/ ARTICLE: Relative Energy Deficiency in Sport - A Cautionary Tale

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UKC Articles 21 Oct 2019
Mina Leslie-Wujastyk. Mina Leslie-Wujastyk writes openly about her recent diagnosis of Relative Energy Deficiency in Sport (RED-S) as a warning for other climbers who may be expending more energy than they take in.

Historically, there is a precedent for unhealthy and unsustainable approaches to training and nutrition that have helped to normalise some really dysfunctional habits. I didn't think I was crazy in what I was doing; I looked around and saw plenty of other climbers doing the same, and sometimes more extreme, things. Knowing what I know now, that scares me.



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profitofdoom 21 Oct 2019
In reply to UKC Articles:

Good article, honest, useful, thanks

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Si Witcher 21 Oct 2019
In reply to UKC Articles:

This is made more powerful by being written by a role model at the top of the sport too. Anything to keep the alarm bell ringing re eating disorders and over-training is great, thank you.

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bouldery bits 21 Oct 2019
In reply to UKC Articles:

Fab article. Thanks. 

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Hardonicus 21 Oct 2019
In reply to UKC Articles:

Synopsis - "More Pies"

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ClimberEd 21 Oct 2019
In reply to UKC Articles:

I'll be honest - initially I thought 'another indulgent article about a female athlete who wants to 'climb hard' and has an eating disorder.

But very very good. Very well written, thought out and explained. Overtraining/under eating is a common problem in other sports, particularly those with a focus on endurance (it is rife in the amateur triathlon world), and a greater awareness of it in climbing is only a good thing. As discussed it can have longer term effects on the body than just a short term slump in energy levels.

One emphasis I would change though is that it can effect men equally as women, it is definitely not a 'female problem', despite in the case of females the main symptom being masked by period issues.

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UKB Shark 21 Oct 2019
In reply to UKC Articles:

Props Mina for going public on this and with such frankness.

RE below quote and by extension presumably currently popular low carb / ketogenic type diets presents extra specific risks?

“Essentially, when the body doesn't receive enough energy (specifically carbohydrate) relative to demand, it will prioritise fuelling movement and down-regulate other physiological processes in order to conserve energy.”

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Qwerty2019 21 Oct 2019
In reply to UKC Articles:

Thank you for a lovely article.  As the father of a young girl heavily into competitive climbing this is very interesting.  At best I bumble along trying my best to ensure she is healthy but articles like this are brilliant at refocussing us parents to promote good habits.

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Ramon Marin 21 Oct 2019
In reply to UKC Articles:

So brave of Mina, well done for writing this. Though I don’t know anyone who diets, i can see how devastating it can be. 

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Niall Grimes 21 Oct 2019

Really interesting article, thank you Mina.

It's an interesting thing, the thing of 'role models' are nearly always folk who push themselves to extremes in one aspect of life.

Often, when I see a statue of a great engineer, or an image of an astronaut, or a programme about someone who sails the world, i think, Do they never spend any time with their family? Do their children ever see them?

Not a criticism of Mina, just reinforcing the point she makes about the cost of Excellence.

Good effort putting it out there.

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jamieevans 21 Oct 2019
In reply to UKC Articles:

Thankyou Mina for a very frank and professional article.

The mention about cycle commuting gave me something to think about. 

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LouisJones 21 Oct 2019

Good stuff, everyone should read this.

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Anna Siodelska 21 Oct 2019
In reply to UKC Articles:

Thank you Mina for such a great article that can help so many!! xxx

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tessa teapot 21 Oct 2019
In reply to UKC Articles:

Well done Mina for sharing your experience. I don't normally comment on articles but felt this probably took some guts to write and share, and you've articulated it really well.

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Clare Dean 21 Oct 2019
In reply to UKC Articles:

Thank you for this article Mina, a very interesting and important topic.

I think it is very useful to highlight how the process of pushing your physical limits (be that through sporting performance or dietary control) can be extremely addictive. You successfully redpoint that route; gold star! You manage to stick to your prescribed diet plan; amazing, another gold star "I feel so good about myself, I'll keep doing this..."

