This article discusses suicide. If you are experiencing suicidal thoughts, please reach out for support. In the UK, call Samaritans on 116 123. In the US & Canada, contact the 988 Suicide & Crisis Lifeline. In Australia, call 13 11 14 to reach Lifeline. Help is always available.

Men’s mental health is now a major issue. Over 75% of suicides are by men, and sadly, a large proportion of men are still reticent to talk about their internal struggles. In professional sport, it is now recognised that the pressures of performance, securing income and the impact of injuries can all lead individuals down a dangerous path. Mental health associations and campaigners are working hard to encourage men to open up.

One of these campaigners is Martin Hills, a 51-year-old cycling guide who, on June 9, 2026, began a post on his personal Facebook page with these words: "Five years ago I decided to take my own life." By telling his story, we hope to shed some light on how individuals can find themselves on this path, share Martin’s story of how he managed to handle his feelings, and encourage anyone struggling with similar issues to seek help. He finished his first sentence with "With support, I very narrowly avoided going through with it."

With our social media feeds saturated with folk posting ‘living their best life’ content, the juxtaposition of this post truly made an impact on his close friends, family, and many acquaintances across the cycling industry.

Hills is a lifelong cyclist. Growing up in a very rural village on the edge of Dartmoor in southwest England, he was a popular teenager in a very active cycling community there. He was very detail-oriented, researching and sharing information with his friends about the latest developments in those exciting days when mountain biking emerged worldwide in the 1990s.

He was an active member of the local Cycling Touring Club, whose twice-weekly group rides were among the few activities for the village's youth. Together with best friends Julian Duquemin and Dayle Guy, they inspired the next generation of cyclists in the village, with some, like mountain biker Llewelyn Holmes, going on to represent Team GB, and several others working in the cycling industry to this day.

He enjoyed the competitive side of the sport, taking part regularly in the local off-road racing scene, and many summers were spent working in bike shops like the iconic Hot Pursuit in the nearby market town of Totnes, mainly to fund or get discounts on always-needed spares.

As an adult, Martin then moved into mountain bike guiding, working across Europe for over two decades. In 2010, he launched the Singletrack Safari business, offering bespoke guided MTB/Enduro off-road cycling holidays in the stunning mountains of Andorra.

His company was featured in several leading mountain biking magazines, a partnership with leading MTB brand Commencal (based in Andorra) was established, and the pipeline of bookings grew nicely. Hills was travelling regularly from his home in the UK to Andorra, leading rides, identifying new ride leaders and trails, and truly living his best cycling life.

In January 2020, everything changed. The first reports of the Coronavirus were circulating, and on March 11, the World Health Organisation declared a global pandemic. The travel and tourism industry entered a near two-year shutdown, with all bookings cancelled, refunded, or deferred. As an international travel operator, Hills faced an uncertain future. However, he was determined to keep things together. Then the floor fell out of his world when his long-term relationship came to a sudden end.

His partner at the time was an avid mountain biker. Living together in North Wales, with some of the UK’s best off-road riding on their doorstep, their relationship - and wider friendship group - was built around riding in the local area. Following the end of their relationship, Hills struggled with the prospect of going riding and encountering his former partner and their shared friendships. His greatest passion became his greatest fear.

“It was a totally unexpected and devastating end to my long-term relationship, which came completely out of the blue, and that relationship was centred around bikes. I became terrified of riding a bike, they became a trigger. It just wound me into a complete twisted panic," he said.

Over the next few months, Hills suffered a complete mental collapse. He said he felt trapped, hopeless, and isolated. He felt he could not forgive himself for what his depression made him think; he convinced himself that he had had a life of poor life choices, which had led him down this road. And at this point, his thoughts turned truly dark.

“I made careful plans and gave a lot of thought to how to manage my death. I prepared my house to make sure everything was in order. I drafted a letter of explanation for my family and friends and made an informal will. Finally, I made sure that my remains would be found by the emergency services," he said. At his lowest, Martin was convinced there was no way out. That he is here to tell this story is a measure of how far he has come, and why he now speaks so openly about it.

Shockingly, this is a thought process that many middle-aged men in the UK, like Hills, go through. According to data from the Men's Minds Matter non-profit, 76% of contemplated suicides in the UK are by men, and one man dies by suicide every two hours.

This alarming phenomenon is not limited to the UK; in the USA, three-quarters of suicides are by men, with 39,000 taking their own lives each year. In Australia, the ratio is the same, with suicide being the leading cause of death for men aged 15 to 44. These figures are profoundly disturbing.

This crisis has also been identified in professional sports, including cycling. Several major studies have recently been commissioned to identify the triggers and warning signs of growing issues, and to understand why men remain quiet on these issues. Several high-profile cyclists have shared their challenges, and we are now seeing several large cycling federations put in place robust infrastructure for athletes and recreational cyclists to access, helping address this issue.

High-profile sportspeople like Fabian Cancellara talking openly about these issues is seen as a key enabler for men to feel it would be OK to reach out and seek help and support.

Cancellara was a high-level athlete, a team leader, Classics winner and time trial world champion. Now, as the owner of Tudor Pro Cycling, he sees the pressures his riders face and makes a concerted effort to ask his riders if they are happy. Tudor are trying to compete at WorldTour level, but are also trying to help and support their riders as much as possible.

"I see how tough being a rider in modern cycling really is," Cancellara said. "Science is important, but at the end of the day, we're all human, and that's important for us; we need to protect our riders."

Ricardo Scheidecker is the Head of Sports at Tudor and a vital cog in the team, managing the riders and staff, their performance, results and their well-being.

"I worked outside of cycling for several years and soon realised that successful companies are always centred around their people. If you don't help your people, you're not going to get the best out of them, and you're not going to be successful. In cycling, you have to care about your riders and about your staff too," Scheidecker explained.

"We try to do this in a very constructive and human way, because we consider the psychological impact on the athletes," he added.

"We've seen more and more examples of riders who were huge talents but ended their careers because they didn't have the support to help them deal with all their needs and responsibilities. We cannot be like that as a sport, and Tudor definitely won't be like that. We have to protect our riders from burnout."

In August 2025, Cyclingnews published a piece on mental health issues in the pro peloton, and that 76% figure re-emerged, with author James Witts stating that there is evidence that over a quarter of professional riders battle with mental health issues during their career, with riders like Tom Dumoulin and Bradley Wiggins sharing their challenges in recent years.

Mark Cavendish was diagnosed with clinical depression in August 2018. At the launch of the 'Mark Cavendish: Never Enough' Netflix special in 2023, the 35-time Tour de France stage winner described his battle with the Epstein-Barr virus and how a subsequent diagnosis of clinical depression left doctors worried about the prospect of self-harm.

“The irony is that you feel so alone if you suffer when, in fact, everyone is probably there thinking they are alone. If you talk, you would be surprised how much you have got in common. It is an understanding that there is a ladder in the middle of that spiral down, and you can get on that ladder and climb up," Cavendish said. "It doesn't matter where you're at. It's keeping that hope and good people around you."

According to a recent report, titled Prevalence of anxiety and depression in former elite athletes: a systematic review and meta-analysis by Adam Runacres and Zoe Marshall, the causes of poor mental health are complex and multifaceted but are thought to be a combination of social factors such as occupation, socioeconomic status, education level and physical factors including age, sex, body mass index and low physical activity levels.

Consequently, elite athletes were long thought to be immune to mental health disorders due to their high physical activity levels and superior physical fitness. Runacres and Marshall’s in-depth study and interviews with many athletes turned this thinking on its head, and they discovered that the prevalence of both anxiety and depression in former elite athletes was over twice that of the general population. They went on to cite a large-scale study of 1,620 current elite athletes who shared that they were three times more likely to have a subclinical mental health condition compared with a non-elite control group.

There is one major barrier when trying to counter this issue: only one in four men who experience anxiety or depression seek help or try to get treatment for it. This is changing, and with more high-profile athletes being open about their mental health, it is reducing the stigma.

The British Association for Counselling and Psychotherapy recently reported seeing unprecedented levels of inbound approaches by men suffering from mental health issues, and an increasing number now seek help to cope.

The sporting world is reacting to this, putting in place much better resources and infrastructure to help athletes identify, accept and seek help for their mental health challenges.

In 2021, the International Olympic Committee introduced the Sport Mental Health Assessment Tool (SMHAT), which is designed to help team doctors detect and prevent mental illness early, ensuring a safer environment for professionals.

Many of the world’s cycling federations have also reacted, and their websites are well stocked with resources, contacts and partner organisations that can help athletes and recreational cyclists with their mental health issues. Full information about the SMHAT protocol is available in several languages on the UCI website.

USA Cycling offers a Mental Health Grant that aims to ensure financial barriers do not prevent athletes from receiving professional mental health support. Eligible athletes can receive up to $2,500 per year to support their mental health.

In the UK, the British Cycling Federation announced in 2021 that it would be providing Mental Health First Aid England courses, offering low-cost, accessible training to British Cycling members and volunteers. The British Cycling announcement was clear on the aims of this partnership:

“With the ongoing challenges presented by the pandemic with regards to both physical and mental health, it is more important than ever that more people know how to identify when someone is experiencing ill health – and how to support them.”

For Hills, that help came by total chance, but it was life-changing.

“Unexpectedly, I met a complete stranger who really understood what I was going through as she had dealt with mental health issues herself. It seemed easier to talk to a stranger than someone I knew, and before I knew it, I was telling her everything, and we quickly became friends. She made me feel…I don’t know…of worth, maybe? She certainly proved that life can suddenly switch direction in a positive way, and that not all surprises are negative," Hills said.

Hills contacted his local doctor, who connected him with a mental health first-aider, who he found incredibly supportive. They knew how close he was to taking his own life, placed him on a list of at-risk patients, gave him a suicide prevention plan, and called him daily to check in, to talk, and to give him a real connection. Happily, this began to work, and he started to see the value of life, and his recovery began. He recently shared that the first aider, to whom he spoke daily and who saved his life, remains anonymous.

As his recovery continued, his new friend, also a passionate mountain biker, convinced Hills to get back on the bike, and he began to rediscover his passion for cycling. His guiding business began to recover, and bookings resumed; he started a new relationship; and he began restoring and rebuilding some of his earliest bikes, classic Saracen and Kona mountain bikes from the mid-1990s.

Sadly, in early 2025, his dear friend’s mental health issues re-arose and although seemingly in a good place to her friends and family, she took her own life. Although devastating for Hills, it was a trigger for him to want to do something to try and help those suffering with their mental health.

“Her suicide was the impetus I needed to commit to a plan that had been forming in my head. In 2026, I would undertake an epic bike ride to raise funds for Men’s Minds Matter, to create awareness of the mental health struggles so many of us battle with every day. It would represent my personal journey with mental health, and along the way, I want to talk very openly about my mental health experiences and difficulties, to help encourage other men not to suffer alone silently," he said.

Starting in June 2026, Hills will be cycling over 4,000 kilometres across Europe, solo and unsupported. He is riding from the northernmost point of mainland Wales – the lighthouse at Talacre – to the southernmost point of mainland Spain – the lighthouse at Tarifa.

He is undertaking this journey on the 36-year-old mountain bike that he owned as a teenager, a rare 1990 Kona Explosif. It is a special bike that has been renovated and tweaked by the legendary English bike-builders Mercian Cycles. The team at ORTLIEB have also supplied him with their best front, rear and frame-mounted bike bags.

Hills' bike and equipment weigh around 43kg, and he will have to ascend over 30,000m on the trip to southern Spain, as well as endure one of the hottest European summers on record. His route takes him through three mountain ranges across Wales, across to London, and on to Dover in north-east France. He will then head southwest to Bordeaux, up the Pyrénées into Andorra, down to Barcelona, and then parallel the southern Spanish coast, past Valencia and Seville, to Tarifa, the southernmost tip of mainland Europe, where he will finish.

Rather than be fully clad in Lycra, he has decided to take on the ride in semi-casual clothing, as he wishes to be approachable and open to everyone he meets on this journey. He believes this is a vital part of telling his story to the strangers he meets along the way and of ensuring he takes his time to experience the flora, fauna, landscape, and people he encounters on this epic journey.

A stranger on a bike truly saved Hills' life. If he is able to do the same for someone else through this ride and the fundraising for Men’s Minds Matter, the many hours in the saddle will all be worth it.

“This truly is the biggest, most challenging, and most important event of my life – and anything people can do to sponsor and support me means the world to me personally. Together we can genuinely help save lives. We can help men who are suffering and suicidal – men who are in the same place I was just a few years ago.”

If you would like to follow Martin Hills’ journey and updates, check out his ‘My Singletrack Mind’ accounts on Instagram and YouTube. He is hoping to raise over £5,000 for the Men’s Minds Matter charity during his journey; donations can be made here.

This article discusses suicide. If you are experiencing suicidal thoughts, please reach out for support. In the UK, call Samaritans on 116 123. In the US & Canada, contact the 988 Suicide & Crisis Lifeline. In Australia, call 13 11 14 to reach Lifeline. Help is always available.

