* Maggie Yankovich running at the GHSA Class 7A Track and Field Championships her senior year at St. Pius X
Photo Credit: Heather McElroy/Georgia MileSplit
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An Open Letter On How I'm Working Toward Overcoming RED-S
By Maggie Yankovich - St. Pius X High School, Class of 2019
Editor's note: This article was originally published in December of 2021. Maggie Yankovich, a 2019 graduate of St. Pius X and a former track and field athlete at the University of Georgia, is sharing her experiences with Relative Energy Deficiency in Sport in an attempt to help anyone who can benefit from it.
For roughly four years, I have struggled with Relative Energy Deficiency in Sport (RED-S).
RED-S, sometimes referred to as the Female Athlete Triad, is an often unrecognized and often undiagnosed disorder that is characterized by low energy availability (insufficient caloric intake for energy expenditure), amenorrhea and low bone density. Over the past four years, I have dealt with an eating disorder, loss of my period and extremely low bone mineral density that has caused me to suffer seven stress injuries in my shins, femur, foot and ankle, and prompted my medical retirement from NCAA Division I athletics in cross country and track and field.
After suffering six of those stress fractures within a span of barely over two years, I vowed to share my experiences with this disorder in hopes that anyone, anywhere, can glean something from it. This is a really difficult thing to share and a really difficult matter to talk about, but I think it is necessary to talk about something that is honestly so very prevalent among athletes, specifically girls and women, and especially so in the sport of running.
* Yankovich achieved her dream of running at the NCAA Division I level before injuries arose
Photo Credit: Anna Burnett/Georgia MileSplit
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I did not grow up as a 'runner'; I played soccer for 13 years and decided to try out for cross country during my freshman year, somewhat on a whim. I was not anything resemblant of a 'freshman phenom,' and actually walked into my coach's office and quit track that year after attending two practices. I ran cross country again my sophomore year, but I didn't really improve upon my performances and was hurt in track season. For whatever reason, I decided to really train for the first time the summer before my junior year and the entirety of those few seasons was truly a breakout season for me. I ran my fastest races by far and the possibility of running in college entered my head for the first time. Going strictly off performances, that year showed potential of what could be the start of a competitive running career.
Running a certain time or winning a certain race may feel like everything in the moment -- trust me, I've been there -- but the resulting physical, mental and emotional problems that can stem from not properly caring for your body to try and do so can be quite major, and long-term, and it simply is not worth it.
However, as good and promising as that year looked on paper, it was truly the beginning of a long and painful struggle with RED-S. I became obsessed with competing and dropping time off my performances and began to try to change every aspect of my life so I could be as fast as possible. This included the beginning of incredibly restricted eating habits. I passed out during the cross country state finals in the fall and my regional races in track over the spring because I refused to eat enough before the races for fear that it would 'slow me down.' My junior year may have appeared to be the beginning of my 'breakout,' but in hindsight it was the beginning of a downward spiral that drastically affected -- and continues to affect -- my health.
By senior year of high school, I was able to commit to my dream school, the University of Georgia, to run cross country and track. Although this was a huge relief after battling issues all year long -- that we later found out resulted from anemia -- I was still dead-set on coming out and running fast on the track, as track had --somewhat ironically, given my beginnings in it -- come to be my favorite season, by far. In the spring, I began to run times that I never could have imagined I would run. I had never won a race before, but suddenly I was winning a lot more races than I wasn't. It seemed that each workout and each weekend's race I would just be able to drop time and get faster. On paper, everything was going 'perfectly,' until mid-April.
* Yankovich won the GHSA Class 4A 1,600m final in 2019 with a time of 5:02. She ran the race, with permission of her parents, on a Grade-3 stress reaction
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A couple days before the regional track meet, I first felt a sharp pain in my shin during a run. I distinctly remember limping off my favorite trail at Cochran Shoals and heading back to my car fighting back tears. I knew what this pain was; it was confirmed days later by my doctor: A Grade 3 stress reaction in my tibia. Suddenly, my 'perfect' season -- which would have, in my mind, theoretically concluded with multiple state titles -- was in extreme jeopardy. I was barely able to run in the crucial weeks leading up to state. I ran my first event at state and scratched the second because I couldn't stand on my leg without pain. I was happy at the time because I accomplished a long-time goal in the one event I was able to run. I was so excited to heal up and get to UGA in the fall to run cross country.