I'd be really interested to hear more about the symptoms you've experienced, as well as your recovery process. If you're happy to share this of course.

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Shani 21 Oct 2019
In reply to UKB Shark:

I've mentioned targetted ketogenic diets and cyclical ketogenic diets before in our exchanges. You might find them insightful concepts.

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alicia 21 Oct 2019
In reply to UKB Shark:

> Props Mina for going public on this and with such frankness.

> RE below quote and by extension presumably currently popular low carb / ketogenic type diets presents extra specific risks?

> “Essentially, when the body doesn't receive enough energy (specifically carbohydrate) relative to demand, it will prioritise fuelling movement and down-regulate other physiological processes in order to conserve energy.”

I would be interested to see what the evidence and/or reasoning is that Mina is relying on for the "specifically carbohydrate" language here as no obvious evidence or mechanistic explanation comes to mind.  Sure, if the body doesn't receive enough energy, there will be down-regulation.  But the energy received can either be direct consumption of carbohydrate or it can be consumption of other sources of energy followed by production of carbohydrate via gluconeogenesis.  This doesn't mean that additional carbohydrate can't be useful for an athlete at times, only that I'm not aware what the evidence is that a lack of carbohydrate specifically, rather than just a lack of energy generally, is the trigger for down-regulation.

The reason I think this is important is that possibly the most logical way to avoid RED-S as an athlete is to focus on foods with the highest nutrient density, i.e. the greatest quantity of nutrients per given quantity of calories.  And because the most nutrient-dense foods tend to be low in carbohydrates (think oily fish, meat, and eggs), this suggests that someone aiming for maximum nutrient density may naturally end up eating a fairly low carb diet.  This in turn makes it important not to be more wary of low carb than necessary. 

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abarro81 21 Oct 2019
In reply to alicia:

Not sure I follow your second paragraph... It implies that you think RED-S is triggered by nutrient deficiecny, not caloric deficiency... I thought it was energy deficiency? Assuming it is (energy deficiency), then nutrient deficiency is only a limiting factor if the thing stopping your body producing enough energy is a nutrient deficiency, not if it's an energy expenditure that's too high or an energy intake that's too low. To a lay-person it seems unlikely that many athletes would fall into that category. Do you have a reason to think otherwise? If not the rest of the logic falls entirely

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Shani 21 Oct 2019
In reply to alicia:

For peak athletic performance in power sports it is reasonably well established that CHO is superior AFAIK.

In Mina's case it looks like over-training. I don't know enough about her training cycles, whether she deloads or tapers etc.... but the following is a common mistake; more is not more:

"Give me a training program and I'd always do extra. Multiple sessions a day, 5-6 days a week, running on my "rest" days. That's what "athletes" do right?"

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sheppy 21 Oct 2019
In reply to UKC Articles:

A really enjoyable and eye opening article and very personal so must have been hard to write. Hopefully the recovery goes smoothly and I believe that you will end up climbing even better at the end of it.

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alicia 21 Oct 2019
In reply to abarro81:

In a nutshell, I think the evidence most strongly suggests that it is about BOTH caloric deficiency and nutrient deficiency.  I do understand that the current paradigm focuses only on calorie deficiency, and I think that is a huge mistake.  For example, in women, one of the more "upstream" issues in RED-S is loss of menstrual function, which results in a cascade of negative downstream effects such as an adverse impact on bone health.  Yet amenorrhea does not actually correlate that well with body fat percentage, suggesting that the issue is not purely about energy availability.  Other aspects of RED-S such as immune system dysfunction and psychological symptoms are specifically linked with nutrient deficiencies.  Obviously there is a dissertation's amount of material to go through here, which isn't really possible for me to do in this post!  But I do encourage anyone interested in treating or preventing RED-S to have a read through the literature with an eye towards whether caloric deficiency alone, or a combination of caloric and nutrient deficiency, best correlates with what is seen.  If it's the latter, that would suggest that there may be a lower threshold for triggering RED-S when the diet is poor in nutrient content.  

