Pace Yourself: Physical Effects of Undereating, Overtraining

By Ingrid Worth

Edited by Pat Melgares

First in a three part series

"I was not supposed to graduate high school as an 18-year-old at the same weight I was as a 14-year-old freshman. Admittedly, many female athletes do experience a temporary dip in performance during this period, but I was determined to not be one of them. Thinking only of short-term results and ignoring the long-term risks, I chose to wage an uphill battle against myself."

Editor's note: Ingrid Worth was a cross country and track and field standout for Shawnee Mission East from 2014-2018, during which time she was a Sunflower League and regional champion in the 3200 meter run, and placed third in that same event at the 2017 Kansas track and field championships. In this three-part series, Worth talks about her struggles with an eating disorder, eventually leading to a condition known as Relative Energy Deficit in Sport, RED-S. After a year running at Carleton College in 2018-19, Worth sat out the 2019-2020 season to seek treatment, aided by a registered dietician and a disorder specialist. This series will publish on Kansas MileSplit each Wednesday through June 17.


The first time I ran a varsity cross country race my freshman year, I nearly passed out.

I had made the classic rookie mistake of going out way too fast. I ran a PR in the first mile of the race, but the rest of the 4k was brutal. In the humid, early September heat, I struggled to finish without walking and, completely burned out, was one of the last girls to stagger across the finish line.  In my excitement to run with the best, I had forgotten that distance running is not a game of unbridled speed, but a game of pacing, patience, and strategy.

Above: Ingrid Worth in her first high school cross country race

After my disastrous first race, I learned to pace myself.  Unfortunately, the lesson didn't carry over to the rest of my training. During the fall of my sophomore year, I began to notice that many of the fastest runners seemed to be smaller than I was. At the same time, I heard several seniors and juniors on my team complaining of hitting a plateau in their performance, and attributing this plateau to weight gain.  I resolved to never allow this to happen to my body. 

At this point, I want to emphasize that weight gain during adolescence is completely normal, and should be expected, according to an article by clinical psychologist Shelly Russell Mayhew. I was not supposed to graduate high school as an 18-year-old at the same weight I was as a 14-year-old freshman. Admittedly, many female athletes do experience a temporary dip in performance during this period, but I was determined to not be one of them. Thinking only of short-term results and ignoring the long-term risks, I chose to wage an uphill battle against myself.

From the outside, it would appear that my tactic worked perfectly. I counted calories and skipped dessert. I spent at least 30 minutes a day strength training outside of practice and walked a lot. On recovery days, I never allowed myself to run at an easy pace, often leaving my teammates behind or opting to run with the boys. For four years, I never took a full rest day unless I was so injured that it hurt to walk. I ignored the constant fatigue, hunger, gastrointestinal distress, and anxiety because I was getting results.

I qualified for the state track and field meet individually for the first time in my sophomore year, then again in my junior year of cross country. During my junior track season, my behaviors were the most rigid and unhealthy that they had ever been, yet I ran PRs almost every week and finished third in the class 6A 3200 meter run at state. Nevermind that the week before state, I had stayed in bed all day because my body was so fatigued. My ambitions distracted me from the damage I was inflicting on myself.

When I entered my senior year, I hadn't had a period in four years, a condition known as amenorrhea. I thought that amenorrhea was common among runners and, unfortunately, it is; up to 69% of women in sports that emphasize leanness, such as running, have experienced at least three missed periods in a row, according to an article in the journal, Sports Health.

Although distressingly prevalent, amenorrhea is not healthy. In healthy individuals, bone mass increases most rapidly during adolescence, according to information from the Hormone Health Network. Hormones, such as estrogen, are needed to build strong bones and maintain regular periods. My missed periods were a sign that my hormone levels were dangerously low. Instead of building bone mass during my teenage years, I was depleting it.

Still, I thought I was the exception to the rule. I had run so well for so long that I figured I was safe. Then, my senior year, I began to feel a nagging pain in the front of my ankle. I was no stranger to injury; it was rare for me to go a single season without dealing with shin splints or IT band issues, all of which were likely due to overuse and undernourishment. However, this felt different.

At left: Ingrid Worth as a junior in 2017

After a few weeks of hobbled runs, I was diagnosed with anterior ankle impingement, an overuse injury that slowly progresses over time and is typically seen in athletes over 25 years old. I wish I could say that at this point I learned my lesson and I backed off. Instead, I doubled down, lengthening my recovery time and adding to the damage I had already inflicted on my body. During my senior year track season, I exercised intensely, doing a weights class four days a week, so I could reach my arbitrary "racing weight" at great cost to my long-term health.

I managed to eke out one more successful season before my body completely broke down.

As I was training over the summer to run in college, my body seemingly crashed overnight. I started the summer easily able to run ten miles, but by the end I was barely able to run five. I trained harder than ever, but my body had crossed some sort of line. During my college freshman cross country season, I could barely finish workouts, let alone races. My fatigue and anxiety both hit all-time highs.

I took a bone scan and was diagnosed with osteopenia, a precursor to osteoporosis. My heart rate dropped to around 35 beats per minute at rest, but jumped to almost 85 bpm simply by the act of standing up, a condition called orthostasis, which is detailed in an article by two doctors at the University of Colorado.

Depleted, I was forced to take a break from competitive running.

In the past year, I have learned that the symptoms I experienced throughout high school and in my first year of college were signs of Relative Energy Deficiency in Sport (RED-S), a condition caused by an imbalance between energy intake and expenditure, according to registered dietician Laura Moretti.

My rigidity around food and exercise were symptoms of an eating disorder. In high school, I had never thought I was at risk of RED-S or that my behaviors qualified as an eating disorder because I had never been "underweight" according to the standard Body Mass Index tables. Later, I learned that anyone, at any weight, can develop an eating disorder or RED-S.  My win-at-all-costs mentality made me particularly susceptible to these issues.  

By sprinting through my first five years of competitive running, I jeopardized my entire future in the sport. I was lucky. My physical injuries were temporary, my period returned despite being absent for over six years, and I haven't had a stress fracture. Many suffer much worse.

I offer my experience as the warning I never received. In high school, everything felt so urgent. I thought that I needed to sacrifice my health for results. I thought that earning medals, scholarships, and impressive PRs would make every missed dessert or extra mile worth it. I was wrong.

Just as the speedy first mile of my freshman cross country race meant nothing when I finished last, my medals and PRs mean very little to me now. Instead, I'm finally learning to pace myself and truly listen to my body's needs. I still have days where I want to exercise too much or not eat enough, but my long-term trajectory looks pretty good. Here's to hoping I'll still be running in 50 years.


If you are struggling with an eating disorder and are in need of support, please call the National Eating Disorders Association Helpline at 1-800-931-2237. For a 24-hour crisis line, text "NEDA" to 741741.