Ann Ashworth: A RED-s Recovery to Running Healthy, Strong, and Fast

Cherie: Hello and welcome to Strides Forward, the podcast where we tell narrated stories about women who run marathons and ultramarathons. Each episode we tell one woman’s story focused one topic. I’m Cherie Turner, a 51 year old trail and road runner and the host and creator of Strides Forward.

If you’re new to the podcast, a huge welcome. And if you are returning, it’s great to have you back.

This episode is part of our series about running in the woman’s body and we’re focused on menopause, pregnancy, and also RED-s.

RED-s, or also REDS, short for relative energy deficiency in sport, is the topic of this episode. If you aren’t already familiar with RED-s or don’t really understand what it means, stick around because that’s really the point: this syndrome isn’t as widely known or understood as it needs to be.

But knowledge is power, which is exactly why I feel like these stories are so important to tell and why I am so grateful that women are stepping up and sharing their stories, like this runner.

Self-intro: Cool. I’m Ann Ashworth, and I am an ultra distance runner from South Africa. Yeah and running long distances is pretty much what I do. I also work full time as an advocate. Yeah, but running radio is my passion

Cherie: Yes, it’s Ann Ashworth. Ann was featured in a couple of episodes in our first series about experiences at the highly prestigious 90-km or roughly 56-mile Comrades Marathon in South Africa. Of course, if you haven’t heard those episodes, I encourage you to go back and listen, but it’s not necessary to have heard them to understand our story here.

What you need to know about Ann for our purposes now is that back in 2017, she decided to take her running to the next level. She’d been a really good runner, but she’d felt like she had even more potential. So she started working with one of South Africa’s top long-distance running coaches, who believed in Ann’s potential for greatness as well. As part of starting out with her new coach, she started training with a new team, which included top-10 or gold medal Comrades finishers.

Ann: In 2017 and in 2018, I was part of an all male training group. I know that for the first sort of three, four weeks of training camp, I was able to keep up with the men, and, and that was even more of a badge of honor, like, Hey, I’m running here with comrades gold medalists and they’re the men, so I must be doing okay. Um, and then, you know, after four or five weeks, I start dropping off because ladies don’t run as fast as over those long distances. And I was like, that’s okay. Cause you know, these guys are the pros and I’ll just try and keep them in sight for as long as possible and just do my thing.

Cherie: And what Ann’s thing was following, with unwavering commitment, the elite level training program her coach gave her. Ann was there to do the work; whatever it took to be the very best she could be.

Ann: For three years I was a mileage junkie. I mean, I would be knocking on a minimum of 160 ks a week training, and with Comrades training, go up to 300 ks a week. So I was running a lot all the time. In addition to that, I was doing quality every single day. Um, sometimes quality twice a day, every single day. Um, so extremely high mileage, extremely high intensity, no cross training at all.

Cherie: So Ann was doing structured, quality workouts every day and a lot of distance. If you’re working in miles, I’ll translate: Ann’s talking about running 100 to 185 miles a week. In addition to this high-intensity, high-mileage program, Ann’s coach had prescribed a very disciplined eating regimen that was very high in protein and extremely low in carbohydrates and fats.

And, as was the plan, she was getting results, huge results.

In June of 2108, Ann Ashworth surprised just about everyone, including herself, by winning the Comrades Marathon. This had been Ann’s ultimate dream, and she had done it.

But soon thereafter, the cracks in Ann’s wellness began to show.

Ann: So in 2018, the end of 2018, I ran the Valencia marathon in December, and had experienced my usual kind of up and down training and physiologically in the buildup to that race. Um, and 2018 overall was quite a stressful year outside of Comrades. Um, and I just sort of wrote off most kind of niggles,  gastrointestinal issues, um, kind of, you know, stress-related physiological issues. I just wrote off to stress, um, and being a bit fatigued. Ran Valencia, had a great marathon, ran a PB there, and kind of thought, there can’t be anything too much wrong with you because you just had a great marathon. But after Valencia really struggled to get going.