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alicia 21 Oct 2019
In reply to Shani:

Did you mean to be replying to me?  If so, just to be clear, my post wasn't about whether CHO is superior for peak athletic performance in power sports...

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Rock&SausageRoll 21 Oct 2019
In reply to UKC Articles:

Really good article thanks, i didnt even know this illness existed before reading.

Coming to climbing from a fell running back ground I totally understand the over training mentality thats easy to fall into. High intensity training like doing laps on routes and traverse circuits defo triggers the same endorphin spikes as running does.

I dont operate at levels in climbing close to the sharp end but have fallen into similar training traps. Especially because i sometime try to maintain both sports.

Suppose my point is i dont think this behavior is always only practiced at the sharp end... and the climbing community who cross the multi sports line are probably at just as higher risk.

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Iamgregp 21 Oct 2019
In reply to UKC Articles:

Fantastic and frank article, props to Mina for being so open and honest.

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abarro81 21 Oct 2019
In reply to alicia:

>  Yet amenorrhea does not actually correlate that well with body fat percentage, suggesting that the issue is not purely about energy availability. 

I was under the impression that RED-S can cause your body to preferentially store fat rather than making energy available for "useful" functions (life, training, making hormones etc.) - hence why you can have issues with it while not looking like you're messed up and eating too little. If that's the case, then you wouldn't necessarily expect correlation with body fat %, and the lack of correlation wouldn't actually imply what you suggest (i.e. lack of correlation would not suggest that it's not just about energy availability)

Got any good links?

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Shani 21 Oct 2019
In reply to alicia:

> Did you mean to be replying to me?  If so, just to be clear, my post wasn't about whether CHO is superior for peak athletic performance in power sports...

Sort of. I'm agreeing with what you wrote but have clarified one or two points in the spirit of wider discussion.

I too was curious as to why fault was attributed specifically to low CHO when it appears (from what i can tell), there are other factors at play.

Post edited at 16:03
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alicia 21 Oct 2019
In reply to abarro81:

I haven't seen anyone proposing what you suggest, about the preferential fat storage.  Read through this:

https://bjsm.bmj.com/content/52/11/687.long

and notice that they do note the discrepancy that many studies find between energy availability as a function of intake v. expenditure and what they would consider the pathology of low energy availability.  They give a few hypotheses for why this may be, but it's striking how contorted they are.  This study, for example, suggests that energy deficiency is involved but not the whole story:

https://www.physiology.org/doi/full/10.1152/ajpendo.00386.2013

Honestly, I'm not totally sure how nutrient availability isn't somewhat obvious as an area on which to focus the research.  Think about what you would expect to happen if you fed someone, every single day, 2,000 calories of white bread unfortified with any vitamins or supplements.  Then imagine how their health at the end of 3 years of this might compare to the health of someone who had eaten 2,000 calories of a mix of fish, broccoli, asparagus, roast beef, yoghurts, and nuts.  That's obviously the extreme end of the scale, but it shows that we all intuitively know that health in general is not simply determined by the amount of calories eaten.  Why do we think that RED-S would be any different?  It's a syndrome made up of discrete components, all of which we independently know (with the exception of menstrual dysfunction, because we lack research--what a surprise to be lacking research on a women's specific health issue) to be affected by not just the quantity but also the content of the diet.  And even with menstrual dysfunction, it seems to be a prevalent (and logical) view that nutrient deficiencies can be causal, although this doesn't seem to be well tested.

I think we have become locked in a bit of a loop since early hypotheses were that all of the components of RED-S were caused by low energy availability.  So, to test this, the research increased energy availability and, voila, improvements.  But nothing, or at least nothing that I've ever found, controlled for the fact that by increasing energy availability, they were also increasing the absolute quantity of nutrients.  And now that the question is viewed as being settled, there is little incentive to go back and properly distinguish between the two factors and the relative causal roles that each might play.

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PaulTclimbing 21 Oct 2019
In reply to alicia:

Think about what you would expect to happen if you fed someone, every single day, 2,000 calories of white bread unfortified with any vitamins or supplements.  Then imagine how their health at the end of 3 years.

