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However, as training load increases, our nutrition needs to adjust too, to match the new demands placed on the body, and this applies particularly to intake of carbohydrates (the body’s preferred fuel for most exercise) and overall calories (energy). 

Unfortunately, whether consciously driven by a desire for greater weight loss or not, this upregulation of fuelling often does not take place. In my experience as a sports dietitian and running coach, runners are not always comfortable taking this step, especially if weight loss and body image concerns have been a longstanding issue, and even less so if they have seen some short-term performance benefit from being lighter.

Unfortunately, this approach can be really dangerous in the long-term. RED-S is a common syndrome that can affect runners across the spectrum, from elite to recreational, old and young, male and female, and yet remains poorly understood and under-recognised by most runners and coaches.

RED-S stands for ‘Relative Energy Deficiency in Sport’, an evolution of a previous syndrome called the Female Athlete Triad. The common thread between the two conditions is that both are characterised by low energy availability; that being the energy left over after exercise to fuel all the body’s essential functions. In 2014, the International Olympic Committee coined this new term of RED-S, acknowledging the growing evidence that a chronic calorie deficit (and thereby state of low energy availability) can affect males as well as females, and many more bodily systems than previously thought. Whereas the Female Athlete Triad focused on links between energy deficit, menstrual dysfunction and poor bone health, RED-S is much broader, and identifies that immune, gastrointestinal, mental, and cardiovascular health (to name a few) can also be impaired by chronic underfuelling. It’s also worth noting that the processes of metabolism itself can be impacted (i.e. slowed down) in RED-S as the body attempts to preserve energy, which can actually make weight loss and body composition goals harder to achieve, potentially convincing the runner they need to restrict even further.

Early warning signs might include frequent or persistent colds and bugs, indicating that the immune system is being downregulated as the body tries to adjust to low energy. Other early signs can be general fatigue, reduced motivation, or reduced performance in or recovery from training sessions. Since these symptoms are, in themselves, relatively minor and perceived to be common, it’s easy to see how they might be overlooked.

However, if these trends continue, more serious issues can arise. Bone scans are not routine within recreational sport, so a runner may have no idea that they have dangerously reduced bone density until suddenly experiencing a stress fracture. By this point, RED-S has likely become quite severe and needs careful management of nutrition and training load, over an extended period (and ideally with specialist input), to overcome.

Another key area is the hormonal dysregulation that impairs reproductive function. In both males and females, this might first present as decreased libido, and in males may correlate with erectile dysfunction, or reduced frequency of morning erections. In females, it can lead to irregular (oligomenorrhea) or total absence (amenorrhea) of menstruation, which can have knock-on effects on fertility that take months or years to overcome. And these symptoms may of course be masked (again, whether consciously or otherwise) by being on the contraceptive pill, preventing runners and coaches from picking up on this big red flag for inadequate fuelling. 

Despite being an uncomfortable topic, this fertility element of RED-S in particular has started to gain more mainstream media exposure, such as this widely publicised interview by Laura Kenny, Britain’s most successful female Olympian.

However, although RED-S awareness among recreational runners is on the rise, it is still poorly understood and under-diagnosed. It is therefore vital that articles and interviews continue to appear across all media, but also that coaches move away from outdated ‘thinner is faster’ attitudes, and that they help to screen their runners for RED-S. It has become a routine part of my practice for all new nutrition and coaching clients.

Indeed, the detection, prevention and management of RED-S should become slightly easier thanks to the updated IOC consensus statement from last year, which summarises the emerging evidence and provides a new clinical assessment tool. I would strongly urge runners of all levels to take a look.

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Planning and prep

In some respects, planning for Valencia started several years ago, when I first became aware of it as such a rapid course. I very nearly took the plunge in one of the covid years but remember thinking that the cancellation policy looked particularly harsh given the state of the world at the time, so backed out and waited for normality to return. With London finally moving back from October to April this year, space was freed up, and 2023 felt a good bet. I booked as soon as I found out they were on sale, which, 11 months in advance, was still only quick enough for their second or third price ‘tranche’. It’s a hell of a long build up in terms of event participation.

This was my first overseas marathon for 8 years (the last being Rotterdam in 2015, when I broke 3 for the first time), and in all honesty, I found planning for it quite stressful. 2023 has been a year of strikes and travel uncertainty. As a man that hones in on detail in race week, this, plus hand luggage restrictions (how to get gels AND beetroot juice across?!), and choosing between accommodation certainty and affordability (I chose the latter), all added a layer of pre-race organisation I didn’t really relish.