Cherie: And this is where the early signs of RED-s can be so deceptive: taken one by one, they can look like the reasonable reaction to, say, post-race fatigue combined with a stressful work life. It’s a bout of bad digestion here, a little niggle or pain there, a few bad days training. Each one explained away, each one a sign taken alone doesn’t look too bad. You train through small niggles. You figure, bad digestion, it’s so common with runners, why not me too.  You bank on tomorrow being a better day of training; this is a bad patch and it will pass. Not one of these issues, in the moment, on its own, is crying out to make you stop and reassess everything you’re doing.

So, if like Ann, you’re dedicated and committed to being a competitive elite athlete, you forge ahead. You keep trying to stick to the program.

Ann: I mean, I was supposed to start Comrades training two weeks off to Valencia. So that’s kind of the middle of December; could not turn the legs over. I just felt deadbeat. And took another two weeks rest, really struggled to get going. January just couldn’t find momentum. I was really struggling with my long runs. February much the same; kind of had a marathon here in early February. I didn’t finish, um, and just was feeling terrible. But tried to push through it, and I wasn’t under a lot of stress and strain at work. And so I thought, gosh, I wonder what’s going on. I don’t know, why I’m feeling like this? My training isn’t too much. You know, I just, I don’t know why I feel like this. Is an iron? Is it like low vitamin B? Like what could be wrong with me?

Cherie: So Ann looked for outside help from a trusted source, the very person who’d helped guide her to that remarkable Comrades victory and on to this personal best performance in the Valencia marathon.

Ann: Basically my coach’s attitude at the time was, suck it up, princess. You’re clearly not working hard enough. You need to get your mind in the game, and so I really just tried to push myself physically as much as I could, but was not making any progress at all. Barely finished any training sessions. Just, I was exhausted all the time. I was crying all the time. I just was a wreck.

Cherie: Ann was a wreck, but there was work to do and she just needed to suck it up. Running at this level is really hard. Pushing your body to the very edge of its capabilities is absolutely exhausting. This is the work to get you there, or so that was the thinking. This program had worked in the past; it would work again. This is what had gotten Ann to that Comrades victory and her best marathon time yet. Let’s just keep at it.

So, Ann tried to regroup and look ahead. She wanted to be ready for the grueling training she’d be facing to get ready for the 2019 Comrades, which would take place in June.

Ann: At the beginning of March, I started my, um, eight-week training camp, in anticipation of Comrades and some sort of just this physiological state perpetuated and got worse and worse and worse to the point that I literally couldn’t run further than 30 kilometers. I was just dead on my feet.

Cherie: The harder Ann tried to dig her way out of this rut she was in, the deeper she continued to get.

Ann: In 2019, like I couldn’t even get out of the blocks. Like I wasn’t even there from the beginning. And I thought, wow, there is definitely something wrong with me this year. I should be able to keep up with these guys. And I just couldn’t, and it was just a big sign to me that I’m not where I need to be and I don’t know why I’m not there. Um, and that’s really kind of, you know, because I was almost training in a bubble because I didn’t know what other people were doing. I don’t know how hard other people are working. All I know is what I’m doing, what I’ve been told to do. But then when I went to training camp and I saw the people that I’ve been running with for the last two years, and I was way behind and experiencing huge problems that they weren’t experiencing, I thought, well, no, this is not normal. So that really was for me, the sign.

Cherie: And as if this wasn’t enough of a sign to alert Ann that she was really in a bind, unfortunately, more was on the way.

Ann: I really just didn’t know what was happening to me, and started to have incredible back pain, that also, I didn’t know what it was. My coach said it was all in my head. Um, and just, I just was really struggling and eventually sort of pack my bags, left training camp, came home, had a sob, um, thought my running career was over. Like maybe I just don’t have it anymore. And started to really research myself, what is going on? This is not normal for me.

Cherie: Frustrated and depleted, and with a clear resolve that something was terribly wrong, Ann became determined to find some answers.

Ann: So RED-s is not something we’ve really talked about here in South Africa, prior to last year. So when I was reading about what I thought I had, it was more commonly referred to as the female athlete triad. And one of the key pins to that is stress fractures. And I thought, you know, I can’t have this because I don’t have a lot of recurring stress fractures. (10:06): Like, you know, this can’t be, it can’t be a thing. And my coach’s attitude was, if you don’t have a stress fracture, your diet is fine. Cause stress fractures are diet related. They’re not over-training related. That was something that he told me over and over again. And so I was like, well, I don’t have a stress fracture. So my diet must be fine. And I mean, aligned to that was the fact that my coach controlled my diet. So if my coach was telling me that I was eating fine and he’d got results for me in the past, you know, it was sort of, uh, you know, okay, well, I trust him because this has worked for me previously.