There is an overwhelming amount of scientific and anecdotal evidence that heat training works. So why doesn't every cyclist do heat training? In fact, one could estimate that only 10-20% of competitive cyclists heat train regularly. Perhaps you've tried a block or two of heat training before, but it can be difficult to stick to long-term. Science suggests that's where the greatest performance benefits lie, so why do we stop heat training?

Some athletes are scared of it – in a way, you can't fault them. The goal of a heat training session is to increase your core body temperature to at least 38.5° C for 30-60 minutes. Some sessions may be even longer or hotter, but the fact of the matter is, you are increasing your core temperature to flu-like levels.

Is this dangerous? I wasn't sure, so I went straight to the experts to learn about the intricacies of heat training. I spoke to doctors, physiologists, trainers, and athletes about the potential dangers of heat training. Anecdotally, heat training is like magic for many cyclists. But I've had many other athletes come to me saying that heat training didn't work for them, that it made them dizzy or fatigued.

There seems to be a fine line here, the border between physiological gains and pushing it too far. I asked experts about dizziness, fatigue, dehydration, iron levels, and even the effect that heat training could have on sperm count and fertility. The answers I found certainly surprised me.

Dizziness and fatigue

One of the most common concerns I hear about heat training is that cyclists start feeling dizzy partway through their heat training session.

This can be extremely off-putting especially if you've never experienced dizziness on the bike. Thankfully, most heat training sessions are done indoors on a stationary trainer, so there isn't a risk of crashing or riding off the road. However, dizziness is still a concern.

Aline Barre, Endurance Performance Lead at CORE (Body Temperature Sensor), said that "dizziness is a sign of overdoing it." If you're feeling dizzy, it likely means that your core temperature is too high, you are dehydrated, or you are pushing at too high of an intensity. When this occurs, lower your power, hydrate, turn on a fan, or step off the bike if you need to.

But sometimes, the fatigue hits after the heat session rather than during. Some riders end up with significant amounts of fatigue after heat training. Because they're riding in zone 1, they may think that heat training sessions are easy recovery sessions. While this may be true for experienced, heat-acclimated athletes, this isn't true for everyone. If you're new to heat training, or you've just begun a heat training block, your body might not be fully adapted to the demands of heat training yet.

The first adaptations occur after around five heat sessions, said Barre. These adaptations include, "decrease in heart rate, increase in sweat rate, and better performance in the heat. Female athletes may see more changes in heart rate, while males may see more changes in sweat."

Total heat adaptation takes 10-14 sessions, and Barre provided a beginner recommendation of "three weekly sessions for four weeks."

It's important to monitor your recovery and fatigue during and after heat training sessions. Dr. Kevin Sprouse, professional cycling consultant who worked for EF Education-EasyPost for more than a decade, said, "Heat training does have its downsides. Heat is an additional stress," on the body that, when used in the right dosage, "causes super compensation." Like any other training protocol, heat stress isn't necessarily the best thing for your body, but it can certainly improve your performance.

"Most things that are going to help you peak are things we don't want to do everyday or long term," said Dr. Sprouse. "If performance is the greatest concern, then you accept the trade off."

Professional cyclists don't do VO2 Max intervals and eat 150g of carbohydrates per hour 365 days a year. But in the right dosage, these are the kinds of practices that lead to significant improvements in performance. It all comes back to the basic training principle of progressive overload: you stress the body with a stimulus, then you allow your body to recover, and in that time it overcompensates and builds itself stronger.

Heat training-induced fatigue is not unlike any other form of overtraining. The biggest mistake that riders make, Dr. Sprouse said, is adding heat training on top of the training they are already doing. Heat training is a big stress on the body, so if you are already handling a heavy training load, the addition of heat training could push you over the edge. Instead, it's best to pull back on other aspects of training to allow room for heat sessions to fit into your plan.

Altitude training is more popular than ever, but still, most WorldTour riders are hesitant to heat train at altitude. Instead, many WorldTour cyclists do a block of heat training before altitude, then continue heat training in maintenance mode at the high-altitude camp. The difference we're talking about is five weekly sessions during a big heat training block, versus two to three sessions per week to maintain the benefits from heat training.

Another one of the most overlooked effects of heat training is sleep. Heat training can affect the quality of your sleep, and Dr. Sprouse said that he had seen many riders who struggle with sleeping during a heat training block. These riders were "always struggling with falling asleep," but a cooling mattress could be used to blunt this effect. In fact, Dr. Sprouse recommended a cooling mattress all the time, not only when heat training.

To maximise the benefits of heat training, you wouldn't want to jump in an ice bath immediately following an active heat training session. But you would want to cool your core temperature down before bed time, maximising sleep quality and day-to-day recovery.

The dangers of dehydration

One of the first things that you'll notice when you first start heat training is the changes in your sweat rate and volume. These physiological changes will make most athletes start sweating sooner, and end up sweating more in total. Despite the clean up job required, these changes are a good thing. Your body is becoming more efficient at cooling itself, starting that process sooner through sweat, and continuing to keep the body cool for long periods of time.

But with sweat comes dehydration, and this is one of the most common mistakes that athletes make when heat training. You will probably need to drink more than you think. In fact, you might need to drink more than you ever have before. There are no additional physiological benefits associated with dehydration during heat training, said Barre. Not drinking enough is needless suffering.

You can calculate your sweat rate in many different ways, and Barre said the best way to measure fluid loss is to "go onto a scale naked and measure how much weight you lost during the heat session."

Weigh before and weigh after, it's extremely simple. "Avoid more than 2% body mass loss during heat training," said Ross McGraw, CEO of CORE. That can take a few practice sessions to calculate, but the math is simple.

Most riders have a sweat rate of 1.5 to 2 litres per hour, but this can vary. During heat training, the "goal is to replace 150% of your fluid loss during and after the session," McGraw said. That means if you are losing two litres of fluid during a heat session, you should replace it with three litres of fluid over the next few hours.

We cyclists also know the importance of carbohydrates, and that applies to heat training despite most sessions lasting less than 90 minutes. "Carbohydrate needs are higher at higher core temps," Barre said, and we actually use, "10-20% more carbs in a heat session." Barre recommends always fueling during and or after a heat training ride due to higher carbohydrate oxidation.

There can be other changes to your physiology as a result of heat training. CEO of Nix Biosensors, Meridith Cass, said that your "sweat can begin having a lower sodium concentration with heat adaptation." Sweat rate and volume also varies between sports and environments, so you can't always use the exact same hydration protocol. A pro's hydration plan at the December training camp will not be effective during the hottest mountain stage of the Tour de France, for example.

If and when you experience dehydration, it's best to lower your exercise intensity and take on fluids with electrolytes. It's quite difficult to overconsume electrolytes while sweating and exercising intensely, but the other side of the spectrum is the extremely dangerous threat of hyponatremia. This is caused by under-replenishing electrolytes, mostly likely because you've been drinking pure water.

It is a, "safer bet to hedge on the higher electrolytes side," Cass said.

This made me think about the consumption of salts and potential effects on our overall health. With consistent training and exercise, consuming electrolyte-rich drinks isn't a concern. But there was one other topic that I had yet to explore. It took me weeks of research to find an expert on the subject, but I'm glad I did.

Does heat training affect fertility?

You may have heard the news that repeated sauna exposure decreases measures of sperm health and motility in men. You may also have heard that multiple weeks of intense cycling training causes similar effects on sperm health. Do you see where I'm going with this?

While we don't have a study that shows a direct link between active heat training and sperm health, "we can extrapolate from what's out there. The question is: does that matter?" Dr. Sprouse has seen countless studies on heat training and sperm health, but he did not at all seem concerned about a potential link between the two.

Anecdotally, there are millions of cyclists, men and women, who are having kids. A certain percentage of the population may struggle to get pregnant, but there doesn't seem to be a strong link between this group and heat training. If there seems to be an issue, the effects of heat and cycling on sperm health are, "entirely reversible. The spermatogenesis cycle is about 60-90 days," meaning that you can cease heat training or cycling for a few months if you're having difficulties conceiving, said Dr. Sprouse.

That is good news for any and all cyclists who dream of having kids in the future.

Is heat training worth it?

Heat training is like any other form of competitive sport training – when applied correctly and in the right dosage, heat training can help you smash your PBs and achieve your peak fitness level. But if you happen to overdo it, you will suffer the consequences.

It's just like strength training, VO2 Max intervals, or altitude training. If you go to the gym twice per week and complete a cycling-specific programme, you will probably make some significant strength gains. But if you start going to the gym every day and lifting the heaviest weights possible, it won't be long until you are burnt out or injured.

The same goes for heat training. Follow the right protocol at the correct intensity and volume, and it's more than likely that you'll make significant fitness gains. There currently isn't any evidence that going 'bigger' with heat training causes additional gains. The sweet spot seems to be three to five heat sessions per week for two to three weeks to build heat adaptations, or two heat sessions per week long-term to maintain those physiological adaptations.

In fact, you could argue that heat training is even better than altitude or strength training. Some riders respond to altitude and gym work better than others. But there are actually some riders who don't respond at all. Altitude training has actually made some riders worse, so much so that they refuse to go to altitude camps in the future. CORE has tested hundreds of professional cyclists, and there have been plenty of non-responders to altitude. But those same riders were all responders to heat training. Everyone that they have ever tested responded positively to heat training. Mads Pedersen, for example, generally doesn't train at altitude but can be found riding in a CORE suit.

That is the reason that many of the world's fastest cyclists are heat training. Why else would Tadej Pogačar or Remco Evenepoel be sitting on an indoor trainer on a warm and sunny day in Spain? They could be riding around in the mountains, but instead, they are wearing a sauna suit in the backyard, spinning away at 200w and making gains from heat training.

To save you time and so you already have the idea in your head whilst you're reading this article, the main thing I have learnt so far in a year and a half as a professional athlete is that less is more.

In 2024, I completed my final school exams, called A-levels in the UK, at my local sixth form. These exams normally lead you to start a university degree, an apprenticeship, or whatever journey you desire in post-compulsory education, which finishes at 18 in the UK. My schooling and formal education ended there, but of course, learning never stops; we learn new things every day. So what have I learnt over almost one and a half years in the professional cycling peloton, whilst also moving to, and living alone in, a different country at 18?

First of all, I can briefly yet completely summarise that learning another language is extremely difficult. As a typical British person who underwent five years of compulsory language education in secondary school - French in my case - I still can’t even string together a sentence in the language now. Therefore, learning Spanish since moving to Andorra has been a very painful process, but slowly I'm getting there (and I very much love life here in the mountains). Don't get me started on Catalan, though. It is the official language of Andorra, and looks similar to Spanish, yet it is completely incomprehensible to a poor Spanish speaker like myself.

I chose to move to Andorra for many reasons, but mostly because I believe it’s a great place for training: the many high mountain passes and flat valley roads, an endless number of people to train with, and a great support system, from physios to personal trainers, thanks to Movistar. But also, the more practical adult reason was that due to Brexit, it was much easier to gain residency here than to obtain a Spanish visa, for example.

So, fresh from the days of balancing school with cycling, I'm now solely focused on living a life where the everyday goal is to be the best athlete I can be. Time and energy seemed to be in much greater abundance than my previous days, which were filled with full-time education and exam revision, alongside training towards a professional contract and, of course, racing. Naturally, the extra time was an utterly lovely and blissful thing: to wake up at will, fuel the day's training, and leave for it whenever I felt like it. However, after some months of training and racing full-time, that extra energy became problematic.

I write this article in May, which has been a reflective month for me. Last year, just like this year, I focused the early part of the season on the Classics, took a few easy, restful days after that block, and then had a big, long period throughout May to train again for the next big goal. This year, it's the Giro d'Italia at the start of June. Of course, the normal thing to do nowadays when granted a long training period focused on one competition is to go to altitude. However, unlike last year, there is no altitude for me this year.

In 2025, I started my first-ever altitude block in Sierra Nevada, Spain, alone. I'm someone who loves the process – the day-to-day training – just as much or even sometimes more than the outcome, the racing. I'm the annoying athlete who is always pushing the coach's limits to increase the amount of training set on TrainingPeaks. I think this is for two reasons: one, because I love to be busy, years of balancing school work and cycling always meant there wasn’t much time for sitting down on the sofa, and now with all this extra time, sometimes it feels strange not doing something productive with it, such as more training.

And the other thing, as I have alluded to, is that I just really enjoy riding my bike. Therefore, when the concept of simply waking up and focusing on training every day – still a fairly new and idyllic phenomenon to me – was combined with being in an environment such as sleeping at 2,400 metres to reach peak performance, the feeling of reaching that goal of being the best you can be looms as near as it will ever be. It is extremely motivating to do everything possible to better that possibility. Because, of course, we always want more.

My time in Sierra Nevada was amazing. I enjoyed carrying out the smaller extra processes that take place at altitude, the sole focus of waking up and completing that day's training without any distractions and the heightened attention to fueling. However, I had been warned about how easy it was to overcook yourself or underfuel, or both. At altitude, the norm of my training became doing 20 to 30 minutes longer than my carefully planned TrainingPeaks session every day. For many reasons, mostly because I believed it was the appropriate thing to be ‘tough’ on myself to become better. But an additional factor became the boring concept of returning to my accommodation with nothing else to do that day other than eat and sleep.