Added to that was the nagging guilt of flying to a race, which, as I have posted on IG about, is something I don’t feel very comfortable with, and equally, of leaving my family behind.

Also, with international races so rare for me, it added an extra dimension of pressure (completely self-imposed, I should add), of a) getting to the start line in good health, which is challenging when all around you are coughing and sneezing their way through November, not least my little boy, and b) to smash the race and really make it count.

All this said, I got relatively lucky and can’t have many complaints about the logistics. I did get a dreaded email about flight times changing, but was then able to renegotiate more favourable times. I struck very lucky with my bargain Airbnb (happy to share details), and I somehow managed to avoid getting sick. I was here!

The event itself

The rumours are true: Valencia Marathon is an absolutely brilliant event, and I would recommend it without hesitation, whether you are chasing a PB or otherwise. Communication in the build up was slick, organisation on the day was great, and the whole city seems to be invested and proud of their race. 

One minor annoyance was the expo. Apparently this used to be in the city centre, but this year was moved to the Feria, some way out (pictured). I understand this might need to be the case as the event grows (and by comparison, the Excel expo is a nightmare to get to even for those who live in London), but getting there and back was difficult. No public transport route from the airport, for example.

The course is essentially flat, with only very minor undulations, before a slight but sustained downhill over the last 6km, which starts with a memorable, intense patch where the passionate spectators are so close on both sides that the course is only about a metre wide (very Tour de France). It all then finishes on the iconic blue carpet under bright skies, surrounded by glistening water. That dazzling blueness all around will stay with me forever…the most special finish to a race I’ve ever witnessed (even if I was absolutely eyeballs-out sprinting at the time).

Conditions play a huge part, of course, and having monitored Valencia closely for a few years, it seems it’s pretty much always perfect on race day. 2023 was no exception: sunny, cool (actually very cold initially), and barely a breath of wind. Marathon dreamland.

My training block

After London in April (2:34:30), I had my usual post-marathon month of running downtime before 2 months of dedicated speedwork, AKA a mini 5km block. This was a great plan, firstly because I got the sub 16 monkey off my back (15.55 in August), but also because I was then able to bring that improved top end into longer races. In September I went sub 33 in the 10k (32:47, Vitality 10k) and sub 72 in the half (71:40, Big Half), for the first time. 

The marathon block was 16 weeks, and generally went pretty smoothly. The exception was a freak broken toe incident at home in October, which thankfully healed in about a third of the 6 week prognosis I was given in A&E. Cross training saw me through that period, and I lost no fitness at all. I have newfound respect for the elliptical machine and aqua jogging!

As a new dad with ICU work and a business to run, free time is close to non-existent, so all but one of my runs each week are run commutes or buggy runs. Sunday early morning is my negotiated me time for a longer run, and it all just about works. 50 miles per week was the target for the first 10-12 weeks, then I was able to increase to 60-70 (a new high for me, in fact) in the final month pre taper.

Race and prep tactics:

Rather than list everything (because it gets refined each year…see previous blogs), I’ll mention a few things I did differently (and better) than previously.

1. Day to day nutrition. Even as my job, there is always room for improvement in nutrition. When sleep quality is inevitably and consistently poor, for reasons that are obvious, I needed to look at what else I could prioritise in terms of recovery, and I became incredibly consistent with pre and post run nutrition, matching this to the needs of the session. My wife and I have also made a conscious effort to improve the quality of our diet, from what was already a good baseline, especially with breastfed Ray in mind. Ultra-processed foods are at an all time low, and, anecdotally, I think it has been a big help.

2. Carb load. I hit 11g/kg on both the Friday and Saturday, which was a new high, on the back of a carb depletion at the start of race week, which takes skill to get right. 11g/kg takes practice, planning, and to learn what foods and drinks work for you, but it really makes all the difference on race day. This was one of the areas that was tougher to plan for an international race, and involved more carbs from drink mixes than usual, and plenty of snacks brought from home to reduce risk. 

3. Mid race carbs

I took 244g from gels over my 2.5h race, plus a few sips of the on course sports drink (it was in paper cups, so of course at least half of it ended up on my face), so I would have pretty much hit exactly 100g/hr for the first time. Again, this takes practice and it makes all the difference in what intensity you can sustain in the back end of the marathon. 