Cherie: Ann was on the right track looking into the female athlete triad. This is the term we used to use for this syndrome before we started calling it RED-s. The name change along with an expanded definition of the syndrome’s symptoms was established in 2014 specifically to address what Ann was coming up against: the triad definition can be too narrow. However, like Ann mentioned, this older term and its definition is still very common.

The female athlete triad identifies this syndrome as involving only three symptoms: low bone density, an eating disorder, and loss of menstruation, also called amenorrhea.

Ann didn’t have any stress fractures, which are a telltale sign of low bone density. And as to that last symptom, the amenorrhea, for Ann that was a complete question mark.

Ann: So if I was an athlete that once upon a time had had a regular period, when I wasn’t having a regular period, that would be a red flag, but I, um, I had used the mirena for many years. Um, and on the mirena , I don’t have a period. So it wasn’t a warning bell to me. I didn’t know that I was in a state where my hormones were in crisis.

Cherie: So Ann wasn’t showing signs of low bone density, the amenorrhea was a blind spot, and she was firm about the fact that she didn’t have an eating disorder.

Ann: I think there’s a lot of misconception about RED-s, and I think that a lot of women might think of RED-s as an eating disorder and that can be embarrassing or shameful or something that you don’t want to admit to or deal with, but that’s not only what RED-s is. And sometimes I just think like, look, I’ve been through an eating disorder. I know what that is. That’s not what I had. And I think if more people are just aware, you know, maybe less people will fall into the trap because it’s so easy to fall into the trap.

Cherie: Ann had been through a serious case of anorexia that started after she entered university, and she had healed from it. More so, she’d vowed that she’d never go down the path of restricting calories again. And she hadn’t. So Ann wasn’t showing any of the three defining symptoms of the female athlete triad, but she was dealing with the syndrome it’s meant to diagnose.

When Ann began to get some clarity on the more comprehensive definition identified by RED-s, things looked very different.

Ann: If you go through the RED-s symptoms, there’s 12 symptoms of RED-s. And at one stage I was like, well, I think I have 11 out of 12. I was, I was really convinced that that was what the issue was. Um, and my, my only thing that was holding me back was this perception that it’s an under fueling, it’s a condition that’s related to under fueling. And I interpreted that as eating disorder and I thought, but I eat a lot. My food bill is enormous. I never stop eating. Um, like it cannot be that I under fuel.

Cherie: And here lies a critical nuance in this conversation.

Ann: And there is a difference between under eating and under fueling, you might be eating a lot, but you might not be giving the body the nutrients that it needs. And that really was my issue.

Cherie: And this is a really important issue to highlight because eating disorders, severely restricting calorie intake in the name of being thin and light, are behaviors that are so common with RED-s they’re practically synonymous. But then there are cases like Ann’s, where it wasn’t an issue of undereating, it was an issue of undernourishing. You may be eating a lot, but not enough of what you need. For women, being too restricting in carbohydrates intake can be particularly troublesome.

And one issue, which experts recognize as a symptom of RED-s, pointed to the fact that at least part of Ann’s problem was related to her diet.

Ann: Something that really just came up was my gastrointestinal issues. I’ve never been somebody who’s had runner guts. I’ve never had to use a port-a-loo, in a race situation, prior to this, whereas, you know, within a couple of months of following the super strict diet and training like I was training, I had chronic gut distress.

Cherie: And unfortunately, Ann eventually got further confirmation that this diet and training program was sending her down the path that’s so common with this syndrome.

Ann: I did have a stress fracture. The back pain that I had in 2019 was a stress fracture in my spine. And there’s no other way I could have gotten that stress fracture in my spine without chronic overtraining and a diet problem. It’s not an area that you would get a stress fracture otherwise as a runner. And then just overall, um, like my physiological, um, craving for sugar and carbohydrates, craving fat, chronic fatigue, um, you know, those sorts of things. But my, my major sign was, was the, was the gut distress, the stress fracture, and then the, and then the chronic fatigue.