Time is unimaginably in abundance when staying in the ‘centro de alto rendimiento’. Shortened to and commonly called the CAR, it is a surprisingly well-known building in the world of endurance sports. The translation of the CAR's name into English is 'the high performance centre'. You'd think the goal of a business's name should be to make the product sound a bit more exciting than it is; however, the CAR is truly unique in that the brand name describes the only activities available at Sierra Nevada in May. Not even the lone 90m squared supermarket is open in between the winter and summer seasons, so there is very much nothing to do other than 'high performance'.

On top of pushing the time to the boundaries of turning that session on TrainingPeaks yellow (an indicator on the platform that a training session has been completed to less than or more than 20% of the total time planned), most of the time, my power would be near the absolute highest watts it could be for zone two. Alongside those extra minutes and unnecessarily increased intensity, I continued to strictly follow the nutrition plan uploaded at the start of the week, and based on the week's upcoming training, without thinking about increasing that intake due to the extra calories I was burning.

Therefore, as you can imagine, training up there was going relatively badly, but that was easy to put down to the fact that I was doing altitude for the first time. It's expected to see much lower numbers; it’s normal to be finishing training every day completely wasted and empty, that is how peak performance will come. But, day-by-day, irrational choice by irrational choice, I was unknowingly digging myself into a big hole.

In the short term, there didn’t seem to be a sign of any problem. I had my first-ever WorldTour win in my first race post-altitude training, yet that month's period still hadn’t come. The success post-altitude turned out to be very short-lived. For the rest of the season, I struggled with fatigue, rarely had a good or normal day in training, and found myself ill much more than usual, which impacted my big goals and hopes for the season.

It felt like I was in a constant battle of trying to understand my body and failing. Sometimes fighting with logic, but most of the time, without logic, and in denial that the problem was so clear. I continued without menstruation for 10 months.

That point just made is why I wanted to share my experience of RED-S. Relative Energy Deficiency in Sport is a syndrome of poor health and declining athletic performance caused by an imbalance between food intake and exercise energy expenditure.

Thankfully, I can say my story with RED-S is quite short: after 10 months, in the off-season on holiday last year, I regained my period (the most telling sign for women), then followed more normal feelings in training and, in general, more normal sensations in my mood and overall energy for life.

I wouldn’t say I’m completely back to normal now. I still have an irregular menstrual cycle, still aim to get more healthy fats into my diet, and as I mentioned before, altitude is completely off the charts for me right now. With the general consensus that putting my body under that much stress again will do more harm than good, even if it is done in the opposite way to last year's doings.

But what did I learn, and what do I put it down to? Those careless and unfueled extra 20 to 30 minutes of training I did at altitude every day? I would say no, although they were likely the start of the problem. The real cause was the lack of logic in my brain that allowed me to justify the decisions and actions made at the altitude camp, and seeing immediate short-term results made those decisions a habit after that solo altitude camp. Until, of course, it clicked in my brain that what I was doing was not a recipe for long-term success, which, of course, in my case as a 19-year-old athlete at the time, should always have been the priority.

In some ways, and because I have to look for some positives in this situation, I would argue that experiencing this very steep learning curve in the first year of turning professional may be the best way to hopefully instill healthy attitudes and thinking going forward. Of course, provided that the learning curve provides lessons, which, for me, it definitely did, as I can say that my experience with RED-S is one I truly hope and believe I will never repeat.

So I share this to hope that what I have learnt can be taught vicariously to anyone willing to listen. Going forward, I am prioritising listening to my body and being patient with progress. I have almost gone full circle back to the start, and I am now considering restarting my studies online. Not because I reminisce on the days of school work and training, but because life, and the world also, is not and cannot be all about cycling. I now realise that for me, it is very important not to be solely reliant on one thing, mainly for perspective on that thing, but also to learn to find happiness and fulfilment in other things that aren’t cycling, because there will come a time when I am not allowed to cycle that day or that month. Or maybe I’m just back in Sierra Nevada in May again. But most importantly, I will be remembering that more is not always more. Less is more.

In the last few weeks, we've been running a really exciting and important series for our Cyclingnews subscribers, focusing in on women's health in cycling. As we head towards International Women's Day, I wanted to tell you a little bit more about the series, and give you the chance to read stories unlocked and for free this weekend – more on that below.

The idea of running a series on women's health is something that predates my time at Cyclingnews, and is something the team here has been wanting to do for a long time. CN has never shied away from covering women's issues in the sport, and we've covered various topics relating to rider health, RED-S and disordered eating in the past, but it's long felt like there was space to go deeper.

So over the last few months, I've been working on getting some of the fantastic ideas my colleagues have had to go from concept to execution, and allowing us to really spend time on this topic.

With so little research into some of the topics we've covered, pulling these articles together has sometimes been time- and labour-intensive, tracking down experts and unearthing information which has gone seriously underreported in cycling media before, including by us.

It's really thanks to our subscriber base that we're able to commit that time and effort to stories like these, so thank you if you're a subscriber, and welcome along if this series prompted you to become one.

Why is women's health in cycling important, though? Of course, as a cycling website, all our stories are told through the lens of cycling, but in truth, women's health in general is highly underrecognised, not just in the world of cycling or sport. Women face long struggles for diagnosis, barriers to access for treatment, and debilitating issues are written off as unimportant or not of serious medical concern.

Many issues are treated as unisex, but we know now that when it comes to biology, very, very little is – be it nutrition, mental health, hormones, or anything else. Female athletes face their own specific set of challenges and circumstances, and it's in the interests of everyone to know more about that.

I think there was also a personal element for me, my colleagues and our freelancers. These are all topics and issues that we have faced in some way or another, and come up against the lack of understanding or information available.

The piece I wrote was about endometriosis and PCOS. Whilst I don't have either of these conditions, I do have real problems with my cycle. I've spent days at races doubled over in pain, and then gone into the press room to find there isn't even a women's bathroom. I've had to take time away from my working day to deal with pain or my period, or to undergo invasive tests, so I couldn't even imagine what it was like to deal with all that and try to race as a professional, too.

The above may sound like oversharing, but the truth is that's only because we don't talk about these things enough. I've heard male riders talk about their stomach issues or saddle sores casually and openly in interviews and articles, so why shouldn't we talk about women's health in the same way?

That's the essence of what we wanted to do with this series. To open the conversation, and to treat women's health as a central part of the performance conversation, not just a side-story to the male-focused norm.

So far, we've covered a wide range of topics. Freelance contributor Emma Cole dove into how female athletes can harness health tech, whether that's by tracking your period or recording your heart-rate and other vital stats.

Managing Editor Laura Weislo spent a day with Human Powered Health to understand how cycling is facing up to the issue of low bone density, which can be caused by hormone deficiencies in women, but is a big problem for male cyclists, too.

As I've already mentioned, my own contribution delved into menstrual disorders, how they affect pro riders, and whether teams know enough to support their riders who may suffer with something like PCOS or endometriosis. I spoke to two female athlete health experts, plus Ane Santesteban, a former pro who has endometriosis.

And most recently, our Editor Kirsten Frattini wrote a fascinating piece about the importance of targeted nutrition and hydration for female athletes, where Dr Heather Logan Sprenger explains women's different nutritional needs, whether that's iron intake or menstrual cycle-synced fueling.

Whether you're a female rider, a cycling fan, or anyone else, there will be something interesting for you in these articles. Whether you're a woman who might find something educational or informative about your own health, or a man looking to understand more about what your female riding companions experience, or just a person with an interest in health and cycling performance, any of these stories are absolutely worth your time.

So, what's next? We still have women's health stories in the works, including a deeper dive into RED-S (relative energy deficiency in sport) and plans to follow up on Immy Sykes' informative women's saddles feature, plus a great long list of ideas about pregnancy, menopause, mental health and more.

But primarily, we'd like to know what you'd like to see. Which parts of the series so far have chimed with you? What topics would you like us to delve into next? Please do share your thoughts and ideas with us in the comments, whether they're about women's health or a wider topic.

Cyclingnews' women's health series

For today, we have specially unlocked some of our women's health series, so those that haven't had a chance to read them yet can dive in and get a feel for the series. If you enjoy what you read, please consider taking out a paid subscription – you'll be able to read the full series, plus our Labs testing content, in-depth features, pro columns and more.

'One of the most under-recognised threats in women's cycling' – Why it's more important than ever for athletes to dial in nutrition and hydration (Free to read)

In an in-depth interview with Cyclingnews, Dr Heather Logan Sprenger, a researcher and scientific advisor specializing in physiology, nutrition and exercise science, highlights the key nutritional factors female cyclists should consider when training and racing at the highest level to optimise adaptation, performance and health.

Menstrual disorders can disrupt lives and careers, so why do we know so little about conditions like PCOS and endometriosis in cycling? (Free to read)

Featuring insight from The Well HQ's Jo Perkins, doctoral researcher and AG Insurance-Soudal female health expert Meg Smith, and former pro Ane Santesteban, we lift the lid on the effect menstrual conditions can have on pro cyclists.

How tracking your period, heart rate and vital stats can help female cyclists with performance – and where should we still 'use our feeling first' (Free to read)

As health-tracking technology becomes ever-present in cycling, how are female cyclists using it to monitor their health, and is all this data actually beneficial to fine-tuning our training? We hear from pro rider Neah Evans about how she uses tracking and data.

How pro cycling is tackling its awkward relationship with low bone density (Free to read)

Although bone density can be a serious concern for men, it is even more so for women who face a normal drop in bone density during menopause when estrogen levels drop. Osteoporosis can predispose sufferers to fractures, especially of the wrist, hip and spine, which can be debilitating and not what active adults who want to keep exercising for their health want. We found out how teams like Human Powered Health are working to combat this problem.

More about women's health

• 'I felt an obligation to be truthful and speak out' – Why Demi Vollering wants to keep periods and women's health in the spotlight in cycling
• 'Breaking the taboo' – Tour de France Femmes riders highlight issues of low rider weight and disrupted menstrual cycles
• 'I need to take the time to fully recover' - Veronica Ewers steps away from elite cycling to continue RED-S recovery
• 'The current system is not set up to protect female health' – The Cyclists' Alliance renews calls for mandatory RED-S screening
• 'I make every decision in my career by putting my health first' – Demi Vollering speaks out on rider weight issue after Tour de France Femmes
• Cycling's most sensitive issue - Why saddle discomfort is one of the most pressing, and silent, barriers to entry for female cyclists

To mark International Women's Day 2026, Cyclingnews is proud to be shining a light on the many women with inspiring stories from across the sport. Subscribe to Cyclingnews for our unrivalled women's cycling coverage, and much more. Find out more.

The science behind training and performance has advanced significantly in women's cycling over the last decade, including a deeper understanding of how athletes fuel their bodies for training and racing.

As the peloton gets stronger, race distances get longer, and the competition season extends to nearly 10 months, it's more important than ever for athletes to dial in their nutrition and hydration strategies. And what athletes intake as fuel sources, and when, must also align with the physical demands of high-performance training, menstrual cycles and hormone fluctuations, changes in body temperature, sweat loss and potential supplementation needs - all have a major impact on an athlete's ability to adapt to the physical demands of sport.

In an in-depth interview with Cyclingnews, Dr Heather Logan Sprenger, a researcher and scientific advisor specializing in physiology, nutrition and exercise science, highlights the key nutritional factors female cyclists should consider when training and racing at the highest level to optimise adaptation, performance and health.

"Metabolism hasn't really changed so much over time, and so the fundamentals, such as our macro nutrients needs - proteins, carbohydrates, fats and nucleic acids - the major biomolecules are the same, and you have to fuel with these things. What has changed are the recommendations and the awareness, which is more present now," says Dr Logan Sprenger, who has worked directly on nutrition and performance with individual athletes and teams, zeroing in on the importance of adequate fuelling to help avoid symptoms of Relative Energy Deficiency in Sport (RED-S).

RED-S occurs when the body doesn’t get enough energy from food to fuel both the demands of exercise and essential daily functions like breathing, digestion, and repairing tissues and can lead to serious physical and mental health problems, according to Project RED-S. Physical symptoms include unexplained fatigue, low energy, and persistent illness and injuries.

"Energy availability is really the cornerstone of female performance. So chronic under-fuelling has always been around. It quietly erodes power, recovery, and endocrine health. What I've seen working with lots of different sports teams on is that low energy availability is one of the most under-recognised threats in women's cycling; it disrupts the menstrual cycle before affecting body weight."

"Your menstrual cycle is really important because it's one of the earliest warning signs of under-fuelling; you lose your menstrual cycle. If the focus on nutrition is about female physiology, then there are a number of key areas that are important to consider for athletes."

Iron status - a key performance factor

At the top of Dr Logan Sprenger's list is iron status, which she says is a key performance factor for female endurance athletes, not just a health concern. Regularly monitoring serum ferritin and iron levels can be essential for proper oxygen delivery, which directly affects training consistency and performance.

Ultimately, she says, athletes need an optimised internal physiological environment to adapt to training loads effectively; without it, even well-structured training will not lead to meaningful improvements.