Is that what happened in that televised/social media 'Supersize Me'

burger experiment where the person just ate a Big M for every meal for a month to bad effect. Like is that true? Is there really a genuine problem with fast food....as it often appears balanced with salad etc. Like a chicken kebab for instance. 

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Shani 21 Oct 2019
In reply to PaulTclimbing:

> Think about what you would expect to happen if you fed someone, every single day, 2,000 calories of white bread unfortified with any vitamins or supplements.  Then imagine how their health at the end of 3 years.

> Is that what happened in that televised/social media 'Supersize Me'

Supersize Me is bollocks unfortunately. The real strory is about "what will a man would do to secure 'Ugandan discussions'?" His vegan girlfriend had more than a passing influence i understand. 

https://www.theguardian.com/lifeandstyle/2006/sep/07/healthandwellbeing.health?

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Ged Desforges 21 Oct 2019
In reply to Si Witcher:

Did I read a different article to you? That didn't seem to be about an eating disorder to me. 

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Isabelle Booker 21 Oct 2019
In reply to UKC Articles:

Well done Mina for sharing this, thanks! I feel that the benefits of physical training and to some extent, weight loss, are being over emphasised somewhat at the moment within climbing media. So much so that people entering the sport might think that the key to being good is doing a one arm pull up and losing a stone.  For people who work full time and train/climb, calorie restriction can just suck the joy out of life and for many it is unnecessary. I have experienced the downsides of over exercising, calorie restriction and holding down a stressful job. Being more relaxed about eating and resting more has enabled me to climb harder than ever. At times this more relaxed approach feels counterintuitive and I can see why passionate driven people people end up having RED S. 

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webbo 21 Oct 2019
In reply to Ged Desforges:

Not eating the required diet to keep you healthy over several years  . How is that not an eating disorder.

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Michael Gordon 21 Oct 2019
In reply to webbo:

'Eating disorder' to me sounds like quite a loaded term, like eating too much/little due to mental health issues, rather than an athlete perhaps just being poorly informed.

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Ged Desforges 21 Oct 2019
In reply to Michael Gordon:

Agreed. I think the whole point of the article is that mina was a healthy weight (BMI of 20). Despite this, and doing what is considered a pretty healthy and acceptable approach to nutrition for a high level athlete, she has ended up suffering. I thought this was markedly different to the usual "malnourished for years and gets ill" non shocker. 

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John Alcock 21 Oct 2019
In reply to UKC Articles:

Well done Mina. It must have taken a lot of bravery to write the article, but it's a really important subject that more climbers and their families and friends should be aware of.

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webbo 21 Oct 2019
In reply to Ged Desforges:

So compulsive behaviour and using exercise as an emotional management tool has nothing to do with ones mental health then.

You might want to read the article again.

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Wee Davie 21 Oct 2019
In reply to UKC Articles:

Jeez. Very honest and important article. I've never been even close to anorexic but still pushed my body well past its metabolic limits to collapse on one occasion. It just re- affirms what I've had a hard lesson in. You can kick the arse of of it for a while but in the end nature will have enough. Sorry for the coarse imagery but its true.

As a newbie climber in early 90's (prior to the arrival of indoor lead walls in Central Scotland) I watched a renowned climber traversing the Kelvin Hall bouldering wall endlessly. His endurance was incredible. Before we knew his name we nicknamed him the 'skint rabbit' as his physique was like an anatomical diagram of muscle groups. 

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I like climbing 22 Oct 2019
In reply to UKC Articles:

Amazing article. Thank you, MLW. 

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abarro81 22 Oct 2019
In reply to alicia:

Nice one, thanks

> I haven't seen anyone proposing what you suggest, about the preferential fat storage.

My understanding has mostly been from conversation not reading so harder to link, but it's alluded to in the article and mentioned, for example, here: https://blogs.bmj.com/bjsm/2018/05/30/2018-update-relative-energy-deficiency-in-sport-red-s/ "Ironically the long term consequences of low energy availability produce adverse effects on body composition: increased fat/lean"

> they do note the discrepancy that many studies find between energy availability as a function of intake v. expenditure and what they would consider the pathology of low energy availability.  They give a few hypotheses for why this may be, but it's striking how contorted they are.

