‘My metabolism had almost come to a halt’: A pro-cyclist on the toll of elite sport

Georgie Howe was excited when she heard her cousin would have his wedding in Oxford, the university town west of London. It was to be in December 2023 and she’d fly over from Girona, Spain, where she’d been based since late 2022 when she joined Liv AlUla Jayco, a professional women’s road cycling team competing on the European circuit.

Howe was one of those gifted athletic types who’d represented Australia in two sports in the space of a decade. The first was rowing, in which she’d excelled at Melbourne Girls Grammar then Princeton, the American university at which she rowed in three Ivy League championship teams, co-captaining the last, one of the few non-Americans to do so. Then came cycling, which she only took up during COVID-19 lockdowns as a way to keep fit, stave off boredom and stay in touch with her Princeton buddies, whom she’d compete with from her North Richmond share house via a stationary bike and app. When lockdowns eased, she’d go on long rides along Beach Road, Melbourne’s premier cycling boulevard, where coach Nick Owen noted her pace and started training her in ­exchange for lattes. “I never meant to go pro, I just wanted to see how fast I could ride,” says the now 31-year-old, in the nonchalant way only those with talent can pull off.

By the time she arrived in Oxford for her cousin’s wedding, though, Howe felt none of the joy one might expect from someone living such a pro-athlete’s dream. To the contrary, she was stressed – and hungry. “I was aware of everything I put in my mouth,” she says. “I was the only tattooed, mulleted person at the wedding and I was the first to bed.”

A few months prior, she says, her team had delivered an unpalatable truth: Liv AlUla Jayco had not performed as well as they’d liked in 2023. Everyone was being put under the microscope going into 2024, and to continue pulling her weight, Howe needed to lose some. The dominant thinking in road cycling is that the best are lean and light, all the better for pedalling uphill in unforgiving multi-day stage races like the Tour de France Femmes. If the 174-centimetre Howe could shed some of her 74 kilograms, the theory went, she’d perform better. The goal, then, was nothing less than to change her body shape – to a kind she’d never had in her life.

“I’d always been built like a brick shithouse,” Howe says bluntly. “I came from rowing, so I had big shoulders and arms, and had been ­lifting weights since I was 13.”

With the help of the team dietitians, Howe says she cut her food intake pretty much in half. Where she might have had eggs on toast for lunch after a gruelling five-hour endurance ride, she now made do with a smoothie. With weigh-ins three times a week – she wasn’t the only ­cyclist asked to shed kilos – she started taking two sets of scales with her wherever she went, one to measure what she ate, the other her weight.

A strange thing happened, though, as the 2024 season got under way. After an initial drop of a few kilos, and despite continuing to eat abstemiously, Howe actually put weight on. What’s more, while in 2023 she’d mostly sat in the front half of the 130-odd riders in the peloton, in 2024 she was now sitting in the back 20 – sometimes pulled off the road mid-race, such was her slowing pace.

Howe’s inability to shed weight had stumped everyone, but when it started twinning with poor performance, they really sat up and took notice. Her blood tests, done quarterly for all riders, painted a worrying picture. “Despite eating no fat and limited carbohydrates, her cholesterol was alarmingly high,” says Dr Alice McNamara, a physician with the Victorian Institute of Sport who’d looked after Howe on and off since her rowing days, and was asked by Howe to look over her results. Howe’s iron stores were low, her liver strained, and her hormones, including her thyroid and reproductive ones, were suppressed. Her cortisol levels were high first thing in the morning, suggesting a baseline stress on her system. “Her metabolism had almost come to a halt,” says McNamara. “The body was in battery-saving mode; it was shutting down non-essential functions.”

‘Howe’s metabolism had almost come to a halt. The body was in battery-saving mode.’

