RED-S Syndrome: Don't Wait for Your Body to Say Stop...for Long!

Fatigue fractures, chronic fatigue, depression, hormonal disorders, repetitive injuries... Whether you are a high-level athlete or an amateur, if you do not learn to stop at the right time, or if you remain too long in energy imbalance, know that your body will find the solution to force you to stop. For some of you, it may be too late. Here's why!

We often believe that everything is fine… until the injury or poor performance. Then begins another race, the one that will allow us to find "our level" as quickly as possible, even if this question of "level", for the majority of us, is more likely a fantasy that animates us and which, precisely, can lead to injury.

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Unfortunately, we doctors tend to approach an injury in a localized way, organ by organ, sometimes forgetting that the machine must function harmoniously as a whole. Medical imaging, biological analyzes and all the new connected features, such as super slow motion stride recording, postural platform, continuous blood sugar monitoring, etc. make it possible to find the pretext of an injury and to focus on a lesion, but these medical innovations can make us forget the essential if we do not pay attention to them.

Read also: How to avoid the terrible heat stroke?

“But otherwise, hormonal level, are you okay? »

In a touching post on social networks, also relayed on the Ravito trail blogging platform, the French triathlete Marine Lecuisinier recently recounted her “two difficult years. Two years of stress fracture and repeated stresses. She describes her journey and her daily life, punctuated by tests of all kinds, opinions, counter-opinions and useless expert opinions until the day when the decisive question was put to her: "but if not, at the hormonal level, How's it going? »

As surprising as it may seem, this banal question, "how are you?" », asked by a doctor, will have been, in this specific case, more decisive and effective than prescribing an MRI (Magnetic Resonance Imaging which allows you to take a picture of the inside of the body). In this case, it will have led to the diagnosis of Marine with RED-S syndrome, the syndrome of relative energy deficit in sport (Relative Energy Deficiency in Sport Syndrome).

Read the full story of Marine Lecuisinier's descent into hell on Ravito

Because it can affect everyone, amateurs as well as elites, and we don't talk about it enough, I suggest you enter the RED-S Syndrom nebula, but by doing a little backtracking, essential for to understand.

How to Diagnose Pericarditis http://bit.ly/KYUUe

— jaky poll Mon Sep 14 03:09:18 +0000 2009

To start, let's cut short to a sexist caricature that fizzled out! We have long spoken of the “Femal Athlete Triad”. This triad includes eating disorders, such as anorexia, amenorrhea (stopped menstruation) and bone demineralization. With such a definition, men obviously did not feel concerned. Wrongly! This syndrome affects women as well as men, and, gentlemen, it's time to become aware of it.

Gentlemen, you are not immune!

Do you think that only women are likely to pay excessive, perfectionist attention to their appearance, that the obsession with thinness is reserved for women? No, no, and no, of course. Eating disorders can affect everyone and therefore have harmful consequences for the health of anyone in a situation of dietary imbalance.

Studies also estimate that nearly half of men practicing endurance sports (running, cycling or triathlon) engage in risky behavior. Only 20% of athletes would behave “without risk”. We therefore forget this first received idea: anorexia is not reserved for women!

Amenorrhea, in other words the cessation of menstruation (excluding menopause and pregnancy) is an “objective” clinical sign which may lead to a medical consultation. This increases the likelihood of a diagnosis. Getting no more periods can be a relatively comfortable feeling, but the thought of pregnancy is quite quick to react. This explains why this famous athlete's triad is more easily diagnosed in women. Since they consult, they!

Finally, it is likely that society and its doctors have been more inclined to look for signs that might discourage women from continuing their sporting activity. Let's remember that a century and a half ago, sport was still seen as an obstacle to fertility. In 1867, the charming Herbert Spencer affirmed in his “Principle of Biology” that “women should be exempted from all activities outside the family home in order to conserve all their energy to bear and raise children! ".

In 1887, William Moore, then president of the British Medical Association, went on with his couplet: "in the interest of social progress, national efficiency and the betterment of the human race, women should be prohibited to study and practice sports that would make them unable to produce healthy children. »

These quotes, revolting today, were based on a theory of the “fixed amount of energy for a woman”, considering that the energy wasted in sport was lacking in her reproductive function. We still hear this in some anti-sport advice for women who choose to breastfeed for example. The weight of history is more present than we think in our representations. Remember, in a “normal” situation, sports practice is compatible with fertility, with pregnancy and with breastfeeding!

Since the mid-2010s, the energy deficit of athletes has been recognized in both men and women. We have abandoned the famous triad to speak instead of the RED-S syndrome. This changes everything, because we finally recognize that it also affects men.

However, the principle is the same. When an athlete practices his sport with substantial training volumes and in return he retains nutritional rigidity, the energy balance becomes deficient. Your bank adviser would warn you if you spend more than you have in your account and you risk personal bankruptcy. Except that your body does not go bankrupt. It adapts.