"Iron status is not just a health issue, it's a performance limiter for female endurance athletes," she says. "It is highly overlooked, in my opinion, and yet, it could be having two or three blood samples a year to make sure an athlete's serum ferritin is within a range that will allow them to adapt to the training load."

What is an optimal serum ferritin range? Dr Logan Sprenger says there are ranges for female endurance athletes; however, it's important for each individual to discuss them in consultation with their sports physician and sports dietician.

"Iron does fluctuate during the menstrual cycle. However, it is more of the consistency of making sure an athlete is getting samples on a regular basis to track those levels, to make sure the serum ferritin is in their [optimal] range. An athlete's checklist should include getting serum ferritin levels checked routinely at least twice a year, maybe more."

She suggests maintaining a diet rich in iron helps support performance and adaptation, but nutrition alone may not always be enough. Understanding your serum ferritin levels is important for athletes to determine whether supplementation or other interventions might be needed.

Carbohydrates intake

Eating enough carbohydrates is the second key consideration that Dr Logan Sprenger says endurance athletes should aim for, with the recommended intake of 5-10g/kg of body weight daily. However, she explained that while many endurance athletes consume enough protein for muscle repair, they often fall short on carbohydrates, which are essential for fuelling performance.

"Most endurance athletes don't have a protein problem; they have more of a carbohydrate problem. They're eating enough to repair muscle, but not enough to fuel performance," she says.

"We live in a culture where protein is overemphasised in terms of recovery, being lean, and being strong, so athletes tend to prioritise protein, and then they deflect carbohydrate off the plate, so to speak. Yet, most of the endurance athletes and cyclists that I've worked with don't get enough carbohydrates, and so that's where carbohydrates are chronically under-consumed."

Dr Logan Sprenger lists some of the health concerns that can arise from inadequate carbohydrate intake, including impaired performance and overall health, reduced training quality, increased stress hormones, disrupted sleep, hindered recovery and immune function, and an increased risk of low energy availability.

She stresses the importance of protein intake, too, but says that many female cyclists and endurance athletes she has worked with usually eat enough protein. However, she suggests that the timing of protein intake around exercise is crucial and that athletes, in general, need to be aware of pre- and post-exercise protein intake.

Menstrual cycles and phase-based nutrition

Let's go back to the basics. The menstrual cycle begins on the first day of your period, which is considered day one. It is divided into four phases: menses, follicular, ovulation, and luteal. The luteal phase runs from ovulation to the start of the next period, usually around days 14–28/30, and is marked by a rise in basal body temperature.

However, because the baseline core temperature is higher in the luteal phase, this can reduce heat tolerance. Dr Logan Sprenger says that this is when hydration and cooling strategies matter more than most women realise.

Whether training or racing, it's important to have a performance plan to ensure an athlete can thermoregulate, or tolerate heat better. She says it's this rise in body temperature that explains why some indoor sessions and or training and racing in the heat can feel harder later in the menstrual cycle.

"Essentially, proactive management is needed, just to be aware. I say this with the caveat that every female is different. Some people don't notice, while other people feel hotter and can't tolerate the heat as well in the luteal phase," says Dr Logan Sprenger.

She says that athletes often find ways to stay cooler before races and exercise by implementing proactive heat and hydration management. Dr Logan Sprenger cautioned that while some women feel bloated in the luteal phase, that doesn't equate to being hydrated; in fact, it can often be a sign of beginning exercise dehydrated.

"What I've noticed in the female cyclists I've worked with is that in the luteal phase, they can start rides more hypo-hydrated, meaning they are more dehydrated because they feel bloated, so they don't drink as much," she says.

"Most of that fluid has moved from their blood and from their plasma to the interstitial space, between tissues and within cells. And so, their actual hydration needs increase during the luteal phase. This all helps with thermoregulation."

What is sweat rate and why is it important?

Sweating is one of the most important byproducts of training, and the rate at which an athlete sweats increases with metabolic rate, so the harder they work, the more heat their bodies produce.

Dr Logan Sprenger explains that since the body must maintain a core temperature of 37°C, it activates sweating as a cooling mechanism when the temperature rises above this point. However, sweating leads to fluid, electrolyte, and other essential nutrient losses that need to be replenished.

"I believe that every endurance athlete needs to do a sweat analysis to find out their sweat rate; assessing your body mass changes over an hour of exercise to see how much body mass you're losing based on fluid loss, and making sure you're drinking to your sweat rate," she says.

"Sweat rate is individually variable, it's genetically determined, it can change with training and acclimation or acclimatization to different environments. How much you sweat is different from how much I sweat, and so you can't do a generic, 'drink this much', to the entire cycling team."

She advises athletes to know their individual sweat rate so they can implement a hydration performance plan for training or racing. She cautioned that showing up to training or a competition dehydrated can cause a range of problems, including exacerbating the core temperature response, raising heart rate, increasing fatigue, and making the rating of perceived exertion feel heightened.

"First, arriving hydrated, making sure you're drinking 500ml, at least, in the hour before exercise. Second, knowing your sweat rate by doing a sweat loss analysis. And then, you know exactly how much, what your performance plan is for hydration, and drinking to minimise your body mass losses," she says.

"Lastly, post-exercise, whatever you've lost in sweat losses, you should replace 150% of your sweat losses. For example, if you lose a litre of fluid during a race, you should drink 1.5 litres in the few hours during recovery to ensure you replenish your body's water losses. This is really important, especially for subsequent days of racing or a Grand Tour."

She recommends athletes do a sweat analysis to determine their sweat rate once a year or at the beginning of the season. However, the analysis can also be done during the hot summer months to ensure athletes are dialled in, because as they become more trained or more acclimatised to their environment, their sweat rate can change.

"Having that sweat analysis and knowing your sweat rate is a fundamental that every athlete should know because it significantly affects performance," she says.

"You can't supplement your way out of a poor diet"

There is a lot of discussion about the use of supplementation in sports, but Dr Logan Sprenger argues for the benefits of adequate nutrition and stresses the importance of athletes consulting their physician to determine whether additional supplements are needed.

"You need to dial in your nutrition; that's the foundation, before you're adding or layering on supplements," she says.

She explained that, in some cases, supplements such as Vitamin D to support metabolism, Omega-3 fatty acids to support myelination of neurons, and increased iron intake to support serum ferritin levels are carefully considered based on blood sample analysis.

"To me, those are fundamentals, and besides that, it depends, but supplements are not a cover-up for a bad diet. You can't supplement your way out of a poor diet," she says.

"It's really important to eat whole foods and make sure you're getting all the biological molecules. It's important to have a wide range of food groups and make sure your nutrition is dialled in before you add on supplements."

As Dr Logan Sprenger emphasises, the fundamentals of metabolism have not changed, but the sport's understanding of how female athletes apply them has continued to grow over the last five to seven years.

Adequate energy availability through a well-constructed, whole-food diet helps athletes adapt to training, along with iron status, carbohydrate intake, menstrual cycle awareness, hydration strategy, and sweat rate analysis, which have become key performance considerations for athletes to perform at their peak.

Developed for people with type 2 diabetes and those living with obesity, nearly 12% of US adults have used weight loss injections according to a 2025 study, with another report claiming that 3.3 million UK adults are expected to use them in 2026.

Cycling has a longstanding and uneasy relationship with body image and weight, forged by a culture that's trickled down from the pro ranks, where every kilogram matters and diet is continuously under the microscope.

However, some cyclists have highlighted how taking weight loss drugs has benefited their health, revealing that it allowed them to get back on their bikes, renewed their sense of happiness, reenergised their energy levels, or, in some cases, simply helped them to start cycling in the first place.

Of course, there are potential health risks posed by under-fuelling, too, with research still in its early stages and cultural stigmas aplenty. But for certain cyclists – several of whom we've spoken to, alongside experts, but did not want to go on the record or would only speak on condition of anonymity – could the benefits outweigh the risks when it comes to weight loss drugs?

How the drugs work

The drugs inhibit appetite and slow digestion, meaning people feel fuller for longer and eat less. They are called GLP-1 receptor agonists, which stands for Glucagon-like peptide-1.

Ozempic, Wegovy and Mounjaro are key brand names, with Semaglutide the active ingredient in Ozempic and Wegovy, and tirzepatide in Mounjaro. The latter works slightly differently as it acts on two receptors, GLP-1 and GIP, which further reduce appetite.

Anecdotally, Ozempic and Wegovy are both produced by Danish Pharmaceutical company Novo Nordisk, which has sponsored an all-diabetic UCI ProTeam since 2013.

They are typically injected weekly, although pill form is now available in the US and is expected soon in the UK.

"Most of the people we're seeing aren't necessarily high performing or recreational athletes; it's people who are obese or overweight, possibly with other co-morbidities like pre-diabetes or metabolic syndrome," said Tom Williams, Head of Performance and Strength & Conditioning Coach at Pure Sports Medicine.

"Their GPs have suggested they get on it, and our job has been working with them to increase their exercise and their activity."

Life-changing health boost

For those overweight or living with obesity, GLP-1s offer a lifeline and can enable them to get back into cycling.

A PT and cycling coach was struggling with weight gain as a side effect of long Covid and started using Mounjaro in July 2025. She was prescribed by a chemist as her BMI was in the overweight category and has since lost 17kg.

"It has been a game changer for me," she said. "I eat well, I've had to change nothing except now that I use the GLP-1, it's shifted something in my body, and I have so much more energy, I have so much more focus and clarity."

It’s given her a renewed sense of joy on the bike.

"I was really struggling to get out on the bike, but when I went out on my bike for the first time, having lost that weight, it was just a game-changer. I did a hill session, and I could do it. I did the hill twice, I had the energy, and I got a PB."

There have been other health benefits, too.

"I think it's helped with inflammation, and all the markers in my blood tests have been amazing the past few months. I've suffered with anaemia my whole life, and that's reduced; I've suffered with ethnic neutropenia, which seems to have gone too."

In a similar vein, a person I spoke to who took Ozempic said she noticed inflammation and water retention dropped, better energy levels, walking was easier, portion control was better, she lost the desire to drink alcohol, and the food noise went away.

She called the drug "life-changing."

Under-fuelling

It could come at a risk, however, because the drugs reduce appetite, which means cyclists may not be able to fuel adequately and be in a low-energy deficit.

"The risk is undernourishment as you're not able to eat as much as you were prior to being on the drugs," said Williams.

"People on these drugs need to ensure they are getting enough carbohydrates, fats and nutrients needed to sustain the workload they are doing. If you are hardly eating, you will fatigue quicker and your endurance will reduce as well."

RED-S (relative energy deficiency syndrome) is also a potential risk that can lead to a series of health concerns.

"The risk of low energy availability will be more immediate which can be a long term issue, alongside picking up illnesses, not responding to training as well, longer recovery times, and the quality of your riding won’t be as good," said said Dr Sam Impey, a performance nutritionist and co-founder of nutrition app Hexis, currently used by eight WorldTour teams.

At the WorldTour level, it’s a battle for riders to eat enough as it is, Dr Impey explained.

"There's almost a trade-off now of whether a rider can physically get enough calories in on the key days and in a WorldTour race. For these athletes to perform, the physical amount of calories they need is already at the limit of what they're happy to ingest."

However, the PT and cycling coach on Mounjaro is conscious of adequate fuelling and hasn’t seen any negative impact.

"I make sure I eat three meals a day, I focus on my protein first and foremost, and if I’m going to be doing extra workouts, I have an extra snack," she said. "I also take collagen to ensure I’m hitting my protein goals."

Muscle and bone density loss

Exactly how much muscle mass and bone density loss GLP-1s cause is up for debate, with varied research thus far. One study reported up to 40%, while another has found it to be around 10% of the weight lost. Regardless, the loss can negatively affect performance on the bike.

"Total mass may come down, but you'll probably lose as much muscle as you will fat, so whilst you might get a very temporary, and this is only speculative, increase in watts per kilo that will shortly be followed by a big drop in total capacity to produce watts," said Impey.

"Your durability will also go down, so your ability to do longer stages, particularly back-to-back days of riding, is going to be impaired as well."

Cycling is already known to negatively impact bone density, and with the addition of GLP-1s, the risk becomes greater. This is particularly significant for cyclists over 50 due to sarcopenia, an age-related decline in muscle mass, as well as female cyclists who are post-menopausal due to higher rates of osteoporosis.

Weight resistance training and a healthy diet are important to mitigate this.

"On these drugs, up to 40% of the weight you lose can be from muscle mass and bone density, which means you need to be in the gym two or three times a week and you need to make sure that what you're eating is correct," said Williams.

Performance enhancing?

GLP-1s are not currently banned by WADA, but they are being monitored.

"I don't see it as a performance-enhancing drug because of the risks of under-fuelling and energy requirements, as well as the loss of bone and muscle mass," said Williams.

"Base volume is king, and you can't shortcut it," added Impey. "There's no HIIT protocol, sprint interval, or any chamber you can get into that will shortcut doing 15 hours a week of low intensity training."

However, a researcher I spoke to suggested that independent components of the drugs could have anabolic qualities, although hard to separate, and the cognitive benefits could also be a consideration. Some research has shown that GLP-1 users have a lower risk of developing Alzheimer’s and overall improved cognitive function.