3. Running to HR

There’s way too much data in running and I certainly don’t get on board with it all, either as a coach or runner, as a lot of it is data for data’s sake, and prone to misunderstanding (prime example: continuous glucose monitoring in non-diabetics). Heart rate is an exception, and one of the simplest but most useful running metrics out there. My own coach, Chris, has long been an advocate of using it, and I certainly work it into my plans, where appropriate, with my own coaching clients as well. 

That said, the idea of running a marathon entirely to heart rate would have terrified me, right up until I did the Battersea marathon in October as a training run with no mid run fuel. This was done on heart rate to keep me well below threshold, and I ended up not only winning the race, but PBing by a few seconds. I was staggered, and also convinced to give this a go in Valencia, working with Chris to plan the race based on percentages of my maximum HR that I could tolerate for certain periods of time.

Battersea also showed me the importance of starting a race relaxed, especially in terms of HR management. My watch suggested I was managing this well on race morning, and it was great to meet and chat to a lovely Irish runner called Trevor (2:35 PB for him) for the final hour pre race to help ease the tension. 

Anyway the HR plan worked an absolute treat, and gave me the confidence that I could really attack the final 10k knowing I wouldn’t blow up. I went through halfway in 1:16:20, then 1:13:50 in the second half (which would have been a HM PB before this summer), with a 16:30 final 5k as I threw everything I had at it. 

I would be lying to say I was completely unaware of time and pace, and in the final 10k was trying to work out if there was an outside chance of sub 2:30. My brain couldn’t quite work it out, and from one km marker to the next, I kept changing my mind. As I approached the final straight I was sprinting, but knew I’d be slightly outside. 2:30:10. Arms outstretched, overly dramatic roar for the crowd…no part of me was anything other than elated. Another 4 minute PB and I’d done myself, my family, and my coach proud.

Could I have found another 11 seconds somewhere out there? Of course. I suspect if I raced the same course tomorrow (marathon legs notwithstanding), I’d be savvy enough to find that time. But sub 2:30 was never the aim. I am now within touching distance of a crazy milestone, but it can wait.

What next?

In the short-term: running downtime, navigating a sociable December, and repaying some favours to my wife. 

Then it’ll be a London marathon block from January, and I think the aim for that doesn’t need spelling out. It’ll be my last marathon before I turn 40 in July, and I’m not going to lie, I’m quite looking forward to being able to favourably compare myself to the V40 crew!

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1. Perspective

Evidently, I love running. More than that though, I love the satisfaction and graft that comes with ticking off session after session of structured training and seeing this translate into race day PBs. It’s my number one hobby by a mile (no pun intended), and what keeps that fire burning inside me.

However, it took several years to become a dad. The unexplained infertility and IVF rollercoaster (with mammoth Covid delays) was a long, emotional, and mostly terrible one, but we were one of the lucky ones to have a happy ending (and a shout out here to the quite incredible NHS service we received throughout all those years).

We now have our beautiful baby boy, who this week comes to the end of his ‘fourth trimester’, so called because human babies are so utterly dependent on their parents for the first three months of life that they may as well still be in the womb.

Anyway, my main point here is that I’ll never get these pivotal first months of his life back, and as much as I love and live for running, it will (hopefully) always be there in my life. I’m happy for it to take a distant back seat for as long as it needs to, especially given what it took to get us to this point.

2. Pick your moments and commit

Despite a thousand warnings, the first few weeks of parenthood were far more intense than I had anticipated (especially while also starting a new clinical job and navigating a flat sale and purchase at the same time). It’s no exaggeration – but undoubtedly gross – to admit that we sometimes didn’t even get round to having a shower or brushing our teeth, such was the intensity of those frenzied evenings.

Trying to wait for a calmer moment for self-care / a long run / strength work etc was and still is a pointless move; it will never come. A better approach is to be realistic, pick perhaps one of these things you want to do each week, commit to a time and try to stick to it. Half of those times there will be a last minute drama that prevents it, but at least you’ve tried!

3. Embrace the run-commute

I have been very pro run-commute for years, but it’s now reached the point where I do very little running outside the commute; it must be responsible for 80+% of my weekly volume currently, and my running would have fallen off a cliff without it. If you can make it work for you (i.e. you have a shower at work – everything else can be worked around with a bit of planning), it really is a no-brainer. For me, the time difference to public transport is negligible, it saves money, helps the planet, and is a journey I have to make anyway, as opposed to finding an excuse or that non-existent ‘good time’ as a new parent to get out of the door for a run.