Dr Alice McNamara

Howe hadn’t had a period since September 2023, and a gynaecologist she saw in Europe told her she had the “uterus of a 60-year-old”. A team doctor diagnosed her with hypothalamic amenorrhea, which is when the hypothalamus causes your period to stop, typically due to excessive exercise, stress or under-­eating. She was put on the contraceptive pill to stimulate a bleed – which some medicos argue actually masks problems by suppressing the natural hormonal cycle – and kept on riding.

In mid-2024, after a final attempt to lose weight through altitude training in the Pyrenees, Howe had a flare up of ulcerative colitis. A kind of irritable bowel syndrome, its symptoms include diarrhoea, not good if you’re sitting on a bike for hours on end. It became a line in the sand. Half an hour into a race in which she needed to perform well to continue cycling at elite level, she pulled out. “I thought, ‘If I have to contort my body into this shape for this lifestyle, I don’t want it any more.’ ”

It was July 2024, and while she didn’t know it definitively at the time, Georgie Howe’s professional cycling career was over. That wasn’t the worst of it, though. Far worse was that her endocrine system was shattered. Ditto, her psyche. She’d been riding professionally for 18 months. It would take another 12 months, and multiple sessions with physicians, psychologists and psychiatrists, for her to get them back on track. It would take time, too, for Howe to deal with the grief associated with a dream cut short – and to understand exactly what had happened to her, and why.

We’re sitting in the kitchen of the family home in Malvern in Melbourne’s south-east: Howe, her mum, Sally, and dad, Nick. Focaccia and chocolate-chip biscuits have been laid out for lunch, and Sally is making a pot of coffee. Photos of Howe and her younger sister, Ellie, line the walls, showing them excelling at various athletic pursuits. A decorated oar from Ellie’s school days hangs above the glass back doors. Howe’s oars used to be up there but, once she’d left school, Sally thought it unfair for Ellie to have to eat breakfast in the shadow, literally, of her older sister’s sporting glory. Not that Ellie wasn’t athletic; she also won a rowing scholarship to a US college, and now lives in San Francisco.

We’re here to talk about Relative Energy Deficiency in Sport, or REDs, which is what Howe was ultimately diagnosed with. In simple terms, it’s when an athlete’s physiological and psychological health suffers following a sustained or severe period of low energy availability, which comes about when what they’re eating and drinking does not make up for what they’re expending through exercise and on baseline bodily functions. Lack of periods are the “canary in the coalmine” for women, with the pervasive sporting idea that if you bleed you’re not training hard enough slowly making way for the understanding that, if you don’t get your period for a sustained period of time, there could be a hormonal problem.

Ditto regular stress fractures or other breaks, which point to low bone density and, in some cases, osteoporosis, also caused by the down-regulation of hormones. Sleeplessness, anxiety and depression, together with the kind of blood results Howe returned, are other signs of REDs, all of it indicating an endocrine system seriously out of whack.

“The biggest thing you lose is your intuition around appetite,” says Howe of how it feels for the athlete. Howe has a pixie haircut, gold earrings up her lobes, and a mix of confidence and vulnerability in her big blue eyes. “In fact, your intuition around everything: fatigue, illness, emotions. You’re very disconnected from your own body, and it takes a long time to get it back.”

A relatively recent diagnosis, REDs was ­recognised by the International Olympic Committee in 2014, via a consensus statement written by a global group of dietitians and medicos who agreed upon its core attributes. It was an update of sorts on the Female Athlete Triad, a term coined in 1992 to capture the congruence of menstrual irregularities, low bone density and low energy availability among some female athletes. The REDs statement extended the idea to men, with low libido and lack of morning erections their equivalent of disappearing periods. The IOC group updated the statement in 2023 to reflect a more ­nuanced understanding of its multiple factors, and to include a diagnostic tool for clinicians.

It’s an issue in dance, too; a risk, really, in any athletic pursuit where weight is closely linked to performance and aesthetics. Which is many, because when it comes to women, ­aesthetics are closely tied to sponsorship ­dollars, which means the pressure is often on female athletes and dancers to be super slim.