I truly believed this tibial stress reaction -- which likely turned into a fracture after racing region, sectional and state -- at the end of high school (May 2019) was a one-time occurrence, a fluke accident that may have happened because I got too excited that I was running well and pushed a little too hard. It was 'only' my second stress injury and therefore I was very much not prepared for the injuries that would follow -- a femoral stress fracture almost as soon as I got to college in September of 2019; a metatarsal stress fracture during the COVID-quarantine summer of July 2020; a left and right tibial stress fracture/reaction when I was close to ready to race again in March 2021; and distal tibial high-grade stress reaction while on the comeback yet again in October 2021.
* Yankovich celebrates with teammates after breaking a school relay record
Photo Credit: Pat Martin/Georgia MileSplit
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Going back to my senior track and field season in high school, people around me would describe the year I was having as a 'dream' or the word I've already used -- 'perfect.' I remember my coach telling me that the coaches of a friendly rival high school would jokingly lament to him, "Well, Maggie's still perfect," after each weekend's meet, as I wasn't losing races.
But it's important to realize that most media outlets never tell the full story. On paper, I couldn't really ask for more -- running much faster than I ever had and competing with the best in the state. But behind the race results, there was a lot more going on. I became so obsessed with getting faster and better that I absolutely lost myself in the process. To be as fast as possible, I thought I needed to weigh as little as possible. I viewed my body as a sort of machine that was only for running fast and treated it accordingly. These ideas were manifested primarily in my eating; I avoided social gatherings where there was a lot of food for fear I would 'mess up' and eat something I 'wasn't supposed to.' This caused me to basically isolate myself for much of my senior year and had resulted in detrimental mental and emotional effects as well. If I wanted to go to an event, I would 'run late' so that I would miss the food and make up some excuse for my tardiness.
Valentine's Day and Easter were honestly huge fears of mine that I would dread because of the prevalence of sugary foods. I lived in fear of what I was putting in my body and as a result did not put anywhere near enough food in it. I was sometimes so tired from going to school all day and running 50 to 55 miles per week at a huge caloric deficit that I would nearly fall asleep on my drive home in the afternoon. The difference between the amount of food I needed to eat to compensate for my energy expenditure and the amount of food I was actually eating was monumental.
* Yankovich placed third at the GHSA Class 4A Cross Country Championships in her senior year
Photo Credit: Marc Logan/Georgia MileSplit
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However, I did not change anything because I was running fast and 'doing well.' This is the mental, emotional and physical danger of RED-S. If a certain 'method' -- in my case, extreme caloric restriction -- is 'working,' why change anything? Over time, I think that my body got so used to the restriction that I didn't have the same appetite cues anymore. However, I still felt empty and was lonely and isolated because of my eating disorder. But I did not want to make any changes or even see the need to make any changes because I still wanted to run faster, help my team score points and set records and achieve my goals. I completely lost my period in this time as well -- this is NOT normal* -- and although I had been told that this was a major red flag, I still did not try to change anything.
Unfortunately, I honestly think the only thing that made me slow down and actually look at the way I had been ruining my body was time away from the sport in the form of injuries. Around the time of my femoral stress fracture over my first couple of months at Georgia, a bone density (DXA) scan was ordered for me. These scans measure different parts of the body -- usually lumbar spine and hips -- and give a Z-score that basically indicates bone health by comparing your T scores to what is average in someone who is your weight and age. Z-scores range from -2.5 to +2.5. A Z-score of -1 and above indicates normal bone density; a Z-score between -1 and -2.5 indicates low bone density (osteopenia), and a Z-score below -2.5 indicates osteoporosis. My freshman year Z-score in my lumbar spine was -2.1, dangerously close to levels indicating of osteoporosis, at age 18.
Women are still able to build bone mass until their late 20s, but being as close to osteoporosis levels as I was at age 18 is still just about as bad as it sounds. DXA scans are usually repeated every 12 months as needed, with six months being the minimum timeframe between scans, as it's fairly unusual to see changes in bone density composition in a shorter amount of time than that. My bone density scans have been repeated frequently in the last two years and have shown improvement, but my bones are still unfortunately not able to stand a competitive training load. The damage that my body endured in high school -- 2-4 years ago -- is with me to this day, despite finally making changes towards better health.
* Yankovich running for Georgia
Photo Credit: Rob Yankovich
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Following this first DXA scan and my femoral stress fracture, I flew to see a specialist in Boston in December of 2019 who was the first one to mention RED-S to me. As she explained the main points that the disorder were characterized by, my blood began to run cold as basically every point** she was describing characterized me. This doctor is basically the leading specialist and researcher in RED-S in America, and in essence, she told me that I was very much not on a good trend. And yet, she said there was still plenty of room for improvement as I had more than a decade to build bone. However, she did tell me that I needed to set myself up for that process now, as there wasn't time to waste on that front. She has helped me greatly since, and I'm incredibly grateful for her expertise.