If a run commute doesn’t work for you, the same can be said for any other journey that you needed to make anyway. Perhaps it’s easier to say from the perspective of someone who lives in a city and doesn’t own a car, but those first few weeks of parenthood were filled with me running to collect second hand baby clothes / kit / buggy from all over London. You spot an opportunity to kill two birds with one stone and you take it, basically.

4. Accept you can’t do it all

All that said, it’s essential to accept that you can’t do it all. This applies to all elements of life when you’re a new dad (with the exception of the five star service I maintained for my private clients, of course ?), but running training in particular. The unpredictable nature of those first months means that consistent training is just not going to happen. My week by week Strava graph from October onwards resembles a child’s drawing of a mountain range, and I’ve long since accepted that this is fine…you just have to be kind to yourself and keep things ticking over as best you can.

Perhaps even more so than the running itself, though, is the impact on everything that goes alongside it. You can pretty much wave goodbye to any good routines you had around S&C, recovery, sleep etc.

Starting with sleep – yes, it is as bad as everyone says, especially in the first couple of months. I had long held the suspicion that my already terrible sleep quality that comes from the trauma of working on ICU throughout the pandemic (plus the early starts of ICU life) might mean that this would all be less of a shock to my system than it might be for some new dads, and I’d say this is probably how it’s turned out. I knew it was all worth it in the long run!

However, what has taken a massive hit has been any sort of S&C, warm-ups and stretching / yoga, all of which I had finally started to develop some consistency with in recent years. With every passing week, I realise these are the good habits that are quickly slipping. Each time, it’s ‘next week’, and so on, and so on. As we all know, it’s so much easier to continue doing something than it is to restart it once you’ve paused.

5. The baby lunge

The only exception to the above is my signature move: the baby lunge. Little Ray seems to love being held while I count through a few lunges (something to do with repetitive movement and me generating heat, I’m sure), and it’s second only to white noise* in terms of getting him to sleep during a crying fit. Naturally then, this tactic gets resorted to a lot, often in the middle of the night, and with the pressure on me to keep the lunges going for as long as possible and Ray slowly gaining in weight, at least I now have quads of steel even if the rest of my body is slowly turning to mashed potato!

*Specifically the ‘Womb Sounds’ app. Words cannot describe how grateful we are for this! We were recommended it during a particularly desperate evening of non-stop crying in about week three, and just looked at each other in disbelief at how quickly it worked – genuinely like giving a sedative. If this little snippet helps any new parents out there, then you are very welcome.

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I did it as a progressive tempo training run, aiming to finish in something like half my target marathon time for London in October. Naturally, I got slightly overexcited towards the end (big crowds, banging tunes etc.) and sped up a bit, finishing about a minute ahead of schedule in 1h17.

It was the first time I’d run Hackney, and while this blog isn’t intended as a race review, the atmosphere was great, and I’ll run it again one day (under my own name) – just not as a PB race. For one, the course is quite winding and not particularly flat. But most importantly, being at the end of the spring race season in late May, it always seems to be roasting hot in East London.

I watched my girlfriend (now wife) run in it in heatwave conditions back in May 2016, and it really wasn’t much cooler this year. I have been lucky that most of my target half and full marathons over the years have been on the cool side, and in fact I can say with certainty that these were the hottest conditions I’ve done anything more than a 10k race in.

On the day of the race, I posted an Instagram story about how I thought the Hackney emergency services would be in for a busy day, and sadly this was very much the case. I received response after response to that story confirming they’d seen people literally dropping like flies around the course.

In the (enormous) race village, all the pre-race chat coming over the loudspeaker had been about ‘hydration, hydration, hydration’, but besides ‘drinking a lot’, what does this really mean, and why is it so important in hot conditions? What does the evidence say about hydration in endurance sport, and how can we apply that to ourselves? It’s undoubtedly a tricky area and one that so many runners get wrong, especially when race conditions aren’t kind.

First then, why hydrate? i.e. what happens if we don’t?

Good hydration is essential, both for health and exercise performance. A quick GCSE biology recap: when we exercise, muscles generate heat as a by-product. Sweating is one of our go-to physiological responses to counteract this; the evaporation of water from the skin surface allows us to lose heat from blood vessels near the skin surface. The lost water needs to come from somewhere though, so if this process continues unchecked (i.e. without rehydration), blood plasma volume will reduce significantly (hypovolaemia) or core body temperature will steadily rise (called hyperthermia when exceeding 40 celsius), or both.