Howe has made it her mission since returning to Australia late last year to help spread the word on REDs, not only among professional athletes but amateurs, too. You know, those of us signing up to do marathons, triathlons and other endurance sports. (If you’re not middle-aged and training for a marathon these days, are you really middle-aged?) And those of us who cherry-pick bits of the intermittent fasting fads sweeping the world (guilty) without understanding what’s safe and what isn’t. Those of us, too, who watch health influencers parade their lithe bodies across social media and think, if I just eat less and train more, maybe I can look like that, too.

“There’s a boom in people interested in ­endurance sports; many run, cycle, do triathlons these days for their mental health,” says Alice McNamara. “They’re also juggling work, study, parenting, so they have a high life load. What crops up a lot is stress fractures, so you look at the reasons they might have developed them.” McNamara is among a number of medicos who report seeing 20- and 30-somethings with hip fractures or “bones like dust”, two things that should not be present at that age.

In some sporting circles, REDs is a bit like attention deficit hyperactivity disorder (ADHD), chronic fatigue syndrome and repetitive strain injury have been over the decades – that is, a hot-button topic du jour. Podcasts, social media posts and online articles on REDs have mushroomed, mostly led by athletes who have had it, or the sports medicos, physiologists and dietitians who work with them on recovery. Pippa Woolven, a star British long-distance runner who developed REDs while on an athletics scholarship to America’s Florida State University, went as far as to establish a website, Project RED-S, to provide ­information, advice and tools for athletes ­suffering from it.

London endocrinologist Nicky Keay treats many with REDs. She’s developed a free questionnaire for people to generate their own risk score. “It’s more widespread than we would have thought,” she says. “Lots of people come to see me and almost apologise; they say, ‘I can’t have REDs, I’m not an athlete.’ They tell me what they’re eating and what training they’re doing. And I say, ‘You’re doing what an Olympic athlete would do, plus you’re trying to hold down a full-time job and run a family; that’s a huge load. Yes, you can have REDs. You do have REDs.’ ”

Dietitian Renee McGregor, who helped Howe recover, believes numbers could spiral in an era of unrealistic body and performance goals. “There are hundreds of influencers working with brands now, encouraging over-training and under-fuelling,” she says from her home in England’s Lake District. “Health has changed, the look of it has changed. It’s now portrayed as someone running in a crop top and shorts and drinking a matcha latte; that scares me.”

Organisations around the globe are starting to grapple with the syndrome. London’s Royal Ballet School now has an annual spotlight on REDs week, while the International Federation of Sports Climbing blazed a trail last year when it introduced REDs screening requirements for climbers. The Cyclists’ Alliance, a member organisation for female cyclists, has called on its world governing body, the Union Cycliste Internationale, to introduce similar screening, while over in Boston, Harvard Medical School associate professor and sports endocrinologist Dr Kathryn Ackerman ­recently launched the Women’s Health, Sports and Performance Institute, a centre that offers a multidisciplinary approach to the health woes of female athletes, including REDs, as well as conducting research into their issues.

Closer to home, the Australian Sports Commission has included REDs in a position statement on disordered eating and added a module dealing with it to its Female Performance and Health Initiative, while the Australian Institute of Sport and Australian Catholic University got stuck into the issue last month, with a two-week study into the energy availability levels of the women’s water polo team.

‘I wanted to do what was right for the team, so I thought, “OK, I’m a team player, I can do this. I’ll lose weight.” ’

Georgie Howe

As with chronic fatigue and ADHD, though, scepticism abounds. There’s no hard data on how many people have REDs, what the breakdown is between men and women, or even whether diagnoses are increasing. According to the 2023 IOC statement, between 23 per cent and nearly 80 per cent of female athletes, and 15 per cent and 70 per cent of their male counterparts, have some indicators of REDs. That variation causes some raised eyebrows, including by the IOC statement authors themselves, who sheet the parameters wide-enough-to-drive-a-bus-through home to the lack of a singular definitive diagnosis and issues around the veracity of various REDs studies.

