When cyclist Shannon Malseed stood atop the podium, victorious after winning her first Australian National Road Race Championships in 2018, she was grinning with the taste of success and the leanest she had ever been. But on the inside, Malseed was hurting, and often starving hungry.
“I just thought that that’s what I needed to do to be the best,” Malseed says about her gruelling training and eating plans which developed into an unhealthy relationship with food. It was fuelled, she says, by a culture of restrictive eating amongst competitive cyclists driven to drop weight to boost their performance, and reinforced by offhand comments from coaching staff. “I thought, maybe you just have to cope with these things. Maybe this is how it is.”
But soon after her national title, Malseed’s performance went downhill. Years of training and eating only the bare minimum caught up with her in her first year of professional racing. “I couldn’t finish races. I couldn’t stay with the peloton; I was getting dropped all the time,” she says. Then she started breaking bones.
“I realised that didn’t love the sport anymore,” says Malseed, who is now retired. “I didn’t want to sacrifice my body anymore, my mental health and my relationships.”
What Malseed experienced was a condition known as low energy availability that can, and did, escalate into a syndrome called relative energy deficiency in sport, or Red-S. It is a mismatch between an athlete’s energy intake and energy output that means little energy is left to fuel their body’s essential needs.
Frequent illness, sluggish recovery, low iron levels and fatigue are common warning signs of the condition. Women might also have disrupted menstrual cycles or lose their periods. Red-S is often seen in endurance athletes and weight-classed sports, such as rowing, where it can quickly derail performance and sporting careers.
“It can affect female and male athletes in any sport, at any time,” says Dr Kimberley Wells, a sport and exercise medicine registrar. But it is usually not until athletes are confronted with serious injuries, such as broken bones and stress fractures, that they realise something is amiss, Wells says.
Female athletes like Malseed have also had to reckon with power dynamics and toxic cultures in elite sports that normalise extreme diets and equate low weight with better performance. “Often an athlete is driven to think about their performance now and not their health, later,” says Wells.
However, an energy imbalance leading to Red-S can occur in many different scenarios, not only with disordered eating, says dietitian Louise Burke, professor of sports nutrition at the Australian Catholic University.
Athletes may at times – after injury or an off-season, for example – need to lose weight or intensify their training, but they could be doing so in a way that is too fast or too extreme. “Sometimes the eagerness to get results means the energy restriction is much greater than the body is happy to handle,” Burke says. Athletes may also face financial hardship and simply cannot afford to buy the food they need to eat, she says.
In a recent study of Australian athletes, Burke and her colleagues at the Australian Institute of Sport found that across eight sports and 112 female athletes, nearly 40% of the group had between two and three symptoms of Red-S, and some showed signs of mental illness.
But many cases go unrecognised, says Burke, especially in male athletes and because the stigma surrounding disordered eating discourages people from seeking help. “What we’re trying to do now is to de-stigmatise it,” Burke says, “to recognise that [low energy availability] exists in many forms, and it can be managed well [to help athletes] meet their goals, in a safer way.”
Sports dietitian Jessica Rothwell, a former racewalker and current national high performance nutrition lead for Athletics Australia, says that with the right nutrition, athletes can continue to train consistently, unhampered by injury or illness, to bring about training adaptations and body composition changes that lead to good performance.
But managing energy needs and exercise can be challenging for junior athletes who might not have access to the same nutritional support as elite athletes, she says. These young contenders may also idealise the ultra-lean bodies of senior competitors before understanding that maintaining peak body composition year-round is often unsustainable.
“What I wish I had known,” says Rothwell, “is how to periodise your training and nutrition across various training periods, how much food you actually needed to eat and what that looks like practically, particularly at that junior level.”
Rothwell says it can be a fine line for athletes between optimising peak body composition and falling into a chronic state of low energy availability so education is key, especially through puberty, adolescence, and in their transition from junior to senior sport. “It’s really about helping them to understand how to fuel their bodies, and how to do it properly” to optimise health and performance, and to prevent injury and illness, she says.
Sports professionals and coaches also need to be clear on the rationale for assessing and monitoring body composition, to ensure the athlete is not placed at any risk, Rothwell says.
Wells, a former professional cyclist herself, says “old-school thinking” that blames food intake or perceived excess weight as a reason for poor performance still persists in sport.
But sporting bodies are trying to address the issue with education programs such as the AIS’ female performance and health initiative, led by Dr Rachel Harris. The initiative supports research into optimal athlete performance and has education modules for athletes, coaches, parents and support staff to raise awareness of female-specific health considerations.
However, Wells says some sports have more funding and education than other codes, so knowledge of Red-S still varies between sports. And according to Wells and Rothwell, the syndrome is also common amongst recreational athletes who would not identify as elite but whose energy requirements are significant all the same.
“There are a lot of people running around in the community, who are low in energy and it’s leaching strength from their bones, it’s affecting their fertility,” says Wells. “Unfortunately, the consequences of doing that show up years down the track. But once it reaches that point, it is really hard to intervene to get back what you lost.”
Malseed turned things around with the support of a dietitian and sports physician. But she says most elite cyclists are focused on making quick gains to win races without contemplating the lifelong consequences of their extreme training and eating habits.
“To try and come back from the detriment that you’ve put on the body and your mind takes a lot longer [than dropping weight to get results],” says Malseed. “It takes a bloody long time to heal.”