As a lot of those Hackney runners found out, this can result in heat-stroke, which at its worse can be fatal. However, well before this grim endpoint is reached, evidence suggests that, although there is huge individual variability, dehydration even at the level of >2% of body weight (i.e. 1.4kg of fluid loss for a 70kg runner) can affect aerobic performance and also cognitive function in hot conditions. This latter effect might be particularly important in the context of, say, decision making about fluid intake or pacing, and exacerbate the problem. These effects all increase as dehydration worsens, and when we reach 6-10% bodyweight loss, cardiac output, sweat production and muscular blood flow can all be compromised. Nasty.

How much to drink?

So, what can we do to prevent this? In general, it’s best to start a race (or hard training session) in a state of ‘euhydration’, that being one of neither over- nor under-hydration, with pale, straw-coloured urine. Clearly, starting in a dehydrated state would be a bad idea, whereas overhydration can cause GI discomfort and unwanted mid-run toilet trips!

During the run / race itself, hydration advice has shifted in the past decade or so. The traditional viewpoint used to be that ‘drinking to thirst’ was unsafe, because if you’re already thirsty, you’re already dehydrated, with runners therefore advised to pre-empt and avoid thirst by drinking early and regularly.

However, this method has its own risks, chiefly that of overhydration and exercise-associated hyponatraemia (EAH). This is known to be very common among recreational endurance athletes, and is essentially when the blood becomes diluted (specifically with regard to sodium content), due to replacement of fluid but not electrolytes (which I will get to later). Without wanting to sound too dramatic, again, at its most severe, EAH can be fatal.

Endurance runners are now advised, therefore, that following their instinctive thirst mechanism is a useful starting point to avoid EAH. There is phenomenal variability in sweat rates (anywhere from around 300ml to 2.5L / hour), both between and within individuals, depending on conditions and exercise intensity. However, for the majority of endurance runners, a range of 400-800ml fluid intake per hour is appropriate, with the higher end applied to faster or heavier athletes or hotter conditions (and vice versa).

Again though, this range remains just a starting point. A dietitian can help individualise the plan, but an athlete should also learn through their own experience about what they need. Sweat rate and lab composition testing can be helpful, but runners can also get into the habit, from time to time, of weighing themselves pre and post run (naked, wiping off any skin surface sweat) and working out sweat losses per hour in different conditions (accounting for any drinks consumed during the session, of course).

What to drink?

So now we know roughly how much to drink – or at least how to go about learning how much. What about what to drink? Let’s kick that off with another quick GCSE biology recap by way of some key definitions. These terms are thrown around freely in relation to sports drinks, but are, in my experience, quite poorly understood:

Hypotonic (e.g. water, dilute squash)

• less concentrated than blood
• best for rapid hydration

Hypertonic (e.g. hydrogels, most ‘recovery’ drinks)

• more concentrated than blood
• best for recovery and rapid carbohydrate delivery

Isotonic (e.g. most traditional sports drinks)

• similar concentration to blood
• all-rounder: compromise between hydration and carbohydrate delivery

When we talk about concentration, what we are really referring to here is the amount of sugars and salts (electrolytes) per litre. And when we consider our drink of choice, it’s important we can understand and weigh up the options, because ultimately it becomes a trade-off between optimal hydration and optimal carbohydrate delivery.

During a run, if rapid (re)hydration is needed above all else (e.g. from a safety perspective), a hypotonic solution such as water could be prioritised. If energy (carbs) are an urgent priority (but no other options e.g. gels are immediately available), then a hypertonic, sugar-heavy drink could be chosen.

However, in most other circumstances, isotonic is the way to go during a run. The rehydration rate is not far behind that of a hypotonic drink, and you have the added bonus of a gentle infusion of carbs (to be factored in alongside your race day fuelling plan) and electrolytes. In fact, current endurance sport guidelines consider the sodium levels found in most isotonic sports drinks to be optimal during prolonged exercise, for most athletes. Again though, there is great variability in sweat composition. Some people regularly see white salt marks on clothes or have salty-tasting sweat. In such ‘subjectively salty sweaters’ (or those that have lab-tested their sweat composition), alternative electrolyte plans are likely to be needed, especially when these runners also have either naturally high sweat rates and / or hot or humid conditions.

Remind me what electrolytes are?