All this inevitably prompts questions. Such as: is REDs just a more palatable term for an eating disorder? Aren’t some health challenges the cost of being an athlete? Suck it up princess, elite sport ain’t for the faint-hearted. And does REDs really exist at all?

Georgie Howe was somewhat surprised by the edict to lose weight ahead of the 2024 season, as she thought she’d had a good 2023, acquitting herself in her inaugural Tour de France Femmes and finishing in the top 10 at the Road World Championships time trials in Glasgow that August. “But I wanted to do what was right for the team, so I thought, ‘OK, I’m a team player, I can do this. I’ll lose weight.’ ”

Her mum noticed Howe’s new approach to food when she came home for Christmas 2023. “She’d stand and stare at the pantry, or open the fridge and just gaze inside,” says Sally, pulling out the red scales her daughter used to weigh her food. “I didn’t like all the measuring but didn’t want to interfere. When I did say something, Georgie would say, ‘Mum, I’m a professional athlete now, this is what we do.’ ”

Sally’s worry grew in 2024 when she saw her daughter on FaceTime, puffy and anxious – then on TV. “I remember watching her in a race in Belgium at midnight one night and Nick [Owen] texted me and said, ‘Something’s not right,’ ” Sally says. “She wasn’t racing with her usual tenacity. She didn’t look like the Georgie we were used to seeing.”

That Howe had lost her mojo was no surprise, given she was failing at the two things she’d been charged with doing: losing weight and performing. She wasn’t used to failure; like most athletes, talent, hard work and sheer determination had always got her where she needed to go. So she kept on pushing.

To McGregor, this is typical elite-athlete ­behaviour. “We can’t forget the athletes’ part in all this,” she says. “They will be a certain type: high achievers, critical of themselves, perfectionists.” That works for them – until it doesn’t. The job of their health teams, then, is to teach them when to keep pushing, and when, for the sake of their health, to pull back. That can be diabolically difficult for athlete and medico alike, given the short time frames in which athletes have to achieve their goals and the opaqueness around when they’re actually in a dangerous period of low energy availability (more on which, later). Taking time out for a broken arm is relatively straightforward. For a broken endocrine system, which might take a year or more to recover from – with the athlete still on the payroll – much less so.

Luca Pollastri is medical co-ordinator with GreenEdge Cycling, which owns the team Howe rode for. He agrees that knowing when to pull an athlete out of training or competition can be ­difficult, and says they use red and ­yellow flags in their assessment. Red flags are fairly simple: if an athlete falls below a certain body-fat ratio, or loses a set amount of weight within a month, or hasn’t had their period for months, the medicos might pull them. Yellow flags are where it gets tricky: if it’s been fewer than 45 days since their last period, if things were moving in the right ­direction but start going backwards, that’s when a judgment call is made. With a psychological component, trust between medico and athlete is key to deciding what to do in such cases, and that’s highly individual. “There’s not one single protocol we can follow that is fit for everyone. Within one group of doctors you can have different opinions.”

On Howe’s case, and why she wasn’t pulled off the bike despite those worrying blood tests, a spokesperson for Liv AlUla Jayco declined to comment. Pollastri, who was not Howe’s doctor, says the team screens all riders for REDs at the start of each season via a questionnaire, and that any edict to lose weight would be done in consultation with the cyclist. “I don’t think it’s a directive to lose weight,” he says. “We discuss the goal for them, with them.”

Endocrinologist Nicky Keay sees an education job ahead, in part to teach those running various sports to prioritise hard health data and actual performance over arbitrary weight and skinfold goals. “It’s the pervasive cultures: the weigh-ins, measuring body composition,” she says. “My message is to look after the health first, and the performance will follow.”