Cherie: Finally Ann had some validation around what had been plaguing her well-being and her performance.

Ann: The more I read about it, the more and more convinced I was that I had RED-s and then went to go and see my trusty old sports doctor and chat to a couple of experts. Um, and, and certainly the consensus seemed to be, yes, I was a perfect candidate for RED-S and let’s, let’s try and manage this as best we can. And that’s really how we came to the conclusion that that’s what I was suffering from. And the more that I read and the more that I learn makes me think that I didn’t just have RED-s in 2018, 2019. I had RED-s for a good two and a half years, but I’d been chalking it up to other things and ignoring the problem until finally my body couldn’t take it anymore.

Cherie: And again that’s one of the biggest challenges with RED-s, you can dismiss each piece of the puzzle as individual issues that are just part of the elite training process. And overall, things can look good, sometimes great, for a long while, until they don’t. You may be winning huge events and PRing, until you aren’t.

And then when you look in the rearview mirror and you can piece all those issues together, the picture starts to become clear; you start to see those pieces as the early warning signs that they are.

Ann: Looking back have been able to see that because the fat content in my diet was so low, um, it actually had an effect on a whole lot of my hormones, all of my chemicals, which require essential fatty acids to kind of move around your body and regenerate. I wasn’t giving my body enough essential fatty acids to even produce my most basic hormones. Um, so I mean, things like my hair falling out to dry and flaky skin, like those are normal things associated with a very low fat diet, but, you know, the hormone effects, like some of my brain chemicals weren’t even working. Like I’m not, I’m not a dim person, but there were days where I literally couldn’t put two and two together. I was like, I don’t know what’s wrong with me, but I literally, my brain is not working today. Um, so a lot of brain fog issues, a lot of forgetfulness, um, I’m, I’m not that person I’m very type A, I’m super organized, I’m really management prone. And there were days where I just couldn’t even keep my own life organized, never mind organizing anybody else. Um, so I think, you know, knowing that there wasn’t enough fat in my diet that that was a key way that that manifests itself.

Cherie: It was very clear to Ann that she needed to revamp what she was doing.

Ann: I had some time off and I had a lot of time to think about what needed to happen and took the very difficult decision then to split up from my coach. Um, because I chatted to him and I said, Look, I think there’s a problem. And I think that we need to rethink our strategy and what we’ve been doing in terms of diets and training is not working for me. And, and we need to, you know, we need to think outside the box, we need to change things up a bit. And unfortunately my coach wasn’t willing to accommodate that. His attitude was we’ve done just fine on how we’ve always done it and you need to keep, you need to keep following the plan. And I wasn’t prepared to do that.

Cherie: It may be tempting here to want to just blame Ann’s coach. But that, to my mind, would be missing the point. This issue is bigger than just one person. We’re talking about changing a culture of training, of reconsidering deeply held beliefs and practices, which can be particularly challenging when they’ve actually gotten you the results that you wanted.

And not to be missed here, this was an enormously difficult decision, however insensitive Ann’s coach may seem in retrospect. This was the person who had believed in Ann’s potential abilities and guided her to victory on the biggest stage in South African long-distance running and one of the most prestigious ultra races in the world. He was the person she chose to be at the finish line of that victory because he’d been that instrumental in her training. This was the person who’d taken Ann from being a really good runner to being a great runner.

But, he wanted to stick with the program he believed in, and it wasn’t working for Ann anymore. It was sad, but it was also simple: Ann needed to take her wellness into her own hands.

Ann: Then I sort of just took a good while to assess, like, do I want to put myself through this again? Like, do I need to be in that state of physical crisis in order to perform at my best, because then I don’t want to be competitive anymore. I don’t want to compete in that state again.

Cherie: So Ann went out in search of a new approach.

Ann: Eventually got in touch with a coach in the states, who had run Comrades a couple of times and who I had a lot of respect for as an athlete and he asked me if I was dealing with RED-s and I said yes, and he put me on a moderate program just to try to dig me out of the hole. And I stayed with him for a couple of months. But during that time I, um, I then broke my ankle running along the stream. I tripped over a rock, um, and ended up in moon boots and kind of everybody just thought that actually, that, that was a sign from God that I just needed to sit down. And so I did, I just took off completely and just focused on my rehab for my stress fracture in my spine, and just rested.