Before moving on, a very quick recap on electrolytes and why they are important. Sodium is the one we hear most about, but potassium, calcium, magnesium, chloride and phosphate are all crucial too. Electrolytes are so called because they carry electric charge across cell membranes, and when this balance is disturbed, heart, nerve and muscle function can all be compromised.

And what about post-exercise rehydration?

One of the other important roles that electrolytes (especially sodium) play is regulating fluid balance, which takes us on nicely to post-exercise rehydration. Despite the pre-run and mid-run hydration guidance above, it is expected that any prolonged endurance exercise is likely to end up with some bodyweight fluid deficit (especially in conditions like Hackney) and the recommendations are to rehydrate with 150% of that lost weight. So, if you’re 1 kg lighter after the run, drink 1.5L.

The most efficient and optimal way to do this is with a surprisingly salty drink. Guidelines state that >60 mmol sodium per litre is optimal for fluid absorption, and it should be pointed out that this is where commercially available sports drinks really don’t cut it. They fall well below this level, because it wouldn’t be palatable to the general consumer and wouldn’t exactly fly off the shelves! So this is where my homemade special recipe comes in handy (and cheap):

• 500ml orange juice
• 500ml water
• 2/3 of a tsp of salt

…mix together and enjoy the salty smugness of optimal rehydration!

Very concise summary of recommendations:

• Pre-run: start euhydrated (pale straw urine)
• Mid-run: drink to thist is an acceptable starting point
• Most fall within 400-800ml / hour range (higher end if heavier, faster or hotter)
• Isotonic usually wins for mid-run
• Individualised plans (for volume and electrolytes) are best
• Rehydrate post-run with 150% of lost weight, and go homemade for optimal results

Right, so there you have it. Hopefully that is a one-stop-shop with everything you needed to know about hydration in endurance sport, but as ever, your friendly sports dietitian (me) can help make sure you’re getting everything right with an individualised hydration plan. Anyone else thirsty?

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However, it remained nothing more than a vague notion for many years. I did do a fair bit of research and shadowing of some prestigious sports nutrition experts early on, but then left it to one side; I knew that I really wanted to first find my footing as an acute NHS dietitian before exploring other options.

Inevitably, five years then sped past, as I became increasingly specialised in gastro, lower GI, and ultimately, critical care dietetics, and there was rarely a chance to have a lunch break, let alone find the right time to start a postgraduate sports nutrition qualification. I probably thought about it once every six months then shelved it again.

And then, towards the end of 2018 I realised there will never be that right time, so I put the feelers out again, but properly this time. I knew from the outset that if I was going to do this, it needed to be done well. I wanted to be credible, and from my perspective, that meant being on the Sports and Exercise Nutrition Register (SENR), which is the nationally recognised mark of quality for professionals in the field.

Of course, there would have been nothing to stop me (or indeed anyone) from giving sports nutrition advice without being on the SENR, and I had certainly already dabbled in some basic performance nutrition – not least for my own running. However, in the world of nutrition, qualifications and registrations are incredibly important. Why? Because everyone eats. Lots of people think a lot about what they eat, and therefore claim to be an expert. Not being regulated by professional boundaries or scientific evidence, these folks can then shout as loudly as they like on social media about nutrition. Of course, those that shout the loudest and make the wildest claims will get the most attention, creating more ‘experts’ in the process, and so on…

The only way to clearly distinguish yourself from this noise is through recognised qualifications. This applies to being a Registered Dietitian (a protected title), but also to sports nutrition. Everyone in the world of sport seems to have an opinion (often strongly-held) about nutrition, and there seems to be a real issue of ‘staying in your lane’. Lots of physios, S+C experts and coaches will readily dish out nutrition advice for which, if we’re being honest, they’re not qualified. Clients often ask me for my opinion on training programs, and I will always make it clear that it’s not something I’m trained in (not yet anyway…watch this space), but am happy to give my non-expert opinion. The best physios, S+C experts and coaches that I’ve encountered do the same, i.e. they may give some basic, generic nutrition advice but would refer on to a Registered Sports Dietitian or Nutritionist for anything specific. I am not for one moment suggesting that their experience working with athletes counts for nothing, but part of training in any specialism is, or should be, learning to work within the limitations of your own practice.

Major digression there, but I think it’s an important point to raise. Back to putting the feelers out, I contacted a range of SENR-accredited course leaders, as well as friends of friends that had completed some of the courses. I settled on the Applied Sports Nutrition Postgraduate Certificate at St Mary’s, and arranged to start in September 2019.