Many refer to sports dietitian Louise Burke as the godmother of REDs, so I call her at the Australian Catholic University, where she’s a professorial fellow at the Centre for Human Performance & Metabolism, for a deeper understanding of the syndrome. Burke, who worked at the Australian Institute of Sport for three decades, was one of the co-authors of the 2014 and 2023 IOC statements. She calls REDs a clinical diagnosis of exclusion, made once other potential causes of health and performance problems are ruled out. It all revolves around low energy availability (LEA); in short, not ­eating enough for all that training. Not that all cases of LEA are bad. “Given obesity levels, much of the world could do with some LEA,” Burke says, “but too much of it is a problem.”

She explains that REDs can occur intentionally, for example when the athlete does have an eating disorder, or unintentionally, such as when they don’t realise they should be eating more for the training they’re doing. A 100-kilogram rower might be training so much they cannot eat enough food to make up for it. Alternatively, “some athletes who get sporting scholarships to the US might not have enough money to buy enough food”, Burke says. “Nor might some athletes in Third World countries.”

Pippa Woolven, the former athlete behind the Project RED-S website, says it took her the best part of a decade to recover from REDs, involving not just eating more and training less but unravelling the vilifying ­beliefs she’d internalised about fats and carbohydrates. “I had to show myself that if I ate properly, nothing bad would happen,” she says. “It was sometimes two steps forward, one step back, but I’m arguably the healthiest now that I’ve ever been.”

Woolven is holding five-week-old baby Lawrence when we catch up on a video call from her home in Henley-on-Thames. She and her husband, Rich, a software engineer and former elite athlete who helped her design the Project RED-S website, also have a two-year-old, Alistair. “I never thought it would be possible for me to be a mum,” Woolven says, smiling broadly. “It’s not all doom and gloom. This is a condition you can recover from.”

A former competitive cyclist – “I was a serious amateur, not at Georgie’s level” – José Areta is associate professor in exercise physiology and metabolism at Britain’s Liverpool John Moores University. He also works privately with athletes to ­improve their health and performance. Argentinian by birth, Areta spent six years in  Melbourne completing his PhD in sports nutrition in the early 2010s.

“I loved it,” he tells me on a video call from Liverpool. “The coffee culture was unreal. I didn’t drink coffee before going to Melbourne. I did a lot of road cycling there, too.” A biologist by training, he sees sports nutrition through “an evolutionary paradigm”, which gives him a different perspective to many ­others working in the area.

Areta was one of eight authors behind a 2024 paper in Sports Medicine journal that threw the cat among the pigeons with the ­provocative title, “Does Relative Energy Deficiency in Sport (REDs) Syndrome exist?” Their main point was that declines in an athlete’s health and performance might be due to low energy availability but might also be due to other things. Stress. Lack of sleep. Anxiety. Infection or some other undiagnosed medical issue. Things happening in their life that are completely unrelated to what they eat and drink and how hard they train. “We say there are many things that can cause these symptoms, which are very generic, and energy deficit is not the only thing,” Areta says. “We don’t have enough data to establish causality.”

Part of the problem, he says, is how difficult it is to measure energy input and output, which “looks straightforward but isn’t”. This helps explain why pro-athletes with dietitians on the payroll can fall into LEA – because working out what to eat for your particular size, genetic make-up and training regimen, as anyone who has done any diet will tell you, is an inexact thing.

There’s also the awkward fact that being lighter can be a competitive advantage. Areta points to research he did on Georgie Howe during the 2023 Tour de France Femmes. Despite already having infrequent periods, indications of an underactive thyroid and a negative energy balance, plus losing 2.2 kilograms during the eight-day race, Howe rode at world-tour level and had her “best performance yet” in the race’s final stage. Two weeks later, she finished in the top 10 at the world time trials in Glasgow. Asks Areta: “Would she have performed better if she’d had more food? We don’t know. What we can say is it appears high performance can be compatible with a state of energy deficit.”

Similarly, 2025 Tour de France Femmes winner, Pauline Ferrand-Prévot, dropped a lot of weight before the race, causing much talk in cycling circles. “I can’t say she won the race because she dropped a lot of weight, but she won the race having lost weight,” says Areta. “It’s quite a complex topic and I can understand how it can be polarising.”