Body image

Research claims that cycling has a high prevalence of eating disorders, and adding weight loss drugs into the mix could increase this while also perpetuating damaging body image ideals.

"The use of weight loss jabs in a context where thinness is already put on a pedestal and where eating disorders and disordered eating is already a concern, is a recipe for disaster," said Dr Garcia Ashdown-Franks, research fellow at York St John University.

"I think the introduction of weight loss jabs is going to perpetuate those norms and expectations around having the lowest possible body weight."

Williams emphasises that the drugs are not appropriate for people who do not fit the prescribed category.

"There will be people who already have a history of eating disorders or body image issues, or people who want to shed a few kilos, and that's where the risks come in. It’s not appropriate for them," said Williams.

However, the drugs have been criticised for being easy to access, and one source based in the US said, "getting prescribed is easier than getting a bag of sweets from the shops."

Weighing it up

For those overweight or living with obesity, weight loss drugs offer a way to improve health and quality of life. It could also enable people to get back into cycling and others to discover it.

However, for amateur and elite cyclists, it’s hard to see many benefits to the drugs amid the risks of under-fuelling and muscle and bone density loss.

More research is also needed to further understand the impact of these drugs too, and there are significant concerns over the potential for these drugs to lead to damaging body image norms.

As Impey said: "I don't see how the combination of cycling and weight loss drugs is a good thing for someone's long-term health unless there's a clinical requirement."

Menstruation and cycling have a complicated history. Not that long ago, professional cycling was seen as largely a man's domain, so little attention was ever paid to female health. In recent years, the status of women's cycling has grown, but the conversation around health still had a way to go – not having a period at all was seen by some as a badge of honour, a sign you were lean and light, rather than a cause for concern.

Fast forward to now, though, and the growing focus on women's sport has also helped to improve and amplify the conversation and understanding around women's health, be that periods, pregnancy or anything else.

We now have Demi Vollering talking openly about her period after races, several riders opening up about Relative Energy Deficiency in Sport (RED-S) and eating disorders, and figures like Lizzie Deignan and Ellen van Dijk pioneering performance during and after pregnancy. The taboo around women's health, or the idea that women experience sport exactly the same as men, is slowly but surely dissipating.

However, for all that things have improved in many areas, there are still many, many aspects of female athlete health that have hardly been researched or understood at all, and where athletes don't always know enough about their own bodies, and how to manage these conditions alongside cycling.

One of these areas is reproductive or menstrual disorders, things like endometriosis and PCOS.

What are menstrual disorders?

'Menstrual disorder' is a wide, very generalised term that we can use to describe a whole host of problems that may be experienced by people born female, relating generally to their period, menstrual cycle, female hormones, or reproductive organs.

These disorders can be anything from unexplained, irregular or heavy periods (menorrhagia), to more specific and diagnosable problems like endometriosis, polycystic ovary syndrome (PCOS), fibroids and adenomyosis.

If you don't know what any of those words mean, or the specifics of the conditions, don't worry, you aren't alone. More than one in 10 women suffer from some kind of condition relating to their period, and at least 30% of reproductive-age women experience some kind of irregularity, but period health – or poor period health – is still an under-researched, under-discussed and often misunderstood topic.

So what are these conditions, and what do we know about how they affect women, particularly athletes? Whilst research is still sparse – and we'll get onto that next – Cyclingnews spoke to Jo Perkins from The Well HQ, a British-based project that works with various organisations to consult on and assist with understanding and coaching around female health for athletes, about how some of these conditions can manifest in the world of performance sport.

Endometriosis is a condition where cells and tissue that should grow in the lining of the uterus (the endometrium) grow elsewhere in the pelvis and abdomen, including around the reproductive organs, but also on the bowel or bladder, which can cause severe pain and heavy periods. It can be difficult to diagnose, and the only treatment is surgery to remove additional tissue, which can lessen symptoms in the short term but is not a permanent cure.

For athletes, the persistent pain of endometriosis can be at most debilitating, and at least performance-hindering at times. Whilst there is little to be done at present in terms of treatment, The Well are working to identify how athletes with endometriosis can be better supported, or at least make the conversation around it more constructive.

"Endometriosis is highly under-reported, especially with female athletes. It is common to see minimisation of their extreme pain, or the 'just push through' culture," Perkins explained. "Some of the ways it affects athletes are missing training sessions, having sub-optimal performance and feeling fatigued, but the psychological impacts cannot be dismissed: anxiety around races, selection and contracts, fear of heavy bleeding, bloating or that extreme pain on training or race day, [and] being perceived as unreliable."

PCOS, or polycystic ovary syndrome, is a hormonal condition where women experience higher levels of hormones, including testosterone, and multiple cysts on the ovaries. It can cause heavy periods, weight issues and excess body hair, as well as fertility issues.

In men's sport, higher testosterone is often associated with improved performance, with athletes even unnaturally elevating their levels (which is illegal); that doesn't mean hormone imbalances in women should be seen as a positive, though.

"Some studies show that increased androgens, normally testosterone, could present some benefits in terms of maximum oxygen uptake, better performance and some endurance tests, and that women with PCOS have higher muscle mass and better performance in certain tests, compared to women who don’t have it," Perkins said.

"However, having PCOS is far from being a positive thing – it’s a health condition that negatively affects many areas of these athletes’ lives. There are metabolic, reproductive and psychological challenges that come with it, such as insulin resistance, irregular cycles, fertility issues, and mood changes. The focus should be on health and managing the symptoms and the condition with specialised support."

Adenomyosis is described by the NHS as "a condition where the lining of the womb (uterus) starts growing into the muscle in the wall of the womb" and can be a cause for heavy or painful periods. Fibroids are benign growths that can grow in or around the uterus and can again cause heavy or painful menstruation.

Of course, there's also the problem of missing or losing periods altogether, which is all too common in elite athletes, and can have severe consequences, from RED-S to bone density problems caused by hormone deficiencies. We'll explore those elsewhere in this series.

Problems like these are wide-ranging, and all have different symptoms and treatments, so they shouldn't be treated as one or lumped together. For this article, we've focused on two of the most common and well-known conditions, endometriosis and PCOS.

There are not many cyclists – or athletes in general – who have openly spoken about having these conditions, but they do certainly affect women in the peloton.

"My understanding is that conditions such as endometriosis and PCOS absolutely exist within sport, including at elite level, but they are significantly under-recognised and under-diagnosed," said Meg Smith, a doctoral researcher at Loughborough University and Female Athlete Health Consultant at AG Insurance-Soudal.

"They’re often perceived as being rare in elite athletes, but I don’t think that reflects true prevalence. Instead, it reflects a combination of delayed diagnosis, symptom masking (particularly through hormonal contraception) and a sporting culture in which pain, fatigue and discomfort are frequently normalised. Many of the symptoms associated with these conditions, such as low energy availability, gastrointestinal issues, pelvic or lower back pain, and fluctuations in performance, can easily be attributed to training load or competition stress rather than an underlying medical condition.

"There’s also likely a degree of selection bias. Athletes whose symptoms are more severe may drop out earlier in development pathways, meaning elite sport can appear healthier than the wider population, even though that doesn’t reflect the full picture."

A dearth of research

Whilst organisations like The Well HQ and individual coaches and researchers are working hard to improve understanding of female athlete health and conditions that affect women, scientific or academic research is still very difficult to find.

Even in 2026, research into the effect of the regular menstrual cycle on performance is limited, with little conclusive evidence – there is not a widely agreed upon consensus on if and how the different stages of the cycle impact performance, either physiologically or perceptually.

With so little out there, even on the foundational level around period health and performance, sports-related studies around conditions like endometriosis and PCOS are nearly non-existent. A quick search will return some useful resources and articles on the subject – some anecdotal, some more academic – but still relatively little information, especially for athletes above the amateur level.

"Historically, sports science has been built around male physiological models. Female athletes were often excluded from research due to the perceived complexity of the menstrual cycle, which was seen as a confounding variable rather than something to be understood," Smith added.

"There has also been long-standing discomfort around discussing menstrual health, alongside practical challenges in funding, study design and longitudinal hormone measurement. As a result, it was often considered easier to control or suppress the cycle than to study it properly. That is changing, but we’re still catching up after decades of under-representation. The growing interest we’re seeing now reflects a recognition that female physiology isn’t a problem to work around but rather, it’s something fundamental to performance that deserves equal scientific attention."

Another possible barrier is that these conditions are highly individual, and do not necessarily affect all women in exactly the same way. Sports science often favours repeatability and consistent results, which can be hard to ascertain when it comes to women's health conditions – a study may not reliably prove or disprove a certain hypothesis.

This also means that it can be harder for athletes with disrupted periods to apply any of the current knowledge around the menstrual cycle, hormones and performance to their own lives.

"It can be more complex, largely because much of the existing research is based on relatively narrow models: typically, athletes with regular, ovulatory cycles and no diagnosed gynaecological conditions. In reality, many athletes don’t fit neatly into those categories," Smith said.

"When conditions such as PCOS or endometriosis are present, hormonal profiles can be less predictable, ovulation may not occur consistently, and symptoms may fluctuate independently of the traditional menstrual-cycle phases that are often discussed in research or applied practice. That doesn’t mean these athletes are ‘too complicated’ to understand, it means our current models don’t yet reflect the diversity of real-world female physiology. In those cases, support often needs to be far more individualised, focusing not just on cycle phase, but on symptoms, recovery, perception of effort and overall wellbeing."

The true number of riders racing with one of these conditions, whether they know it or not, may be inline with the number in the general population, but it's also likely that these conditions are underrepresented in sport, because they may act as a barrier to starting, participating in or sticking with a sport.

"It definitely does," Perkins said when asked if period problems can get in the way of sporting success. "It affects participation in terms of logistics, pain and fear of bleeding, stress. We have some studies that prove that 7 in 10 girls avoid being active during their period. In elite British track and field athletes, 76.8% reported that their menstrual cycle negatively affected their performance at some point during training or competition. And, among professional female rugby players in the UK, 87.8% perceived the menstrual cycle to negatively impact performance."

"If young athletes are repeatedly told that severe symptoms are ‘normal’ or something they simply have to push through, many will disengage before appropriate support is ever put in place," Smith added. "We often talk about increasing female participation in sport, but we rarely address the physiological experiences that can quietly push girls out."

If these are the numbers among female athletes in general, it's not hard to imagine that pain from endometriosis or consistently heavy or irregular periods caused by PCOS could only amplify the problem. So if there is a lack of these problems in the pro peloton, it may well be because riders stopped or faltered before they got there.

In the pro peloton

However, just because there may not be conclusive evidence or studies on the topic of conditions like PCOS or endometriosis, that doesn't mean there aren't anecdotal stories of how they can affect female cyclists.

The topic is far from a main talking point in women's cycling, but a small number of pros have spoken out about being diagnosed with conditions including PCOS and endometriosis. In 2019, Welsh track and road rider Elinor Barker spoke for the first time about her struggles with endometriosis, and how severe pain almost stopped her from competing. Dutch ProTeam rider Quinty Schoens is a former triathlete, but quit the discipline to focus on cycling after struggling with injuries and PCOS.

"I was also diagnosed with PCOS earlier this year. An abnormality on my ovaries, what still affects me on a regular basis," Schoens wrote on Instagram at the time. "This makes it hard to be at my highest level sometimes."

More recently, Spanish veteran Ane Santesteban made headlines for her candid comments about being diagnosed with endometriosis and ovarian cysts, and how long it took to understand the problem, with her coaches putting her performance dip down to mental factors.

"In 2024, I felt unwell all year; a lot of lower back pain, pain in one leg, and general discomfort," Santesteban explained to Cyclingnews. "I visited many doctors and had blood tests done, but we couldn’t find the cause of the pain. Many told me it was psychological, and after so many visits, I even started to doubt myself. But I still felt unwell.

"During a visit to the gynaecologist, they saw that I had a cyst on my right ovary, and that’s when they started asking questions, and we identified the problem. Everything stemmed from the fact that in December 2023, I had my hormonal IUD removed, and that’s when the pain began."

The reasons why riders like Santesteban sometimes struggle to find answers seem to stem from the fact that these conditions are misunderstood in the general population, let alone in sport. In researching for this article, I heard more than once from people working in performance at pro teams tell me they simply don't know enough about this topic, and therefore, it's probably not surprising that problems aren't being identified or managed appropriately.

"In my case, before every important race, I had to make certain visits to an osteopath, a pelvic floor physiotherapist, and do INDIBA treatment [a non-invasive radiofrequency therapy used in sports rehab to treat pain and inflammation]. That helped me a lot so my body could perform at 100%. Of course, I also made certain changes to my diet," Santesteban said about how she managed her condition.

But there is no easy fix, and riders may not always find the support they need at their first port of call – perhaps their coach or team doctor.

"In my experience, understanding varies hugely. Some coaches and practitioners are very engaged and keen to learn, while others feel unsure or uncomfortable, often because they’ve never received formal education on the topic," says Smith, who is one of a small number of female health specialists working in professional cycling.