Fast-forward to the course itself, and if I’m being completely transparent, I had not expected to learn anywhere near as much as I did, from the hardcore science of exercise physiology, to the very practical components applying the theory to the athletes. This was obviously a good thing and very reassuring, seeing as I had parted with a significant sum of money and all of my free time for a year, but also a real challenge on top of full-time work in ICU.

The coursework projects in particular were extremely interesting but more time-consuming than I can ever remember from previous academia (MSc included), and this was before we even got to the mammoth, heavily weighted final task…the slightly ridiculously named ‘Sportfolio’. This was where we worked directly with an athlete, leaving no stone unturned as we produced 100 pages of theory and practical nutrition and hydration strategy. I am not exaggerating when I say this took more time than my MSc and BSc dissertations combined, but on the whole, I loved it (again, reassuring).

The only problem of course, is that by the time this big project started, we were in a pandemic. No need to remind everyone of how crazy ICU was during these months, but I think it’s fair to say it was the busiest and most relentless year of my professional life. So, completing this project during this time, and in the process, the PG Certificate, definitely goes down as one of my proudest achievements.

I handed it all in in May 2020, and then had to wait patiently for results, degree classification, and ultimately, to get my name on the SENR. Of course, the pandemic affected all of that as well. I did not wait to set up Tom Hollis Health and start seeing clients, but it was not until a few weeks ago in 2021 that I finally had confirmation that I had been awarded a Distinction. I immediately started the application for SENR, and as of this week, I can now, finally, see my name on their register. This marks the end of nearly a decade of thinking about this, but also the official start of an exciting new chapter.

Why did I bother writing this blog? Well, some people may not necessarily care where they get their sports nutrition advice from, whereas others may not realise that SENR exists. But for those that do care, and want credibility, I proudly display the SENR logo on my website, and I want you to know that it has been hard-earned!

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Despite having promised to myself in 2013 that my life in academia was finally over, having qualified as a Registered Dietitian, there I was in the classroom again, ready for Exercise Physiology – the first module of my Applied Sports Nutrition postgrad.

Most of the students on my side of the course had a nutrition background of some description (while the other side had a sports background), including a sprinkling of dietitians with differing levels of clinical experience. I was the only one coming from a critical care (ICU) background though, and this caused a few eyebrows to raise. At least two or three of my new coursemates asked ‘why would an ICU dietitian be interested in sports nutrition’ or stated that ‘you couldn’t pick two more different ends of the dietetic spectrum’. I knew that this wasn’t the case, but I could also see why someone who didn’t work in critical care might make these assumptions…and no doubt there are others visiting my website who will be thinking the same. So these conversations stayed with me, and I’ve been meaning to write this blog ever since.

I make no secret of the fact that I specialise in critical care and endurance sports nutrition (plus plant-based nutrition, but I’ve covered that in lots of other blogs so won’t mention here), and I feel lucky to have found two areas of nutrition that I feel so passionate about. Importantly though, there are huge areas of overlap that mean that, far from being totally separate entities, a greater understanding in one really benefits my practice in the other.

1. Precision nutrition

ICU is all about numbers, data, and precision – or at least the pursuit of precision – and this is certainly part of the appeal. This is true for everything from biochemistry to ventilation settings, and certainly for nutrition too. Patients are generally fed via enteral feeding tube or intravenously, and every ml of delivered nutrition is documented. That’s not to say that how we set our nutrition targets is without some controversy, nor that feeding always goes to plan (there are always interruptions and unexpected breaks in feed), but as long as everything is accurately documented and analysed, we can monitor and react to those individual nutritional ‘balances’ (comparing feed prescription to delivery), as we seek to optimise that patient’s nutritional status.

The same can be said for sports nutrition. As with ICU, there may never be absolute consensus on how we calculate athletes’ nutrition requirements, but as the evidence base continues to grow (and it’s my job to stay on top of this), there is now undoubtedly greater precision and specificity in the guidelines. Through electronic food diaries, we can then quantitively track a client’s progress against these targets and be extremely precise in our recommendations. In my experience, this is what clients want, and it’s great to be able to provide this with confidence.

2. Periodisation

In a similar vein to the point above, there is a broad acceptance that nutrition advice on critical care needs to be periodised, adjusting for different stages in a patient’s journey from early acute illness (where substrate utilisation is impaired) through to the late acute and then chronic and rehab phases, when physiology and metabolism shifts dramatically.