Letters went back and forth after the “Does REDs exist?” paper. “Yes REDs does exist!” was the title of a letter to the editor in which 17 authors, including Louise Burke, said that while they agreed with much of what Areta and co said – yes it is difficult to accurately measure energy availability, yes it can be over-simplified – waiting for long-term studies to establish causality would be both “unfeasible and unethical”. They concluded with the punchy statement that “as sports medicine physicians, psychologists, physiologists, scientists, dietitians, coaches and athletes, we – the IOC consensus co-authors – know that REDs exists. We see and treat it in our athletes daily.”

Areta and his colleagues returned fire, arguing that a statement like “we know that REDs exists” was “not compatible with the scientific process” and that “we believe it is important to challenge dogmas and encourage rigorous ­scientific processes”.

Those working on the diagnosis frontline stress that REDs is a clinical call, made on a patient in front of them, based on what they see and hear from that patient, ruling things like Areta’s other reasons for problems in and out. Renee McGregor does not dispute that Howe performed well while in a state of LEA during Areta’s trial, and agrees that lighter can lead to better results in the short term. Hence, many athletes successfully manipulate their weight in the lead-up to competition.

In the longer term, however, she argues, it will catch up with them. In Howe’s case, it was eight or so months after Areta’s research on her that everything started going wrong. “People can get away with under-fuelling for up to 18 months before seeing negative consequences,” McGregor says. “By the time they turn up to me with a problem, their body is often in a pretty poor place and they can’t identify the behaviour that’s got them to where they are.”

What they all agree on is that more research needs to be done: on the causality links between weight loss, health and performance, on why some athletes who lose weight rapidly will develop REDs and others won’t, on how an athlete’s particular genetic make-up plays into all this, just for starters. On women athletes in general, on whom only 6 per cent of sports medicine research has traditionally been done. As physiologist Stacy Sims is fond of saying, “Women are not small men” – meaning systems designed for male athletes can’t always be simply transferred across to women. The difference in women’s physiology and psychology needs to be better understood, and adaptations made where required.

Given the rising numbers of women participating in sport, and an associated flow of money into it, there’s hope more ­research will eventuate. Meanwhile, the question we should be asking, Areta says, is: “What price are you willing to pay to win the race? And is this a price you should pay?” What price, indeed.

In mid-2024, after Georgie Howe pulled out of that final race, she caught the train to Paris, where she met her parents and friends ahead of the Olympics. They went for dinner to a local wine bar, where Howe ordered steak frites, and drank beer. She measured nothing. “I saw the joy start to come back in her eyes,” says Sally. One day, Howe went for a leisurely cycle along the road race route. “I’d stop at boulangeries and get a croissant if I felt like it,” she recalls. “Previously I’d have said, ‘No, not today, you don’t need that today.’ ”

I ask Sally and Nick whether, knowing what they know now, they’d encourage their daughter into pro-cycling. No, says Nick, a Tour de France tragic: “There’s always sacrifice, a lot of social activity you miss out on, but I don’t think any young person expects to have their health permanently impacted by pursuing a particular sport.” Sally, a former nurse and health administrator, and a former board member of Swimming Australia, says no, too. She says she’ll know things have improved when endocrinologists are par for the course on sport medical teams. “Do no harm – that’s the first rule, isn’t it? That’s the lens that should be put over every decision. And too often, it isn’t.”

Howe recently had her 12th menstrual cycle in a row, a sign she’s coming out of REDs. She’s been working in a friend’s bike shop in Collingwood and writing and podcasting for various cycling publications. Last month, she began a new job with a sports marketing firm, and she’s looking to move out of home again with some mates. She’s getting her mojo back – but the costs are still front of mind. Recovery is still a work in progress.

“The penny really dropped for me when I went to see my psychiatrist recently, and he validated my feeling that sometimes being an athlete is the worst job in sport,” she says. “Because you retire and in the transition out you realise, ‘Holy shit, I really was just a commodity. They really didn’t care about me.’ ”

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