"As a result, responsibility often falls on the athlete to raise issues themselves, which isn’t always easy in high-performance environments. Education is improving, but it’s still inconsistent, and much of the knowledge currently comes from individual interest rather than structured coach education systems."

"Many team doctors are excellent clinicians, but most will not have received formal training in female-specific sport endocrinology or menstrual health in performance contexts. As a result, menstrual and hormonal health can sometimes fall into a grey area – not quite medical in the traditional sense, and not quite performance – meaning it isn’t always fully owned by anyone," Smith continues.

"This can leave athletes feeling unsure about where to seek support. Improving this doesn’t require every practitioner to become a specialist, but it does require education, clearer pathways, and greater collaboration between medical and performance staff."

As for what riders themselves can do? "Visit the doctor and don't normalise menstrual pain or even amenorrhea [not having a period]," Santesteban said.

Will understanding grow?

In the medical world in general – let alone the sporting world – conditions like PCOS and endometriosis are still in a relatively nascent phase when it comes to diagnosis and treatment, so it's perhaps not surprising that the understanding is even less when it comes to athletes.

However, no matter how slow or belated the progress may be, the depth of knowledge around women's health conditions and how female athletes' bodies are different from their male counterparts is growing.

A rider like Santesteban, who has been racing since 2008, has seen the understanding around women's health in cycling grow and change, even before having her own experiences with more complicated conditions.

"I think that more and more importance is being given to women’s health in cycling. Before, it seemed that not having a period was a sign of good performance, when in fact it’s the complete opposite," she said.

"Fortunately, that has changed, and in recent years, one of the first things the team doctor and nutritionist ask you about is your menstrual cycle. Progress has been made. It’s true that endometriosis is still not talked about that much in general, but this too will change over time."

However, for her, her own diagnosis and the gradually improving situation in women's sport, it came too late. She called time on her career at the end of 2025.

"It has changed me a lot, both as a woman and as a professional cyclist," she said. "Living with pain and having to make so many doctor’s visits greatly affected my mental health, and I saw it as unfeasible to continue down that path for another year."

Organisations like The Well HQ are working specifically to improve the situation for women in sport – at all levels, from recreational to professional – by working with various federations, coaches and stakeholders, and change is slowly coming, though barriers remain.

Teams like AG Insurance-Soudal, where Meg Smith works specifically with riders and staff to focus on female athlete health, are leading the way in incorporating the menstrual cycle and more into their performance, coaching and culture.

"There’s more openness around conversations, greater interest in cycle tracking, and increasing recognition that athlete health can exist in parallel to performance. That said, progress is still uneven," Smith explained.

"In many cases, improvements are driven by specific individuals rather than embedded systems. At the moment, how well an athlete is supported often depends on whether the right people happen to be in the room, rather than on consistent organisational structures. This is an important aspect of performance at AG Insurance-Soudal, and we are working hard to find innovative ways to think about female physiology in order to best support our riders."

For all that things are far from ideal – the lack of research and understanding we found just in trying to write this article showed that knowledge on this topic remains minimal in professional cycling – there is a feeling that women's sport is on the right path.

"Things are definitely improving," Perkins said. "We are seeing more and more coaches and organisations committed to not only understanding the unique needs of female athletes, but to creating environments that truly support these women. They are seeking knowledge and guidance on how to properly train female athletes, and the ones who have already started to do this work have been seeing incredible results."

Just this month, Smith launched a survey on female athlete health in cycling, helping her team at Loughborough University to originate research into menstruation and performance in cycling. Other sports, like athletics, football and rugby, are taking women's health and female-specific training more seriously every year, with tangibly positive results.

As the focus on women's health improves, research into menstrual disorders will surely eventually follow, and riders who find themselves in the same position as Ane Santesteban or Quinty Schoens will find the support and knowledge they need sooner.

Exercise is supposed to be good for you - and by most measures, it is. However, cycling has a little secret: too much of it is bad for your bones, and you might never know you're doing damage until it's too late.

What makes it so dangerous is that there are few to no symptoms of low bone density, it can occur at any age, and it is notoriously difficult to reverse, especially later in life. Demanding endurance sports like cycling and swimming are increasingly being studied to understand how they can negatively affect bone health.

In 2023, Spanish researchers published a paper entitled, 'One Season in Professional Cycling Is Enough to Negatively Affect Bone Health'. They followed 18 male professional cyclists aged 20 to 40 at the top level of the sport who had raced at least one Grand Tour in recent years, measuring their bone health using various tests during the pre-seasons of 2018 and 2019.

They found that over a single season, there was an overall decline in bone mineral density in these men, which followed previous studies on youth, masters and amateur cyclists and swimmers that showed similar results.

Although bone density can be a serious concern for men, it is even more so for women who face a normal drop in bone density during menopause when estrogen levels drop.

Osteoporosis can predispose sufferers to fractures, especially of the wrist, hip and spine, which can be debilitating and not what active adults who want to keep exercising for their health want. But to truly understand why cycling can harm our bones, and how to combat these negative effects, we first need to go back to basics.

What's in our bones?

Your skeleton isn't just minerals. They're made of hardened tissue containing living cells that constantly break down and form new bone. In the more porous core is the cancellous/spongy bone (trabecular bone) that includes your bone marrow, where your red and white blood cells are produced.

Around 80% of your bones are a hard exterior of 'cortical' or compact bone - it's what holds you upright and lets your muscles lever off them to move you around. Inside are microscopic tubes full of the cells called osteoblasts, which make new bone, and osteoclasts that break down bone tissue.

The strength of your bones starts early in life, with bone density peaking in a woman's early 20s or a man's late 20s. How at risk you are for low bone density (osteopenia) or osteoporosis depends on how strong a start you're given - a good diet and weight-bearing exercise are important factors in building strong bones.

Because your bones are a massive store of calcium, when you exercise, you need that calcium to fuel muscle contractions, and the calcium stored in your bones is critical for 'calcium homeostasis' - your body keeping up with the muscles' demands.

In women, estrogen appears to be important for maintaining bone health. Once women reach menopause and their hormone levels drop, bone density can decline rapidly. Hormone replacement can slow the decline, so it's important for women to speak to their doctors about bone density and get professional advice as early as their mid-30s.

Pro cycling and bone health are a not-so-perfect match

When you lift heavy weights, run, jump, or do other impact- or weight-bearing exercises, the strain stimulates osteoblasts to strengthen the bones. Conversely, long periods of inactivity, weightlessness like in space, certain drugs like glucocorticosteroids, age, and, for women, menopause, can shift the bones into breakdown mode.

Unfortunately, bike riding or racing isn't in the bone-promoting category and, according to research, can do just the opposite.

Even when riders are stomping on the pedals in a sprint or dancing up a mountain, the force on the bones isn't enough to stimulate bone growth, as it is with jumping or weightlifting, and intense aerobic efforts can cause the body to break down bone to fuel demand for its minerals elsewhere.

Professional cycling historically has embraced practices that put riders' bone health at risk: encouraging riders to be very light by restricting calories and discouraging weight training or impact sports during the season. The culture is slowly improving, thankfully, according to Therese Hammerschmith, the Head of Performance at Human Powered Health.

She explained how the team uses all the resources of the Human Powered Health labs to ensure the riders address all risks to bone health.

"That's something I'm really proud of our team for prioritising the health of the athletes first," Hammerschmith said. "We're powering human potential and health and performance by doing baseline assessments [on the team] every year just to see where they're at across the strength side, bone mineral density, resting metabolic rate, and the aerobic side of things as well. Then we can tailor the specific needs of each athlete, as well as the team overall, with what they need not only to be able to perform on the bike during the races, but off the bike as well."

Thanks to greater awareness of bone health, most pro teams have added bone density tests, such as DEXA scans, to their annual assessments to ensure riders aren't at risk of osteopenia or worse, osteoporosis.

"I think, because the conversation is getting louder and more prevalent, that we are moving in the right direction," Hammerschmith added. "When it comes to cycling overall, I would say that there's more attention being brought to this specific topic.

"The cycling season is so long that it wouldn't be uncommon to see some [bone density] decrease. I've seen the decreases happen year over year, but more so in those athletes that aren't prioritising also doing things off of the bike, such as [weight] lifting, even some Plyometrics, or even going for a run, maybe even once a week - things like that can really help offset some of those implications with lower bone mineral density.

"For us on the Performance Lab side of things, being able to give actionable data insights that can then be addressed by the medical staff, the nutritionist, and the sports coaches, to make sure that we are providing the appropriate training regimens as well as any other insights that we see that could guide those specific professions to serve the athletes really well."

The risks you can and can't mitigate

Some osteoporosis risk factors can be fixed, and some can't. A poor diet as a child can start you off with a lower baseline of bone density and set you up for problems later in life, especially if controllable factors like smoking tobacco, drinking alcohol and an adult poor diet aren't corrected.

Chronic use of glucocorticosteroids can increase the risk of osteoporosis, as can celiac disease, which, if untreated by a gluten-free diet, can prevent absorption of important nutrients like calcium and vitamin B12. There is also a risk in cutting calories or, as experts call it, 'low energy availability', which can disrupt hormones that help keep bones in balance.

Other aspects of bone health aren't easily remedied: being female poses a higher risk because of the potential for a rapid drop in bone mineral density during menopause. Ethnicity - especially for Europeans and Asians - and heredity can predispose athletes to bone loss, and small stature is also associated with osteoporosis. These are physical profiles of many pro cyclists.

Women are also generally smaller with less bone mass, making them more at risk for osteoporosis.

If you have untreated celiac disease, inflammatory bowel disease, kidney or liver disease, cancer or rheumatoid arthritis, you're also at higher risk for osteoporosis regardless of gender.

What can we learn from pro cycling?

First, according to Hammerschmith, athletes need to pay careful attention to their diet, not only ensuring they get all of the essential vitamins and minerals but also eating enough calories.

"If we don't have enough of the other fuel sources that help power our body, it's hard to have a well-functioning body," Hammerschmith said.

"We don't want people to go into low energy availability - because it doesn't matter, if you have enough calcium, you're not going to be able to perform at your best [in calorie deficit]. You want to make sure you're getting enough fuel overall - not taking in enough overall fuel can cause hormone imbalances."

Those imbalances can lead to RED-S (relative energy deficiency syndrome). It was originally referred to as 'the female triad', but severe caloric restriction can lead to RED-S in both men and women. While women have an easy early warning if menstruation stops, symptoms of RED-S in men are more vague - decreased performance, irritability, insomnia, depression or low libido. RED-S is linked to low bone density in both genders.

Other steps to maintain bone health include adding some impact exercise to an athlete's routine - add a few runs, plyometrics and weights into the weekly schedule. Some studies have shown that eating calcium-rich food or a calcium supplement before exercise can reduce how much your body mines your bones for calcium during efforts.

Human Powered Health take an approach of tailoring each rider's diet and training to their physiology, and Hammerschmith suggests that this can go a long way toward preventing a pro cycling career from negatively impacting bone health.

"I think that we're moving in the right direction, one, by talking about it and two, having more teams and more individuals screening for [bone density]. It shows care for the athlete and putting them first, and helping them have strong bones or putting on a little bit of muscle mass, which can be beneficial to them in performing.

"We need to take each individual as they are and make sure that we're fueling their individual physiology for their best outcomes, for success, both on the performance side as well as the health side."

Designed to be worn all the time, a health tracker can provide a comprehensive view of a rider’s health, offering data on lifestyle and recovery metrics. They can be useful for everyone, but when it comes to female athletes, where your monthly hormone cycle and vital stats can play a key part in performance, using tracking technology to really get in touch with your health can be a training superpower, but there are limitations, too.

The most significant factors for female riders are heart rate, heart rate variability (HRV), body temperature, and the menstrual cycle, many of which can be linked to hormonal fluctuations.

Health trackers are hugely popular and come in many forms, including smart rings, watches, and bands. In October last year, Oura, the leading smart ring company, reported revenue of over $500 million in 2024 as well as expectations for this to double in 2025. There are several other leading health tracker brands too, including Ultra human, WHOOP and Garmin.

However, while the metrics can be beneficial for female riders to understand their health, do these trackers also encourage an over-reliance on data rather than feeling, and pressure from constantly monitoring performance?

Training strain and pregnancy indicators

Let's start with two commonly used health metrics which can illustrate strain, training readiness and spot signs of illness: HRV and resting heart rate. For female cyclists, HRV data can help indicate signs of pregnancy and hormonal fluctuations, making it particularly useful.

Research on how wearables could monitor hormonal changes in pregnancy has shown that health tracker data could help identify abnormalities, especially heart rate.

Scientists at Scripps Research found ‘compelling’ evidence that heart rate data from devices such as the Apple Watch, Garmin and Fitbit correlated with hormonal fluctuations.

The team concluded that these wearables could offer methods to monitor pregnancy-related physiological and behavioural changes and could also enable early risk assessment for adverse pregnancy outcomes, including miscarriage and preterm birth.

I’ve also seen how a wearable can indicate the first signs of pregnancy: a friend was trying to conceive saw her HRV drop significantly into the red zone on her Garmin, tested and discovered she was pregnant.

Alongside hormonal fluctuations, heart rate data has also proven useful for identifying trends in a rider’s training strain and general health.