You mean in the "Measurement of EA" section? I wouldn't say that the main hypothesis (that it's hard to accurately track energy expenditure) seems at all contorted to me, it seems highly probable

I don't doubt that micro-nutrients can play a role, I guess my skepticism is just whether it's likely to be key in most athletes. Most people I know who are into dieting and training hard are also the people who are into maximising nutrients-per-calorie... I guess my instinct is that too much focus on that aspect is more likley to lead you down a risky path than not focusing on it. Perhaps we just differ on our thoughts on that front... but I'm not convinced I’ve seen anything to back this up "In a nutshell, I think the evidence most strongly suggests that it is about BOTH caloric deficiency and nutrient deficiency"

Can't comment on carbohydrate, keto, low carb and RED-S as not read anything on it or talked to people about it properly

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Michael Gordon 22 Oct 2019
In reply to webbo:

> So compulsive behaviour and using exercise as an emotional management tool has nothing to do with ones mental health then.> 

Plenty climbers / active people are mildly addicted in that they wouldn't be as happy if they stopped. Participating in sport can be good for one's mental health. This doesn't mean they have mental health issues.

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webbo 22 Oct 2019
In reply to Michael Gordon:

It would appear that I see things differently from you. There is a thread on UKBouldering about this which explains where my perspective comes from.

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Ian Patterson 22 Oct 2019
In reply to webbo:

> It would appear that I see things differently from you. There is a thread on UKBouldering about this which explains where my perspective comes from.

I can't speak for Mina obviously and I don't think its completely clear whether disordered eating formed a part of the issues she faced.  However I do feel that some of the responses on here come across somewhat negatively about discussion of eating disorders/mental health.  A quick look at some of the linked resources will show that in many cases disordered eating issues are a significant part of these sort of problems in athletes particularly (but by no means exclusively) in young women.   I think its important that these things are discussed and awareness raised so that issues can be recognised and support is available when needed

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Graham Briffett 22 Oct 2019
In reply to UKC Articles:

Great article Mina... Very informative, very well written and very frank. Thanks for the honesty and putting this out there.

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JMarkW 22 Oct 2019
In reply to alicia:

> Honestly, I'm not totally sure how nutrient availability isn't somewhat obvious as an area on which to focus the research.  Think about what you would expect to happen if you fed someone, every single day, 2,000 calories of white bread unfortified with any vitamins or supplements.  

https://www.bbc.co.uk/news/health-49551337

they go blind....

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Damo 22 Oct 2019
In reply to UKC Articles:

A very good, and well-written article. Being so open and frank about such personal issues makes the piece even more powerful, and hopefully, helpful to others.

I rarely read articles about rockclimbing anymore, but I have noticed pieces before written by Mina as being particularly good - articulate and intelligent in world with so much vacuous boosterism and hype.

I hope she writes more, and spreads her abilities and ambitions across other aspects of our climbing world, rather than punishing herself just to 'climb hard'. It's a good world we have, the high numbers mean f@$ck all.

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Southvillain 22 Oct 2019
In reply to UKC Articles:

"At 170cm my weight has fluctuated from 56kg to 63kg; a constant inner conversation was at play. As I'm sure you can imagine, moves feel easier at 56kg than at 63kg. Yes, I liked being lighter for climbing, but I wasn't ever noticeably underweight and I always thought I was supporting my body enough..."

Whilst Mina's main point may have been about an energy issue (i.e. getting enough in for the work being done) rather than about an eating issue per se (i.e. simply trying to lose weight), as some posters have been arguing about above, the above quote shows that `pure' weight was on her mind. And, from my observation, it's a big issue, especially at junior level, about which not enough is being said. I attended the National Lead comp at the Beacon Centre in September. I was shocked by the sight of some of the female juniors. Now they may well say that they're naturally skinny, or have high metabolisms etc etc, but I spoke to the father of one junior competitor and he confirmed that it's a huge issue at junior level.  Interestingly, I asked him about male juniors and weight/finger training (which also has its dangers to those with developing bodies) and he confirmed similar issue. I hope the BMC is doing all it can to help/educate parents?

