Is there a world where health and performance coexist?
That answer depends on what you consider high performance and what you consider health.
Maybe you train hard and suffer some aches and pains, but make it to race day just fine. Or you train hard, invest in it emotionally, perform great, and eventually change to a new activity because you burned out.
In those cases, there are some warning signs that health was compromised, but the tradeoff was reaching a goal you were passionate about. Get out of jail free.
However, there is no beating around the bush that training hard, performing well, but blowing out your nervous/hormonal/cardiovascular systems has any benefit of any kind.
Everything has a cost. When those costs add up, the body gives signals. When you ignore the signals, you can land in hot water.
This is the descent to illness that characterized my experience with Relative Energy Deficiency RED-S.
It is a condition that does not “happen” to you. There are plenty of points on the way to ruin that indicate you should do something. It is not a condition that warrants sympathy but rather corrective action. It is a self management issue. You cannot see the forest through the trees, signals get ignored, control is lost, and before you know it you are fried.
What is RED-S and why is it complex?
RED-S is defined as: a chronically inadequate energy intake relative to exercise energy expenditure, which can manifest into various negative health and performance consequences, including osteoporosis, stress fractures, menstrual dysfunction (women), and reduced testosterone (men).1
From the outside looking in, one might say “Oh, just eat more.” or “Put on some weight!”. That is sure to solve the issue, right?
It would be nice if it were that easy, but there are numerous external factors that make RED-S more than a dietary problem.
Training
Work travel
Work stress
Family stress
Disordered eating
Psychological instability
All of the above and many more factors can contribute to running up a large energy deficit. There are even times where a deficit can be adapted to and one suffers no consequences or perhaps a performance improvement. That is tricky.
The body can adapt to a lot…until it cannot. This is where low energy availability becomes problematic instead of potentially useful.
My perspective
If you wanted to develop a linear path for developing RED-S, my path to illness follows it closely. Part of my shortcoming was not understanding the numerous factors outlined above. I will take a moment to describe the path so that you can see how eating habits contribute to only a portion of the pie chart.
In the fall of 2023 I was finishing my final didactic semester of Physical Therapy school. It was stressful, but training volume was relatively low. The body seemed to be in a good place even if the mind was preoccupied. I got a stomach virus late in the fall that dropped me 5 lbs almost instantly. However, over the next few months, I never noticed those 5 lbs come back and felt a bit limited in training. By this time I was well into my final two clinical rotations which was a new stress with being under the microscope all day long from my instructor. I was also preparing for the board exam with any and all of my free time. Throw in a few family-related events and the cup was getting full. The crazy part? The numbers I was putting up in training were encouraging, so I kept cracking on despite
Extreme hunger
Occasional sleep disruption
Anxiety
Inability to turn the brain off
Trouble concentrating
Mood swings
Once the spring weather rolled around, it was almost as if my body rolled around too. April was a strong month all around as I passed the board exam, put in the foundation for some summer racing, and made some advances for my coaching business Elite Edge.
The rest of the spring went great with a strong run split at a local Olympic triathlon and a well-rounded performance at 70.3 Des Moines. You can read more about those below
I was pleased with the result in Des Moines, but a new stress was being added—Starting my career as a physical therapist.
The excitement to get going with what I had worked hard for was encouraging. I needed this pick me up after a rough winter mentally and physically. The first 3 weeks of work were a challenge but I was having fun. Training kept rolling along as I was going before, I was meeting new people and learning new things on the job every day. Adrenaline rush.
What I failed to acknowledge during this time was that
I was not eating enough and with an active job as a PT demonstrating exercise all day long, there was an increased demand for raw calories. This is where RED-S becomes a calorie equation in some cases.
I was not sleeping well
I was having digestive issues
I was on high alert 24/7
I was still 5 lbs underweight
I was having massive energy ups and downs at random points in the day. Almost like manic episodes.
The body is amazing in that it can sustain this high alert mode for quite a while. It can be advantageous too because you are constantly amped up which translates to bringing fight or flight energy to everything you do.
This grace period lasted for 3 weeks and my body and brain gave up. I hit an absolute wall in late July kicked off by the first true injury I have ever had. My right quad blew up on a run and I knew something was off. It did not end there.
There was eye twitching
There was constant hunger
There was even poorer sleep
There was trouble concentrating
I was cold every waking hour and sweating at night
There was zero indication that my reproductive system was operating as it should
Anything stressful resulted in an absolute meltdown physically and mentally
My heart rate during exercise was going nowhere. A handbrake
Training at moderate intensity was the only thing that felt good. WEE WOO WEE WOO Warning! Warning! When physical stress is the only thing that makes you feel good, please pay attention.
I was in deep s***. It is interesting to note from the paper linked here that poor judgement is actually a common manifestation with RED-S. I absolutely had that which further fueled decisions that made my condition worse. Trapped.
Despite all of this, I still threw down an Olympic distance race in late August where I ran 34 minutes for 10K off the bike on a really hot day. I hated every second of being at that race. No excitement. I wanted to get in and out of there in a hurry. Maybe that is why I went so fast!
