed body image of attractiveness. The third cause is when energy intake restriction happens because of a clinical eating disorder.

But what is the cost of RED-S on the body? In Activity 1 Anna Boniface, an international marathon runner, shares her experiences.

Activity 1 Stress fractures and osteoporosis

Timing: Allow about 10 minutes

Listen to the audio clip where Anna Boniface tells her story of how long-term under eating and over training impacted on her body and performance in marathon running.

Then answer the following question:

• What impact did Anna’s overtraining and undereating have on her skeleton?

Download this audio clip.Audio player: boc_sfps_1_session7_activity1.mp3

Show transcript|Hide transcript

Transcript

INTERVIEWER

Tell me about the Toronto marathon.

ANNA BONIFACE

So, unfortunately, sports is quite cruel in some ways. So I’d had a bit of pain in my ankle leading up to the race, but I was still able to run. As a marathon runner, you get a lot of little niggles and things. So I just thought it was just another little niggle. So I started the race and it started just to get worse and worse throughout the race. And we were still running quite quick. I was still on for quite a good time. We went through 10 miles in under 60 minutes. But I just remember just all of a sudden the pain really, really suddenly increase, and then I just couldn’t run another step. And I just classically tried to hobble on, but I couldn’t, because the pain was too much and I couldn’t wait there. So I just sat on the curbside. Reminded me of Paula Radcliffe in Athens, just sat there waiting for someone to come and find me.

INTERVIEWER

This should have been the pinnacle of your career, representing your country at an international marathon. And there you are sitting by the curbside at mile 10, unable to go on. How was that?

ANNA BONIFACE

It almost feels that I don’t really justify being able to wear that England vest because I never finished the race. So I’m now quite hesitant to say that I’ve had an international debut, because I feel like it didn’t really happen because I didn’t finish it. So I feel like I have a lot of unfinished business with the England vest.

INTERVIEWER

When you came back to the UK, you had tests done. And what was the outcome?

ANNA BONIFACE

So I saw a sports medicine doctor. She clinically diagnosed me with stress fracture, and then had an MRI which confirm that. Consequently, we also found out that my bone density was reduced, so. Having osteopenia, which is like the precursor to osteoporosis, and some osteoporosis in my spine as well. So it was a bit of a shocking revelation.

INTERVIEWER

And your problems with your spine were linked to RED-S, relative energy deficiency in sport.

ANNA BONIFACE

Yeah. So when I saw my sports medicine doctor, that’s her main diagnosis. And the cause of the stress fracture. So low bone density, stress fractures. One of the big things that’s often associated with it.

INTERVIEWER

And what caused that?

ANNA BONIFACE

For a long period of time, I wasn’t menstruating. So I wasn’t having periods. So it was probably eight years of not having periods. And it’s a really important process. I think people go, oh, wow, you don’t have them. That’s a great thing not to be having to deal with every month. But actually, it’s very important for your bone health as the hormone oestrogen and some other hormones as well are very bone-protective and they help build up your bones, so--

INTERVIEWER

So having your period is actually vital to building the strength of your bones?

ANNA BONIFACE

Well, your hormones are part of that. And obviously, your period is part of a hormone process and a hormone cycle. So your period is more like your barometer to your hormone health. So it’s actually a really good sign to say that, hormonally, you’re quite healthy. So by not having your period, it’s this indicator that your hormones aren’t doing the job that they should do. And that because you’ve not got enough energy, your body’s shutting down one of those processes.

End transcript

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Discussion

Anna says that she had not had a period for about 8 years and identifies the lowering of the hormone oestrogen as damaging to her bone health. As a result she experienced a stress fracture to her ankle due to reduced bone density (‘thinning’ of the bones). It was also found that she had osteoporosis in her spine which could have led to thinning or fractured vertebrae.

Anna outlines the link between bone health and disruptions to the menstrual cycle. The loss of a regular menstrual cycle (amenorrhea) leads to lower bone mass, less bone strength, and higher rates of fractures among athletes (Elliott-Sale et al., 2018).

What is the relationship between low energy availability and the menstrual cycle? You will explore this in the next section.