Post edited at 15:37
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TobyA 22 Oct 2019
In reply to Wee Davie:

Sounds a bit like my old mate Neil! Before he even started uni, he had managed to do a load of damage to his elbows - on the Kelvin Hall Wall doing what they thought was "training" back then, mainly traversing with a weighted pack on from what I remember!

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Duck Egg 22 Oct 2019
In reply to UKC Articles:

Great article. Well written and really interesting. Well done for taking the time to write it and being brave enough to share your experience and knowledge to help others. Nice one. 

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Wee Davie 22 Oct 2019
In reply to TobyA:

Your comment made me think. I probably did witness your friend with the back pack there amongst other hones (not me!), but the guy in question was infamous for shunning the limelight while doing cutting edge onsights of top level dangerous trad routes. 

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roberto18 23 Oct 2019
In reply to UKC Articles:

Great article thanks for sharing. We have similar issues in triathlon at all levels. 
 

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L jason111 23 Oct 2019
In reply to UKC Articles:

Yes the insight is quite true. Climbing takes a lot of energy and to recuperate this energy a nutritious diet is needed. So there should be balance in energy expenditure and nutrition intake to keep healthy and moving.

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Wry Gob 23 Oct 2019
In reply to UKC Articles:

Hey Mina, well done, great piece, and you are not alone. At the end of the day, the true joy of climbing is about aesthetics - the feeling of the rock under your fingers - not about performance  

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Iain Smith 23 Oct 2019
In reply to UKC Articles:

Thanks Mina for sharing your experiences with a wider audience. I appreciate your candour and bravery. That for me is what makes a true role model.

Regardless of some of the discussions on here, I am sure that your article will help many more people consider their approach to training and nutrition in our sport. It is too easy with some motivation to cut calories and loose weight whilst remaining in the so called healthy BMI zone. However, as many of us also know, we participate in a sport which promotes a higher level of muscle mass than the average person in our culture has, and therefore sometimes our BMI does not correspond to that expected from the average population sample. To use the BMI as a measure of health can, as you rightly pointed out, be very misleading.

As you also mentioned, we climbers do live in a bubble, so thank you for popping mine and hopefully many other peoples.

Against all temptation, I managed to avoid the phrase 'food for thought'...……..

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Flinticus 25 Oct 2019
In reply to UKC Articles:

Great article and well written. 

Wasn't aware of this issue before...probably edge into this kind of practice the odd time.

Yesterday was a great example: work, rush a dog walk as time is short, cycle to TCA for a bouldering comp, finish at 9pm, buy a Cliff bar, eat that, then cycle home. Did the comp on empty, but the atmosphere was great, good humour, chat and was 'psyched', so didn't feel the hunger until later when tallying up my results. The last few miles of the cycle were a real drag as I was by now running down energy wise and the buzz of the comp was gone. Got home and had a late ready meal.

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Jay S. 25 Oct 2019

This is a very brave, intelligent and unusual article. Thank you Mina!

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emeraldsong 25 Oct 2019
In reply to UKC Articles:

Excellent article, thank you for your openness. Great for everyone, but women in particular due to the issues you mention, to be aware of RED-S.

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In reply to UKC Articles:

I mentioned this article to my physio in passing, and she said that she was going to a lecture / seminar on the subject soonish.  She said that people in her profession are being encouraged to seek information about RED-S and watch out for its symptoms in patients (particularly young women). 

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Dob Dob Dob 25 Oct 2019
In reply to UKC Articles:

Really enjoyed this article. Clear, considered and personal. Best wishes for a healthier, more holistic climbing future. 

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Alison Page 25 Oct 2019
In reply to UKC Articles:

Thank you so much for sharing this. I had no idea of it, and will be thinking of who would benefit from reading this article now

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L tahaakkus 07 Nov 2019
In reply to UKC Articles:

Thanks for sharing your experience. 

Would like to hear more about the changes you've done in your diet.

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Southvillain 08 Nov 2019
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