But I did not want to make any changes or even see the need to make any changes because I still wanted to run faster, help my team score points and set records and achieve my goals. I completely lost my period in this time as well - this is NOT normal* - and although I had been told that this was a major red flag, I still did not try to change anything.
Unfortunately, I have suffered four more stress injuries following that trip to Boston and it seems that although I am now trending in the right direction, my body is still not ready to train at a competitive level without my bones breaking. This is incredibly disappointing and medical retirement is never the position I imagined I would be in. It was truly an honor to have the privilege of wearing the Georgia uniform three times and I'm so incredibly thankful for each time -- but I never imagined the last time would be my last. I absolutely love running and I already miss it and my team dearly, but I'm so very grateful for my time in the sport and I'm hopeful that my body will be able to do it for enjoyment purposes someday in the future.
I did not write this to accuse anyone of having any type of disorder; I just wanted to share my experiences. I do not mean at all that anyone running fast has an eating disorder, has lost their period or has low bone density. That is simply untrue and that is an absolutely false assumption to make. However, I do believe that this disorder is a lot more common in endurance sports than numbers may suggest or for which we care to believe. If these words can open anyone's eyes -- athlete, coach, parent, teammate, trainer, friend, etc. -- to this problem, even if that just looks like knowing more about it in the future, then the purpose of this writing is fulfilled.
I also want to be clear that I did not write this to scare anyone, but I do want to give a heartfelt warning to anyone who reads this and can relate. Unfortunately, low caloric intake and high energy expenditure will catch up to you; it is inevitable. No matter how long you think you can make it, the human body is simply not made to sustain under-fueling compared tot he amount of energy you are expending. I promise that you do not have to starve yourself and deprive your body of the nutrients it needs, and the care it deserves, to run a certain time. Everyone's body is different and everyone's training is different, but there are so many examples of women who have or have not dealt with problems relating to RED-S at any point in their lives who would say the same exact thing: Harming your body may seem like a "quick solution" for the time being, but it truly just creates long-term issues.
Running a certain time or winning a certain race may feel like everything in the moment -- trust me, I've been there -- but the resulting physical, mental and emotional problems that can stem from not properly caring for your body to try and do so can be quite major, and long-term, and it simply is not worth it. It can be difficult to try to look months, years and decades into the future -- when I was in high school, I certainly didn't do this and had a "well, I'll deal with that later" mindset -- but as someone who is currently 'dealing with it later,' in the form of continued struggles with RED-S and which has prompted my medical retirement from the sport and team I love, it was simply not worth it. We are all given one body -- one singular body to take care of. Please, please, please listen and take care of it now.
These conversations can be so incredibly difficult and awkward to start and to have, but I do believe that there is a necessity for them. Personally, if someone had come up to me during my last couple of high school seasons and suggested that I may have some sort of problem, I honestly likely would have been pretty upset, frustrated and dismissive. People in my life whom I love did notice warning signs and try to help me in those years and I dearly wish that I had listened. However, at the same time, I'm oddly grateful to be in this position for the perspective it has given me and the hope of raising awareness and helping others. That would mean way more to me than anything I could have ever accomplished on the course or track would have!
Although I may be away from competitive running for now, I want to help as many people as possible in whatever way I can. I am more than open to talking in any capacity with anyone who would be interested or has any more questions. I'm not a medical professional, dietician or expert of any kind, but would love to share any insight I can.
Finally, I would be incredibly remiss if I didn't thank all the people in my corner. Sincere thanks go to all my family, friends, teammates, coaches, trainers, doctors, nutritionists, etc. -- the list goes on. I could not be more grateful for all the support over the years and sharing this wouldn't be possible without you all.
Many thanks for reading!
Maggie Yankovich - @maggieyankovich - myankovich5@gmail.com
* I believe there is sometimes an underlying message -- spoken or unspoken -- in endurance sports, especially running, that losing your period is "normal" or a thing that "just happens" to women/girls, if they are "working hard". This is false. This isn't "normal" and can signify an underlying issue(s).
** To clarify, there are many physical and psychological/behavioral signs and symptoms of eating disorders and RED-S. Different people may exhibit different symptoms, and people exhibiting some symptoms of RED-S -- again, there are many -- may not suffer from RED-S. There's not a "one size fits all" model.