That was the nail in the coffin. I was done and needed some help so I started with getting a full blood panel. My doctor’s eyes bugged out when I mentioned all of my symptoms and we ordered nearly every test under the sun.
I drove my testosterone down to 75 ng/dl (normal is near 300)
LH and FSH were low which work together with testosterone for reproductive function
My white blood cell count was low indicating an immune compromise
My platelets were low but this was not an extreme concern
These results made sense but mentally crushed me. There was finally some objective data showing something was severely wrong and it was all my wrongdoing. Despite pulling way back on exercise, I started feeling even worse through the fall, but I suspect this was how my body was dealing with grief from the situation.
Upon a second blood test, 8 weeks later, testosterone had increased to 116 ng/dl which is still awful but better. This told me that this process was going to be longer than expected. I also had a MRI of my brain to rule out serious pathology and that MRI came back clear.
In that moment, I took agency and realized everything I had done was controllable. I just needed to park the ego and work on some self management.
So, if you have kept reading, do you see how this goes way beyond the amount of food you eat? I never intentionally made a decision to eat less to improve body image or anything of that sort.
Everything you do takes energy. Yes, at the end of the day eating more calories probably could have helped, but the organization of my lifestyle was the vehicle that drove me off a cliff.
What does returning look like?
The first thing that marked my process of returning was getting in touch with a mentor. I will keep the named concealed for now, but the relationship I have cultivated with this mentor has been the single most productive part of my life in the last five years. There have finally been explanations about why I feel the way I do and how it led me off the rails. There has been guidance for how to frame athletic goals in a context that does not jeopardize health. Most importantly, there has been reassurance that I am not broken and can actually make a return.
Little to no 2025 racing
I have made the tough decision to spend most of the year on the sidelines. Putting events on the calendar makes it more likely that I rush this process and relapse. It is not out of the question that I turn up to a local tri come spring or summer, but there will not be a set racing schedule for the year.
This does not mean no training. Throughout this whole process I have continued to be active with a variety of swim, bike, run, and strength.
Having a year away from the races might also give me the space to pour more time into attending events for my athletes at Elite Edge which would be a nice way to develop the coach-athlete relationships further.
Metrics
In the past, I have been vocal on tracking sleep, HRV, and every other metric under the sun. It got to the point last summer where I got so wrapped up in these metrics that I gave myself anxiety. It also made it harder to see the forest through the trees with the situation. As my mentor said: “drilling into the core magma of the earth to measure everything often creates noise and nothing else.”
So with that, I dropped measuring anything more than heart rate during sessions, how I feel, and whether I am controlling what I can control. It has been freeing to operate this way. If I find a better use case for more data, I will go back, but for now, I am keeping it away.
Optimizing everything often results in optimizing nothing.
Organization
If all I did was change eating habits, I would have been missing the big piece of the puzzle that landed me in this mess. After consultation with a dietitian, we determined that my overall diet was solid. Good intake, good nutrients, just a few hundred calories per day short of where I needed to be. Over the course of 8 months, that comes out to a major energy deficit. Starting the process of being more attentive to that issue was relatively simple.
In terms of lifestyle, changes needed to be made to get anxiety, sleep, and digestion all under control. The first change I made was adjusting my work schedule to put me home earlier a few nights per week. I have always gone to bed early, so having a few hours to tend to other tasks on my mind from the day and not going to bed with a million ideas in my head has been helpful. I had periods throughout last year where I would be wide awake at midnight thinking through how to be better for clients and athletes. It became a vicious cycle where my brain could not turn off. As a result, poor sleep led to poor mental and physical recovery from day to day.
I have also made an effort to remove all of the “have to” for training right now. Success is currently not defined by anything more than keeping myself on a path that does end in ruin. Race times, personal bests, and results are not the immediate goal. There are bigger fish to fry.
Making these changes have been a genuine help, but am I totally out of the woods? Likely no.
There will be more setbacks in this process which is why I am forecasting that this return will take longer than anticipated. You need to generate a ton of proof that things are better before you are truly better.
Where I am right now
Life started to turn a corner at the first of the year. Taking ownership of the situation and not blaming anyone else was a major step to making a return to health.
There was also a period of being honest about the motivations for my athletic pursuits.
Is targeting a big race an excuse for justifying more exercise? For taking the body to the limit?
Those are lousy reasons, but had motivated me in the past. The longer distances were enticing because I was able to justify large volumes of exercise, create fatigue, and feel productive because that was what was required. All the while I was ignoring an issue of being unable to manage myself and my emotions. Obsession is both good and bad.
I also continue to be in a spot of feeling ashamed that I am backing away from pursuing maximum performance. I reserve the right to feel this way, but with time that feeling will pass.
This year will be an exercise in answering the question that opened this article—Can high performance and health coexist?
That remains to be seen for my specific case, but I do know that the goal for the year is to better understand how energy is finite and that there needs to be a careful approach for where, why, and how that energy is being allocated.