World champion track cyclist Neah Evans predominantly has used HRV data to keep tabs on her training and overall health.

"I export that data into a different app called HRV4U because it gives you the minute snapshot just before you wake up, and that's more accurate for measuring your trend," said Evans.

"It then automatically uploads onto my Training Peaks, which is also nice because it's available for my coaches to see if they so wish."

However, Evans doesn’t let the HRV data dictate her sessions, nor is over reliant on the data.

"I think the apps try to convince you to use that number as a dictator of how refreshed and how ready you are for a big session," she added.

"That doesn't work for me because my training is set, and although we have adjustability, I'm not going to turn around to my coach and say I'm not going to do those intervals because my HRV is compromised.

"But it will then mean I'm more aware of why my HRV is compromised, for instance, I know if I do a gym session, the next day it'll be compromised.

"If it’s down randomly, I'll spend a little bit more time checking in with myself. I'm not overly reactive to a one-off, but it's more the trends and understanding where I am in the training block and what it's going to tell me."

'Menstrual cycle tracking apps assume everyone's got a normal cycle'

Another key area where female riders could benefit from tracking their health data is with the menstrual cycle. Meg Smith is a doctoral researcher at Loughborough University and is writing a PhD on understanding the physiological and perceptual effects of the menstrual cycle in female cyclists.

Smith is currently running a survey exploring the effects of The Menstrual Cycle on Training, Performance and Health in Female Cyclists, and is also a female athlete health consultant for AG Insurance-Soudal, where she encourages riders to track their menstrual cycles.

"At World Tour level, riders have such an incredibly high training demand, and because cycling is so energy demanding they can struggle a lot with energy balance,” explained Smith.

"I think a lot of it is unintentional, but it's led to several riders suffering from chronic RED-S and amenorrhoea, which is the absence of periods, all of which makes menstrual cycle tracking very important."

RED-S, also known as relative energy deficiency in sport, was the reason for Veronica Ewers announcing at the end of last year that she was stepping back from pro cycling to focus on her recovery.

Health trackers typically use body temperature to help users track their menstrual cycle, while apps, such as Flo or Clue, rely on user input on cycle dates, as well as options to track many other cycles. Most wearable tracker apps also allow users to input data about their period, which can then be analysed against other stats.

"I've had issues previously, with RED-S, some irregular episodes and my body temperature used to just be like a bit all over the place,” said Evans, whose Oura ring helps her predict her period.

"Now, when it gets more regular, I've started to see a pattern again, so I know that my body temperature is going to increase and then drop, and then the next day, likelihood is I'll probably get my period.

"I'm not always the most regular with how long my cycles are, but I can see if I've had five or six days of increased body temperature, my period is probably going to come, whereas if my body temperature hasn't increased, I'm going to be late."

Smith agrees that body temperature can be a good indicator.

"We had a rider who wasn't tracking her menstrual cycle or any of the symptoms around it, but she started complaining that at certain points she was feeling really hot," explained Smith.

"When we realised the points at which she's feeling hot, it was always two to three days before her cycle. We've put something in place to support that, and if she has a race in that phase, we ensure that recovery is slightly different for her compared to the other riders."

However, she says to get the most accurate data, athletes need to use ovulation strips to show which menstrual cycle phase they are in. This is because women can bleed but not ovulate, which can lead to this being misinterpreted as a normal cycle.

"Menstrual cycle tracking apps assume everyone's got a normal menstrual cycle, everyone’s different," added Smith.

"For those who don’t have a normal cycle, and so who may be bleeding but actually going through a menstrual disturbance, the app tells them they've ovulated and that they’re in a phase which they aren’t. Without ovulation detection, you're never going to know that."

The number one metric to improve

Research has shown that sleep and hormonal fluctuations have a direct relationship, with the menstrual cycle affecting sleep and vice versa. Tracking sleep can also help show a rider’s recovery trends.

Evans has been tracking her sleep patterns since using an Oura ring.

"When I first started with these metrics, one of the biggest things that shifted for me was seeing the tracking of when I was going to bed and when I was waking up," she said.

"It’s interesting seeing how it shifts with different patterns like time zones and training camps. It’s something I’ve then worked on and found a real positive."

"It is the number one metric that everyone should try to improve," added Henry Latimer, cycling coach and coaching partner at Vekta.

"I don't think people quite understand how much you're supposed to have and how much they really get so sleep trackers are great as they can help you spot trends and identify where it relates to training."

Finding a balance

For a health tracker to work best, many brands say you need to wear them all the time to capture an accurate snapshot. They also send notifications and, much like a phone, are addictive to check but this constant surveillance and data output can put pressure on riders.

"I know athletes who will take off their device when they come to major competitions,” said Evans. “They don't want to know because at that point if you're two days out from competition, it's just going to build stress."

Latimer takes a similar approach and advises all riders to take a balanced view of them.

"These wearables can make extra noise and take away from the clarity of what an athlete is trying to achieve," explained Latimer.

"From a mental health perspective, removing or not using a tracker can relieve a bit of pressure because it is one less thing to focus on."

Just part of a wider toolkit

It’s also not just about managing how often riders look at the metrics but also their reliance on them.

"We've got so much data, and we live in such a data-rich society, it's so easy to be over-reliant on these trackers," said Latimer.

“Health trackers are part of a toolkit, and it’s important to put them in the context of how someone is actually feeling and to inform their training.

"My advice is to use them as a tool and as part of giving context to the way you're feeling but always use your feeling first."

Evans agrees and is mindful of over-reliance on her Oura ring.

"I tend to look at it in the morning because otherwise life happens and I won't go back to it, but I'll try and check in with myself first and see how I’m feeling," she said.

"Metrics like HRV are useful but not the definitive. I'll let them indicate certain things and use them as an extra tool, but I’m not going to let them dictate my life. I always trust what my body's telling me first."

Remco Evenepoel officially moves from Soudal-QuickStep to Red Bull-Bora-Hansgrohe on January 1, 2026. Unofficially, the work is already well underway to turn the Belgian superstar into a rider capable of challenging Tadej Pogacar and Jonas Vingegaard at the Tour de France, with the support staff analysing every facet of the 25-year-old’s performance in search of small but significant gains. That includes nutrition.

Here, we catch up with Red Bull-Bora-Hansgrohe's head of performance nutrition, Stephen Smith, to serve up the science-backed fuelling strategies that he claims will not only shape Evenepoel’s season, but could also help recreational riders cook up a new PB in 2026…

Welcome to Food Coach

What will the move mean for the Belgian’s menu? Presumably, very little when it comes to the time trial. "I’ve been eating the same thing before a time trial ever since I was a junior," the Evenepoel commented in 2023. "They are ‘pistolets’ with jam, a banana, some honey, half a litre of Fanta and slices of chicken fillet. It turns out to be a good meal to prepare for a time trial, because when I eat it, I almost never miss the podium." A pistolet is essentially a bread roll.

Despite what the data might say about Fanta and its fuelling qualities, they’d be foolhardy to change something that’s historically given the Belgian such rapid wings. What Evenepoel will discover is that he has many experts to turn to in search of optimising each and every session.

"We’re lucky on this team as we have five nutritionists. Some teams might only have one," says Smith, who recently took up that head of performance nutrition role after working across Red Bull’s Athletic Performance Centre for the past five years, where he fuelled a range of athletes from MotoGP riders to skiers, downhill mountain bikers to triathletes.

They’ll be in attendance at the team’s pre-Christmas training camp, where new riders will be introduced to the team’s Food Coach app. The app was originally developed in 2018 for Jumbo Visma (now Visma-Lease a Bike) in collaboration with Jumbo Supermarkets. The German-licensed team have been using it since early this year, arguably driven by Asker Jeukendrup, who formerly worked for the Dutch team where he contributed to the app before taking up his current position at Red Bull-Bora-Hansgrohe as Director of Sport Strategy in October 2024. This, says Smith, provides the basis for ensuring riders have a rich and varied diet while hitting performance goals.

"You can select from a large range of recipes whose macronutrient content is based on your training session, so calculated via the effort duration and your average power output," he says. "It achieves this by syncing with power software like TrainingPeaks."

This ability to match input to output is key to periodising nutrition, which is simply the concept of your diet reflecting your training workload and physiological aims. "We put the goal of the session at the centre," says Smith. "So, what is the adaptation we’re looking for? Then, how can we tailor the nutrition before, during and even after a ride to make sure that we maximise those adaptations? That will change depending on the focus of the year or, more technically, the macro cycle."

Limiting to liberate performance

We’re in mid-November as I type this, which means no racing unless riders are moonlighting on the cyclocross circuit.

"In general, that means training intensity is a little lower, so we might use this time of the year to target enhanced adaptations," says Smith. "That would include carbohydrate-restricted training for specific riders."

Well, there’s a term you might not have heard for a while. ‘Carbohydrate-restricted’, ‘glycogen-depleted’ or ‘fasted’ training, where activity is carried out with low levels of stored carbohydrates in the body. It previously dominated the WorldTour nutritional narrative for years, ostensibly from Team Sky’s application and them working with James Morton, professor of exercise metabolism at Liverpool John Moores University, who now works with Manchester United.

The Belfast nutrition guru worked with the British team for years and, through his academic and practical work, was a strong proponent of reducing carbohydrates to stimulate cycling gains. Of course, the idea of cutting carbohydrates is at odds with the zeitgeist for carbohydrate overload, but this is off the bike, not on it and is applied at a time of year that’s ideal for tapping into the mooted gains, namely the off-season.

Those targeted adaptations Smith referred to are, according to a recent paper led by Morton, entitled ‘UCI Sports Nutrition Project: Nutritional Periodisation: Strategies to Enhance Training Adaptation and Recovery’, numerous and include cranking up mitochondria numbers – a boon for riders as these are the energy powerhouses of the cells – and retraining the metabolism to focus more on fats. These changes are activated by reduced access to glycogen, amplifying these molecular signalling pathways.

Interestingly, for those of you who believe in the power of glycogen-depleted sessions, Morton and his co-authors cite a recent review of the literature by Javier Diaz-Lara and his team that noted "absolute post-exercise muscle glycogen concentration may be more of an influential factor" than pre-riding glycogen concentration and that "adaptations associated with carbohydrate restriction are particularly evident when the pre-exercise muscle glycogen concentration permits exercise-induced depletion to post-exercise concentrations that are less than 200-300mmol/kg dry weight".

Arguably, measuring your blood-glucose levels in search of that 200-300 figure at the end of every fasted ride is unrealistic for the majority of riders, albeit there are continuous blood-glucose monitors available like those from Lingo and Ultrahuman.

The authors also note a reason why glycogen-depleted training had fallen off the media radar: that there’s limited evidence that these physiological adaptations result in performance improvements. But they contested, "Given that the metabolic adaptations associated with 'train low' are especially relevant for prolonged cycling (i.e. increased muscle oxidative capacity and lipid oxidation), future studies should utilise performance testing protocols (e.g. exercise durations of four to six hours) in which such physiological adaptations are more likely to translate to improved exercise performance."

Choice of underfuelling

There are various theoretical models of carbohydrate periodisation – the fasted model whereby you ride before breakfast; twice-per-day model that involves a morning ride, minimal feeding after followed by an afternoon ride; sleep low model where you ride in the evening, restrict post-ride feeding, sleep and then ride again before feeding; and the recover low model, whereby you ride as normal but restrict carbohydrate feeding after. Smith highlights that some of his riders will generally ride for two hours fasted before feeding when carrying out glycogen-depleted sessions.

Like any adaptation, its root cause is stress. This is why glycogen-depleted training is generally at low to moderate intensity. Too intense, and your immune system can suffer. That’s something Smith considers at Red Bull, which is why he advises limiting these sessions to a maximum of twice a week during the off-season. "We’ll often restrict for the first couple of hours of that ride and then start to introduce carbohydrates.

"But whether we use that strategy or not also depends on their role in the team and [the] rider’s physiology," he adds. "It doesn’t always make sense for a sprinter or a Classics rider to be racking up hours of low-carbohydrate or fasted training, unlike a climber, say. Another thing to consider is training history. If a rider’s experienced, we’ll often do it; if they’re a young rider with a relatively minimal training experience, we might not.

"The thing is with elite cyclists, it’s something that they’d have done from a very young age when they’re simply cycling. They’ll get up, go out on their bike for a few hours and generally not take any carbohydrates. In general, the elites can tolerate a fair duration on low feeding, certainly lower than someone like myself, a hobby cyclist."

Smith says that while carbohydrate intake might vary throughout the season, protein and fat intake remain relatively constant, though he stresses that the elites will naturally consume far more protein than Everyman, at a rate of 2.5g of protein per kilogram of bodyweight compared to 1.6g.

Monitoring fluctuations

The application of fuelling science, married with app usability, is why riders turn up at the Tour Down Under in January looking leaner than in times gone by. It’s also one reason behind the ever-increasing speeds in the peloton. Whether that all-year-round lightweight maintenance is conducive to long careers remains to be seen, but it’s something Smith is aware of.

