Body positivity has taken centre stage, for good reason and high time at that too.
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However, performance areas where having a certain body type confers special athletic or aesthetic advantages are still plagued with archaic beliefs about lower body weight and the need to look a certain way. The high-profile case that shone the spotlight upon this widespread yet unknown condition, was the Nike running campaign fiasco in 2019.
In 2013, Mary Cain, 17, was the fastest, youngest American track and field athlete to make a World Championships team and was signed on to the best track team in the world, the Nike Oregon project, under star coach Alberto Salazer. High-profile athletes trained under him include Amy Yoder Begley, Kara Goucher and even Mo Farah.
What followed next, is an unfortunate trail of events. Salazer did not just push his athletes via training. He body-shamed them and led a culture that emphasised “thinness” for athletic greatness. A New York Times op-ed on the issue, ran so ‘I was the fastest girl in America, until I joined Nike’. Begley and Goucher both confirmed the toxic practices of Salazer that not just demeaned the women but risked permanent health damage.
Begley, a 10,000-meter runner, has reported that she was explicitly told she had the “biggest butt on the starting line.” The toxic culture is not just a one-off incident. It is may more likely be the norm than the exception. The athletes in question (and allegedly more women), were then shamed into cutting down on food and ridiculously low dietary intakes. All to fit the ‘ideal’ of a certain individual’s athletic aesthetic. Cain suffered from amenorrhea (loss of the menstrual cycle) for three years and lost so much bone density, she broke five bones. This also caused her to have suicidal thoughts, before finally leaving the program in 2016.
The sinister string tying these athletes is the nutritional mishaps that caused LEA (Low energy availability) leading to the ‘Female Athlete Triad’ as named by the American College of Sports Medicine, in 1992 for the interrelationship between bone mineral loss, disordered eating and loss of menstruation in women athletes, or RED-S (renamed in 2014, by the International Olympic Committee-IOC- to emphasise that the syndrome affects all athletes, female and male).
According to the IOC, relative energy deficiency implies that low energy availability occurs when an individual’s dietary intake is insufficient to support the energy expenditure required for health, function, and daily living, in addition to exercise and sport. Normal body functioning is impaired in RED-S due to the energy deficiency that can affect the metabolic rate, menstrual function, bone health, immunity, and cardiovascular health. In addition, RED-S may lead to a gradual reduction in the athletes’ performance by a number of factors, including decreased endurance, increased risk of injury, poor response to training, impaired cognitive function, decreased coordination, concentration, depression, depleted glycogen stores, and decreased muscle strength.
A sustained mismatch between energy intake (due to disordered, restrictive diets) and exercise energy expenditure (EEE) (due to excessive training) can lead to Low Energy Availability (LEA), health and performance impairments characteristic of Relative Energy Deficiency in Sport (RED-S).
This can sometimes result in irreversible physiological and performance impairments. RED-S is more prevalent in sports where lower body weights are preferred, and even in dancers, both male and female, who need to ‘look a certain way’.
New Zealand 3000m steeplechase runner Rosa Flanagan has also spoken about her own debilitating experience with RED-S, beginning as an obsession with her weight, leading to over-training and under-eating. While her speed improved as her weight dropped, she suffered a series of injuries, including three stress fractures (in both hips and a leg), and did not have her first period until she was in her early 20s.
Flanagan required a year off to recover, before returning to training.
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Diagnosing RED-S is difficult as the signs and symptoms are subtle, and only detected upon a high index of suspicion. Screening tests for energy deficiency must be done like- basic evaluation of energy and nutrient intake, possible eating disorder behaviour, menstrual status and history, weight change and presence of cardiac arrhythmias including bradycardia.
Early identification is key to prevention and treatment. Team physicians should be alerted by any signs of eating disorder behaviours, or LEA, as well as by menstrual irregularity, anaemia, depression, fatigue, electrolyte imbalances, and history of stress fractures.
Prolonged energy deficits ultimately cause detrimental effects on performance as the depleted energy stores cannot sustain requirements and thus hamper sport performance and cause more match errors. The emphasis on weight and body composition as a performance measure is inherently flawed. The sole focus, for all athletes, should be on nutrition and the development of healthy weight and body composition goals.
For such a widespread phenomenon, this condition has received far less medical attention than it deserves. There needs to be the understanding of the differences in injuries and illnesses between men and women (and between different ethnic groups).
We are only slowly realising that not only the pathophysiology, but also the signs, symptoms, response to treatment and side effects differ significantly between various groups. Despite these potential differences, most research study designs still do not stratify results according to gender, meaning that we may be comparing the proverbial “apples with pears”.
It is also highly significant to not treat female athletes with the same yardsticks as male counterparts, as their nutritional and physiological needs and demands are notably different.
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