A major outstanding question in critical care nutrition is how to recognise the flow between these different phases. Fortunately, this is not a problem in sports nutrition, where the evidence and guidelines allow for nutrition advice to be neatly periodised around far more clearly defined phases, both on a ‘macro’ level in terms of training seasons and race build-ups, but also on a ‘micro’ level, in terms of key nutrient intake windows around individual sessions and rest days: essential to getting the best adaptation from all that hard work in training.

3. Body under stress

I mentioned earlier the acute phase of critical illness and how this impacts on nutrition. Critical illness puts a huge amount of stress on the body, and, certainly in its earliest stages at least, induces a hypoxic and catabolic state where the metabolism of glucose, fatty acids and amino acids is all likely to significantly altered.

The same is true in sports, of course, where we push ourselves to the limit and induce physiological stress, albeit deliberately! We deprive our working muscles of adequate oxygen to respire aerobically, tipping us into and beyond our anaerobic or lactate thresholds. We also need to remember that exercise alone (whether resistance or cardio) is catabolic, and it only becomes an anabolic (i.e. muscle-building) process when combined with adequate nutrition. I’ve often come across statements such as ‘one day on ICU is like running a marathon’, and this is all rooted in the massive overlap here in terms of stress on the body.

I look out for rising blood lactate, electrolyte depletion and reduced oxygen saturation in all my ICU patients. It’s no coincidence that these are all also key elements  of exercise physiology and performance nutrition!

4. Rehab and recovery

As ICU medical management improves, so do patient survival rates. And with this being the case, in recent years there has been an ever-increasing emphasis on achieving far more than just ‘survival’. Post Intensive Care Syndrome (PICS) is a dreadful but all-too-common combination of cognitive, psychological and physical impairments that persist for months, if not years, after ICU. One benefit of the current pandemic has been the increased media attention (and clinical funding) that post-ICU has received, but the reality is that this is not an issue specific to COVID-19.

We have the most fantastic post-ICU MDT recovery clinic at my hospital, where patients have access to a consultant, nurse, physio, occupational therapist, psychologist, pharmacist, and of course, a dietitian – me! I feel very privileged to be able to guide these incredibly vulnerable patients through their rehabilitation and recovery, as they deal with a bewildering mix of symptoms and changes in appetite, intake and body composition.

The language overlap with sports nutrition in terms of ‘rehab’, ‘recovery’, and ‘muscle wasting’ is immediately obvious, and in fact, this is another area where the evidence base in critical care rehab nutrition lags behind and actually borrows from the comparably well-defined guidance for sports and performance nutrition. Logic suggests, for example, that the ‘muscle full effect’ of protein dosing and timing that is so well described in performance nutrition should also apply to the rehabilitating post-ICU patient. I do therefore often adopt a similar strategy in my post-ICU clinic, but the reality is we don’t yet have the data in this population to confirm the theory. Watch this space, hopefully…

The other benefit of working in the post-ICU clinic is that I get to actually speak to my patients (!), many of whom have no idea that my colleagues and I were also providing their nutritional care when they were sedated, mechanically ventilated and tube-fed on the ICU a few months earlier. Given that all of my sports clients are awake (hopefully), it’s probably no bad thing that I’ve been keeping up my clinic skills, not least negotiating goals that work around individual patient lifestyles and schedules.

5. Holistic physiology

Working on a mixed medical and surgical ICU means that every patient that comes through the door is completely different, and critical care dietitians, perhaps more than any other, need to be experts on the body as a whole. Organ systems don’t fail in isolation; a patient might have respiratory, kidney and GI failure simultaneously, for example, and each of these has nutritional implications that we interpret and respond to. It’s sometimes incredibly complicated and may mean prioritising one component over another, but coming from a biology background, I relish the opportunity to think so holistically.

Once again, this really benefits my work in sports nutrition, where it’s all about different organ systems working together. Of course, there are the fundamental and overlapping roles of the working muscles, lungs and heart. But we also need to consider, for example, the complex relationship between exercise and the GI tract, and the massive impact of the central nervous system on performance. All of these can be influenced by or impact on an athlete’s nutrition and hydration strategy, and this is what usually occupies my mind when I’m running (genuinely!), and certainly when I’m advising clients.

Hopefully I’ve managed to convince you that, far from being alien ends of the nutrition spectrum, there is a HUGE overlap between the wonderful worlds of critical care and sports nutrition, and that expertise in one massively benefits the other.

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