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Drop in estrogen and testosterone = alert

To do this, it will modify its hormonal secretions, and in particular its secretion of sex hormones. In women, the depletion of estrogen leads to amenorrhea, bone fragility, etc. In men, it is testosterone that sees its levels drop. Sorry for our runner friends who believed, by practicing their sporting activity, to affirm their virility, but, joking aside, it's the opposite that happens when you do too much.

Quebec champion Elliot Cardin concedes it in a testimony full of humility, which he recently shared on Facebook: “For some time, the speed has not been there and I have decided to investigate. Result: testosterone slightly below normal. The cause is not established yet and I have to pass further tests, but it is probably due to a high training load. »

The RED-S integrates a series of signs partly linked to the reactive hormonal disorder and which affects the whole of physiology. The inventory is long, but take the time to pay attention to it: chronic fatigue, weight loss, repeated injuries including stress fractures (testosterone, like estrogen, contributes to bone health), poor performance, anxiety, lack of motivation, depression, insomnia, motor restlessness, cold extremities, cold intolerance, impotence, infertility, low libido, dry skin, hair loss, brittle nails, muscle wasting, low blood pressure, low heart rate (think again you, it's not "the lower the heart rate, the fitter I am", in this case, it's a warning sign), etc.

energy imbalance

The reason is simple: the input-expenditure balance is out of balance. Either the contributions are insufficient, or the expense is too high, or the two are combined. This last hypothesis is more insidious, because the contributions exist, but are ultimately those of a non-athlete. And the high training volume for non-standard events may appear normal. The athlete is then unable to realize that his lifestyle is wrong.

Every extra pound is an unnecessary burden, and buddies' Strava accounts make you think you're not training enough.

Kilian Jornet has put on 100,000m of elevation gain and 139 hours of training in the month of January 2021 alone. sport. We add 2000 calories to meet the energy needs of the day excluding sports activities, so we arrive at 5500 calories per day. I don't know his plate, but you have to understand that a monstrous workout like his requires gargantuan meals. However, one of the risks faced by those who want to sharpen up is to naturally intensify training at the same time as paying attention to their nutrition.

Sports where weight is fundamental, or weight-class sports like boxing, are particularly at risk, and ultra-endurance is no exception. “Perfectionist” athletes are also more predisposed, as are those who are exposed to pressure from those around them, their coach, sponsors or the media.

Overtraining and undernourishment are never without consequences. Some renowned athletes sometimes break the omerta. The testimonies are then poignant and tell of a form of descent into hell with counter-performances that accumulate and, for only answers, a worsening of what led them to this. The wounds are linked together, we then seek the "healer" who can quickly put them back on their feet, where it would have been necessary to analyze the causes, more or less unmentionable.

In men, the drop in testosterone reinforces confidence problems and poor self-image. These disorders are then hidden, in a shameful way, making this complication of intensive sport little recognized, little diagnosed.

Read also: The formidable placebo effect of motivation

How to get out?

Prevent. In health, the best treatment will always be prevention, to avoid harm before it occurs. Let's hope that this column, all the articles on the subject, but also the testimonies of the athletes affected will help to raise awareness of the problem.

Screen. There is no indisputable score, but during medical checks, it is important to look for eating disorders (several measurement scales allow this), to look for risky personalities and to explore anxiety levels. Athletes must maintain sports diaries, respecting breaks each week and at least one longer annual break. Be careful, cutting training does not mean stopping everything. It doesn't stop you from staying active.

When the RED-S is installed, it is naturally necessary to increase energy intake and limit sports activities as much as possible. It is also necessary to be patient, because the hormonal corrections will take several months. As for the bones, they will probably take several years to erase the damage. The doctor often has to roll his eyes to get this treatment accepted, because denial is common.

An explanation for meteoric careers?

It would be interesting to analyze why some athletes have meteoric and fleeting careers. My doctor's look makes me fear RED-S syndrome. This new name is a bit of a catch-all, but it has the merit of bringing together all the hormonal and physiological consequences of the excesses of athletes which lead to a deep and lasting deficit in the energy balance.

It would also be interesting to see if this syndrome does not find systemic roots. Indeed, the qualification rules for the most prestigious trails, the ultra-trail season which now runs from January 1 to December 31, the creation of challenges (running two races during the weekend) on several trails, the semi-professionalization of some trail runners, making their calendars insane, are all levers on which trail authorities could play to protect runners.

Despite all this, playing sports will always be preferable to a sedentary lifestyle. I also leave the final word to the doctor and philosopher Paracelsus who, in the 16th century, already affirmed: “everything is poison, nothing is poison: it is the dose that makes the poison”.