The GP and multiple world 100km medallist on her journey of dealing with relative energy deficiency in sport
Joasia Zakrzewski started out as a race doctor and expedition medic but was soon tempted to “try it from the other side”. Since taking part in a multi-stage race across the Atacama Desert in Chile, the 43-year-old has gone on to compete for GB numerous times in ultra-distance events – winning multiple world 100km medals – and ran for Scotland at the 2014 Commonwealth Games in Glasgow, finishing 14th in the marathon.
She has completed the prestigious Comrades Marathon four times, winning three golds and one silver medal, and last year turned her hand to team managing and coaching.
Zakrzewski thought she knew her body, but when it started to break both she and other medical professionals were left baffled. Eventually she was diagnosed with relative energy deficiency in sport (RED-S) – where nutritional intake is insufficient to cover energy demands, which can affect physiological systems including menstrual function and bone health.
Here she shares her story.
Fuelled by cake
I’m quite famous for liking cake. I know the distance to every café from my house because every run ends with coffee and cake!
When I’ve done ultra-running events like Comrades, people have said ‘oh, proof that the wine and chocolate training diet works!’ People make a joke of it but I always think – I’m not a professional runner, and I never have been, so it’s got to be fun. If I ever restricted my diet, then it wouldn’t be fun, so I thought I’d never have the problems that you might see skinny runners suffering from.
I never really changed what I was doing – I didn’t increase my training, I didn’t restrict my diet – but at one point I just stopped having periods.
Because I was in my mid-30s, I thought that I could just be going through an early menopause as I wasn’t underweight, having a normal BMI. As a medic I have seen that and I’ve only seen athletes lose their periods when they are underweight and training too hard or not refuelling enough.
I checked my hormone levels, my iron, my thyroid function, and everything was normal, so I ignored it. As somebody who had really bad periods when they were younger – I got admitted to hospital with horrendous heavy bleeding once – I thought ‘brilliant, they’ve gone away!’ and never thought any more of it.
But then just over 18 months ago, I developed a lump on my leg that would swell when I ran, and it would hurt for the first mile or two but then the pain would go away.
I rested it a bit, went to see a physio and he said he didn’t think it could be a stress fracture because a fracture wouldn’t swell, so to keep running.
With my leg like that I then did the World Trail Championships, I ran 100km at altitude on concrete and I did a few marathons. I don’t know if the actual fracture came because I had been knocked down on cobbles earlier in the year, but six months on, just before a race where I was going to run across the Omani desert in six days, I thought, ‘I’ve still got this fluctuating lump’.
To run or not to run?
Prior to the desert, I went to see my GP and he agreed that it didn’t sound like a fracture ‘but we’ll do an X-ray – however, I’ll sign your form to say you can go and run across the desert, that’s fine’.
It didn’t hurt at all when I ran in the sand and I did quite well in the race, finishing second to a Russian lady. But when I came back I had several voicemails from my GP saying, ‘I hope you’re not anywhere running, because surprisingly, you’ve actually got a fracture’.
The reality of RED-S
I went to the British Association of Sports and Exercise Medicine conference because it was about RED-S. The main topics were stress fractures and the female athlete triad to which I thought, ‘this sounds like me’.
I made contact with one of the consultants there and we discussed different blood tests you could do. One is called a T3 – it’s a type of thyroid function test but not one which is usually done as the doctor has to specifically request it. Mine was abnormal and I’ve since discovered that most people with RED-S have an abnormal T3 though their other thyroid function tests can be normal.
I contacted the local hospital to ask for a bone density scan, which showed osteopenia. I thought ‘this is weird’, as I’ve got a normal body mass index and I don’t restrict my diet.
That’s when I started looking into it more and discussing it with the sports and exercise medicine people and basically the only thing we could think of was that it had to be RED-S.
I then stopped all exercise completely. I spent over a month not even walking any distance. I didn’t swim or cycle, I didn’t do anything at all. I have always had a good appetite, but I had to eat even more, which was hard because I was almost force-feeding myself. I managed to put on several kilos and my periods came back.
So that was great (well, except that I really didn’t want my heavy periods back, but hey ho), I thought, ‘I’ve healed myself’. But then I had another X-ray which didn’t really show anything different. I spoke to an orthopaedic consultant who said, ‘you’ve done lots of resting, you’ve fixed your body from that point of view, your periods have come back, you might as well start running again to see what happens but be careful’. So that’s kind of where I’m at right now – I’ve started to run again with an added awareness of looking after my body. I’ve got to keep telling myself that I’m not ‘heavy’, I’m ‘healthy’.
It was horrible starting to run again. I felt so unfit. I couldn’t do my normal easy recovery run loop without stopping to catch my breath.
It felt like I was going back to basics, but I have to do that because running is just meant to be enjoyable for me, and long-term my health is more important.
People get obsessed by calories and it’s a bit of an issue. They will say, ‘I deserve that because I have been for a run’.
When training, people go through this honeymoon period where they get faster because they have lost weight but then they stop getting better, they feel more tired and cold, and they don’t sleep well. That’s a signal that there’s something wrong.
You see it less in hill runners and in events such as mountain marathons. The best advice I had was from someone who said, ‘if you’re hungry, it’s too late. You need to be eating regularly every half hour or every hour.’
I remember speaking to a road runner who said to me being hungry is the normal state to be in and I was like, ‘no, that can’t be right’. He thought he should always be hungry as that showed his body was working hard, he would lose weight and he would get quicker. But your body is hungry because it needs something.
Maybe I didn’t eat the right things or I didn’t realise that my metabolic rate is so high. I found it quite hard to accept that I need more food than other people. In fact, I still find that quite weird.
We also need to understand that people can have differing body mass indexes and weight before they stop having periods.
When you have lost your cycle, you often have to put on more weight to kick-start it again. You have to go over the top the other way and that’s what I don’t think a lot of athletes will do, because it can make you feel horrible about yourself and your sport.
Last year was the first year I’ve not run at the 100km world champs since I started competing at that level. I went as team manager and it was quite difficult. I think I’ll be better at it next time, but as it was my first time not running, I didn’t want to be saying to the athletes, ‘you haven’t got enough fuel’ or, ‘this is the way I did it’ because you don’t want to be all ‘look at me’ but then a couple of athletes afterwards did say ‘you were right, you were trying to make me eat stuff and I wasn’t having it and I faded’. It showed in the performance on the day but it is also important to be thinking long-term.
I find it really hard now when I see people restricting their diet because I think ‘you don’t know what’s going on’. People don’t realise a lot of it until something happens, for example I thought there was nothing wrong because I didn’t know enough.
With men, it can be harder to realise as they don’t have periods to lose. There are hormonal changes in men, such as losing early-morning erections and that kind of thing, but it’s not something that people talk about. I think a lot of younger women won’t want to talk to their coach about their periods either.
It always used to be thought that if you’re training hard your periods will stop, and that’s good as it shows you’re putting the work in, but actually we have got to get out of that way of thinking.
I’m a medic and I didn’t know much about RED-S until I got it and started looking into it. I found that I’ve been sent to hospital consultants and I’m having to tell them what it is.
So, if athletes don’t know and medics don’t know, then how are people meant to help themselves?
» You can find Zakrzewski’s blog at joasiazakrzewski.blogspot.com
» This article was first published in the January 31 edition of AW magazine