Cherie: Eventually Ann decided she wanted a coach closer to home and turned to the Coach Parry team in South Africa. Lindsey Parry and his coaching staff are highly regarded in South Africa and use a scientific approach to training that appealed to Ann.

Ann: I know that he’s got a very scientific background and, you know, he’s very highly regarded here in South Africa. And I thought, you know, um, I really need a professional. I don’t, I don’t just need a coach. I need like a sports scientist to work miracles with me, like, please can you help me. So I started with Lindsay and very slowly, he has worked me back into shape. Um, but it’s been a very long process. Now I do probably equal cross training to training and I don’t train as much on the road. So my mileage has come down drastically, but I keep my fitness up by swimming and cycling and then doing a lot more focused strength work, basically to protect my muscles and to protect my bones because weight bearing exercises, obviously build bone density, which is what I need at the moment. And so it has actually been a complete shift.

Cherie: With this dramatic change in workouts has come a dramatic shift in the day-to-day impact of training.

Ann: I’m not tired. I was always tired, always sore, yeah, I can’t remember a time where I started a training session and I wasn’t kind of really having to mentally prep myself up for session ahead. Now I get out on the road, and I’m like, woo hoo, let’s go for a run. I mean, I almost feel like I’m on holiday now. Um, cause the trainings really light compared to what I’ve done in the past, but it’s so enjoyable.

Cherie: And now that she’s going into running workouts less tired, Ann’s discovered something else.

Ann: Now there are very different speeds at which I’m able to run. Like there is flat out and there is tempo and there is slow. It’s quite nice to have a difference. So, so yeah, I mean I can’t believe that it’s taken me what, like 20 years, more, 20 plus years of running to be like, Oh, I don’t just have one speed. I do actually have different speeds. But you know, that really comes from the difference in training because if you’re not trying to kill yourself every day, you can save your major sessions for the days that count.

Cherie: So, Ann was running fewer miles and adding in other types of workouts, like swimming, cycling, and strength training to get fitter and stronger. This was helping her maintain fitness and to go into her running workouts fresher, mentally and physically. And all of this is wonderful. But ultimately the goal is to be able to perform well in races, and Ann got that chance toward the end of 2020.

Ann: But it’s been really good for me. I ran a 5k PB, which, you know, at 36 years old and despite having won Comrades, to still being able to run a 5k PB was hugely affirming for me that we are on the right track. So although I feel like I’m just playing, cause I’m not very stressed out about my running, overall in terms of life and health balance, it’s been much better for me.

Cherie: The changes in training were working well, but a crux of the issue had been Ann’s very strict diet plan.

Ann: One of the things that I did after as part of the recovery from RED-s was to go and see a dietician because my relationship with food had become so distorted that I couldn’t actually remember how I needed to eat. So because for three years I only ate certain things and I did need some other things. And I was like, Oh, can I eat that? Should I eat that? How often should I eat that? I couldn’t remember what normal eating is like. And so going to, to work with a dietician called Christine Rice, you know, and she would, she would do me an eating plan and I’d say, No, I can’t eat this. And she’d be like, well, why not? I’m like, no, it’s bad. And she’s like, well, why is it bad? And I say, well, doesn’t it have like a lot of fat and cholesterol in it? Like, I don’t, I don’t think I should eat egg yolk, for example. She said, you have to eat two eggs every day. And I was like, no, I’m going to die of a heart attack. And she said, why, I, she said, there’s conditional and there’s too much fats in there. Like, I’ll just eat the egg whites. That’s fine. And she was like, there’s iron and there’s fatty acids. And these, all the things that you need as an athlete in an egg please eat two eggs every day. And I mean, it took me a couple of months to be able to eat two eggs every day. But, you know, like we just get into funny patterns about food. Um, but working with a dietician really has made a difference. And when she wrote me my eating plan, I was like, you want me to eat how much food I’m going to be eating all day. But the more that I followed her plan, I was actually hungry all day to eat all her food. It wasn’t a problem. Um, and I did, I lost weight. I leaned up and I had incredible energy levels, which I’ve been able to maintain. Um, and I do, I feel so much better. And I actually now eating the fat, having ice cream twice a week, not being afraid of having a chocolate every now and again, I’m totally a fan of cupcakes. I love cupcakes. I can’t tell you why, but I’m obsessed with cupcakes. I eat all those things now, and I’ve never been so lean, even when I was training on the super strict diet, I am lean and I am strong and I feel amazing. And, and I think that that’s been a huge affirmation for me.

Cherie: Ann was learning what foods best nourished her body, and she was beginning to fuel herself with everything her body needed to thrive. But it wasn’t only Ann’s physical health that benefitted by this change in eating.

Ann: I’ve never been super conscious about what my body looks like. I’ve more being concerned about how my body performs and when I was following the super strict diet, I wasn’t enjoying my food. I didn’t eat to enjoy. Um, I ate two fuel and it was very much like putting petrol on a car. Um, and so I didn’t, I mean, I didn’t cook anything exciting, it was steamed everything and grilled everything else. And you know, it was bland and boring and it was purely functional. Whereas now, like I think I’m quite a foodie. Like I experiment, I’ve just been buying cookbooks every month in the past 18 months. I’m so excited about trying new recipes and I make all my own sauces and all my own dips and I’m getting really adventurous in the kitchen. My husband thinks it’s the best thing ever. And we eat the most tasty, delicious, wholesome food every single day. And just from a life balance, like it makes my soul happy to eat good food and to cook good food and to not have all this pressure about you can’t eat this and you can’t eat that and don’t eat too much of this. Now I just eat as I feel, keep a balance. And it’s, it’s definitely made me a happier, more relaxed person.

Cherie: This time of recovering has given Ann some perspective on her own journey and the prevalent mindset around what it takes to be a competitive woman athlete in long-distance running.

Ann: RED-s is something that you need to recognize, diagnose, and deal with. It’s . . . you can, you can exist on RED-s. You can race on RED-s. You can train on RED-s. I don’t know for how long, depending on how bad it is or what type of racing you’re doing, but you can exist in a perpetual state of what they call low energy availability, which is the precursor to RED-s. You can exist in that state for a while. And I think that that comes in and is related to the point about not menstruating as a badge of honor, you know, like people think that they can exist and do well in this state of crisis. And so they’re just going to keep doing what they’re doing, but I think the long-term ramifications or consequences of that type of attitude and the damage that you do to a body in the long-term is not worth it. And there has to be a healthy way to race and train competitively. And I think that we need to be far more aware of racing and training in a healthy state because the more people who continue to exist in an unhealthy state, in a state of low energy availability, the more prevalent it is, the more acceptable it is.

And so I for one, I’m looking forward to seeing how I do healthy.

Cherie: We are, too, of course, and the signs are pointing to, well, Ann completely crushing it. At the end of April 2021, Ann won her very first 100km trail race on a tough, technical course in South Africa’s Drakensberg mountains.

A big thank you to Ann Ashworth for sharing her story, once again! It’s always an honor. If you haven’t heard the previous episodes that Ann’s featured in, I’ll link to them in the show notes. One focuses solely on Ann and her victory at Comrades and the other one is about Team Massmart, the South African all-women’s elite running team Ann founded and ran.

Also in the show notes, I’ll provide ways to follow Ann Ashworth as well as Strides Forward on social media. New for the podcast in that realm is we started a private Facebook group. Please come join us discussing all things women’s longer-distance running and sharing our own running and adventures.

As always, I’m very thankful to you for listening. We love making these stories, but they are  made to be heard, so you being here is a critical part of the equation. And, if you want to support the show in other ways, we have made to order merch, with several different designs to choose from. You can order mugs, T-shirts, tanks, stickers, all sorts of fun stuff. Just go to womensrunningstories.com and find the merch link on our home page. A portion of what we make goes to charity and the rest goes to covering the costs of the show.

 

The Strides Forward team includes me, Cheire Turner, your host and producer. Cormac O’Regan creates and places all of the music you hear. And he does it from his studio in Cork, Ireland. April Marriner of Bonfire Collaborative does all of the design work for the show, including the website, merch, and logo. She comes to you from Truckee, California. You can find April at bonfirecollaborative.com.

 

Strides Forward will be back in a couple of weeks with another episode about running in the women’s body. Until then, this is Cherie wishing you many strong and healthy strides forward.