"As well as weight, we monitor the riders’ body composition throughout the season, not only for performance reasons but more importantly, health," says Smith. "We do that via two means. One is DEXA, where we can also monitor bone mineral density, and the other is callipers, more specifically, the ISAK method. You take eight measurements – six on the upper body, two lower body – and you’re given an accurate average."

Smith says there’ll be dialogue with the riders about how their bodies are responding to changes in training and fuelling strategy to discuss "the best composition for them in each scenario. There’s interaction between the nutritionist, coach and the DS, and we try to understand what the role of that rider is for each specific race and then make sure that their weight and body composition are appropriate for each scenario.

"For instance, for the Spring Classics we might want a domestique that little bit heavier, including a higher level of body fat, to battle the weather and the terrain. We’ll look to drop that for the Tour de France and the mountains, as not only do we look for them to deliver GC riders into key positions come the bottom of the climb, they must also be able to survive the climbs themselves to make the cut-off."

That’s not a new idea. I recall chatting to Rob Child, then nutritionist at the Cervélo Test Team, who revealed how they prepped Thor Hushovd to win his second green jersey in 2009, despite the stiff and rather fast competition from Mark Cavendish. "Because of Cav’s speed, we devised a strategy that moved away from simply going for wins on the flat stages," he said. "That plan involved helping Thor lose 3kg in the final few weeks before the 2009 Tour de France."

Hushovd was regarded as a Classics specialist where muscle mass is an advantage. Come the Tour, his body fat nestled around the 6% mark. "That was due to losing some muscle mass as well, but we’d accounted for that, and it didn’t affect his power. On the contrary, his power-to-weight ratio went up, which meant he could climb much more effectively in the mountains."

It allowed the Norwegian to rack up significantly more intermediate sprint points than Cav. "He lost every single final sprint to Cav [who won six stages that year] bar one," said Child. "But with our weight-reduction tactics, he won the green jersey."

How a rider’s weight ebbs and flows throughout the season was the focus of a 2021 study in the Journal of Clinical Medicine, where nine well-trained male cyclists’ weight dropped by an average of 12.44% from the base period to the main competition phase. The body fat reduction, from 10.73% to 9.17%, stemmed from burning off around 1kg of fat (7.84kg to 6.62kg). As aerobic capacity (VO2max) features a weight component – lose weight, boost VO2max – that grew from 65.78ml/kg/min to 69.67ml/kg/min. What this meant for performance wasn’t included in the study, but, in theory, it should mean more sustained speed.

More is more

As the race season approaches, glycogen-depleted sessions are put on the back burner; instead, there’s a greater focus on carbohydrates, especially during rides, with Smith a proponent of increasing how much the likes of 2025 Tour de France third-place finisher Florian Lipowitz and multiple GrandTour winner Primož Roglič can tolerate in an effort to delay fatigue.

"If it’s a new rider, we might start by analysing how much they can tolerate via testing at the Red Bull Athletic Performance Centres," says Smith. The cutting-edge sports science facility operates at two main locations – Salzburg, Austria, and Los Angeles, USA – and is a data-driven dream where athletes have access to advanced biomechanics testing and performance diagnostics. "We might start off with a little trial-and-error of what they can tolerate, but it’s a good platform on which we can look to gradually increase their carbohydrate intake without causing gastro distress."

Smith says they look to crank up carbohydrate intake both before and during the session. "Part of gut training is increasing the activity and expression of transport proteins in the gastrointestinal tract," adds Smith. "These are responsible for transporting the carbohydrate through the gut into the blood."

More specifically, glucose and fructose – a common energy product formulation used by many manufacturers, including MNSTRY, who fuel Red Bull-Bora-Hansgrohe – are absorbed in the small intestine via transporters SGLT1 and GLUT5, respectively. Research shows that consistent exposure to high carbohydrate loads increases the abundance of both, which is one reason behind the increased carbohydrate rates.

Typically, teams will target one or two sessions at different times of the year to crank up carbohydrate intake, which not only raises the activity of these transporters but also forces the stomach to become better at pushing fluid and carbohydrate into the small intestine for, in theory, greater carbohydrate absorption and less risk of nausea, bloating, sloshing or cramping.

Supplementing speed?

Supplementing with carbohydrates is a proven performance-enhancer. But what about supplementing with other mooted ergogenic aids? How do the likes of Smith determine what’s touted by marketing teams as a game-changer without treating their valuable assets – the riders – as guinea pigs?

"There are various steps we take. We’d start by looking at the mechanism behind the claimed benefits and the body of evidence. What methods have been used to research that end product? We’d look for randomised control trials as a gold standard for assessing the likelihood of it being effective."

A randomised controlled trial is a study where subjects are randomly assigned to one of at least two groups: a treatment group and a control group (placebo). This means each of the triallists has an equal chance of being placed in either group, removing potential bias. The outcomes of the groups are then compared to see if the intervention made a difference.

This heightens the chances of proving whether a supplement is of benefit or not. But it’s not infallible. As Smith knows only too well from his academic background at Liverpool John Moores University, the university students that are the predominant cohort of many studies are a very different beast from elite cyclists, whose physiology is so finely tuned that they have less bandwidth to grow than the rest of us.

"Luckily, we have access to the performance centres that have their own research and innovation departments. We can use higher-level athletes, plus we can obviously test the claims of products, which might be needed if the only evidence of that product working is from that company’s research."

For most riders, including us amateurs, Smith says a good general diet that contains a hearty mix of macro and micronutrients negates the need for the majority of supplements, albeit immune-boosting vitamin D should be a staple during wintertime.

All in all, Smith says periodising nutrition is a useful strategy to optimise performance, whatever level of rider you are. At its basic level, it’s about shifting that carbohydrate slider up and down depending on workload and physiological goal. High carbohydrate intake before and during high-intensity efforts results in better-quality sessions and higher power outputs. Low-carbohydrate training efforts in targeted sessions boost fat oxidation and mitochondrial adaptations that will lay the foundations to optimise those harder sessions as race season approaches. Do that and you’ll crank up your chances of riding up the results listings. Will a change of nutritional scene have the same effect for Remco? Watch this rather rapid space…

Pro cycling has an unfortunate association with crashes. High speeds, a big peloton, and very driven athletes taking every chance to win does result in some riders exceeding the limits of grip and space available, resulting in crashes. There, of course, have also been concerns about course design and safety, with riders and rider unions calling out what they deem to be unsafe racing conditions that have led to crashes. It’s not just in the races as well, but out in training, sometimes crashes happen and can have serious ramifications.

But how do riders recover from these, sometimes very serious, crashes? We’ve seen incredible cases of riders winning races just days after fracturing an elbow, completing a Grand Tour with a fractured back, and riders returning from crashes most medical professionals would deem as career-ending, in less than a year.

The damage that these crashes can do

Injuries in sports are certainly not uncommon. We see in football various ligament injuries or muscle strains that can take athletes out for weeks, while tennis star Andy Murray was plagued by injuries and hip problems in the latter stages of his career. High-impact sports like rugby have become almost synonymous with concussion incidences, while track and field athletes are commonly plagued with tendon, ligament, and muscle issues. However, there are not many sports, outside of those deemed on the more extreme end of the spectrum, where there is quite such a common occurrence of broken bones as road cycling. More than 150 riders jam-packed on roads, sometimes one lane wide, racing at average speeds of 40-45kph and exceeding more than 80kph on descents, all jostling and fighting for position to continually move up.

The only protection they are afforded, some wafer-thin Lycra that covers half their body and a helmet on top of their head. An inevitable result of this is that almost every single race features a crash, and in those crashes, it is not uncommon to see a high incidence of broken bones along with bruises, cuts, road rash, and concussions. In the most serious of cases, riders can suffer truly horrific and traumatic injuries, known as Polytraumas, which not only put their careers at risk, but also their lives.

Recently, a new scientific research paper looking into polytrauma in professional cycling was published, assessing the impacts of these significant injuries on riders both in the short and long term. Though the cyclist in question is not specifically named, the identifying details confirm that the rider in the study is Egan Bernal (Ineos Grenadiers), who suffered a horrific crash while out training in 2022 that very nearly put an end to his already stellar, but still very much young, career.

In this paper, the full extent of Bernal’s injuries are looked into in quite incredible detail. An Injury Severity Score (ISS) is also given, with a total score of 41. To put that into context, ISS scores are determined from 1 (minor injury) up to 6 (incompatible with life). This is then applied to nine regions of the body: “head, face, neck, thorax, spine, abdomen/pelvis, upper extremities, lower extremities, and unspecified.” This means the maximum score that can be given is 54, so a score of 41 averages 4.5 for each region, putting this rider mostly in the category of Severe to Critical injuries across the body.

As for the term ‘polytrauma’, this has been defined in the paper as “injuries suffered from a high-energy trauma which affects two or more organ systems accompanied by an ISS of more than 16 points, successfully predicting a mortality rate of >10 %.”

This puts into haunting perspective just how terrible these injuries can be. Just a few of the injuries Bernal sustained included a fully displaced patella fracture, a clean break of the femur, eleven fractured ribs, along with broken vertebrae and spinal disc herniations.

This is one of the worst-case scenarios when a crash occurs in cycling. Most commonly experienced are broken collarbones due to putting the arms out to break a fall, with contusions, road rash, and concussions also being not uncommon in cycling injuries. What is most astounding in the case of this polytrauma study and Bernal is that after just ten weeks of recovery, he was able to cycle again. Then, seven months after suffering this list of extensive and highly severe injuries that were genuinely life-threatening, he returned to competition.

How do riders recover from these injuries?

So just how do cyclists recover so quickly from such horrendous crashes and injuries? To get some more insight into this, we spoke with Jan-Niklas Droste, then Director of Health and Performance at Red Bull-BORA-Hansgrohe. He explained that the process starts from the moment the crash occurs, where, along with the first aid provided by the race organisation, the team also rely on their own medical team with extensive traumatological training and experience for on-site care.

“It is important for us that we can provide the best possible support for the athlete and the necessary care at a very early stage with our internal expertise and network.”

This requires not just internal staff within the team, but also relying on a network of expertise to determine, in each specific case, what is required for the individual and the injuries that they have encountered. It may be covered by the on-site team provided by the race for lesser injuries, or team staff may be required for further checks and care. In cases where surgery is required then a balance is determined between how rapid a response is required, or if further travel for more specialist treatment that will result in a faster and safer Return to Sport (RTS).

It's well known that after these injuries occur, there is then a far longer process of recovery from them. Initially, while the bone is healing, it is common that riders feel more lacking in energy. This is due to an increased metabolic demand as the healing process begins. There is an inflammatory response, an increase in cellular activity, greater nutrient demands, and the formation of new blood vessels in the afflicted area to increase blood flow and healing. All of these increase energy demands based on the severity of the injury and can increase levels of fatigue as well as energy requirements. This is why it then becomes essential for riders to work with team dieticians to best determine a diet that will enable adequate recovery while meeting the new demands of their healing body.

Beyond that, there is a process of strength and conditioning (S&C) to make sure that the body can repair itself in the best way possible. The issue faced with broken bones, and especially immobilisation of any sort, is that it is often then followed by muscle atrophy and imbalances, especially with unilateral injuries. For example, breaking one leg can result in greater muscle loss in that leg while the other still takes on forces and becomes relatively stronger. A proper rehabilitation programme is then required to address these imbalances and also strengthen the afflicted part of the body. In fact, Droste did confirm that off-bike work is used to speed up the rehabilitation process after an acute injury.

Another strong benefit linked with S&C work is injury prevention. Although this is sometimes a difficult one for teams and athletes to buy into, since there are old-school and evidence-based approaches that can’t necessarily determine if it prevents an injury that might never occur. Did it not occur due to S&C, or did it just not occur? In a sport where time is an investment, investing this time in something that does not actively show results for injury prevention can be a hard sell.

“Prevention is such a big topic and is definitely very important. What makes it so difficult to organise prevention efficiently? Because good prevention means that we minimise the risk of something negative happening. So if we do good prevention, nothing happens. That is psychologically difficult. Precisely because prevention usually means doing ‘more’ or doing things ’differently’. The structure of many sports is often very experience-based and tradition-driven,” added Droste.

He followed this up with a fairly comprehensive support of S&C, though, “Is off-bike work important: yes.”

Can different recovery methods rush the recovery rather than allow full healing?

Sometimes, however, it can almost seem like these recoveries happen far quicker than would be expected. Uno-X Mobility's Jonas Abrahamsen, for example, was nearly a non-starter for the 2025 Tour de France due to breaking his collarbone just three weeks before the Grand Tour. In this situation, he had the fracture pinned or plated – it was only confirmed that he had surgery – to keep the bone structure in place and allow it to heal without the need for a sling. After seeing an expert in Manchester, he was deemed to be making an exceptionally fast recovery. Some of this could even be to do with his confirmed adequate fueling, as insufficient energy and nutritional intake can slow the repair of broken bones. It also worked out brilliantly for the team, with Abrahamsen delivering a first Grand Tour stage win on stage 11, likely bringing in greater return on investment for current sponsors as well as great bargaining power for additional sponsorship down the line.

However, there are risks to this rapid recovery approach that have to be balanced and weighed up. Droste again provided very useful insight in regards to this, as their motto for recovery is: “as quickly as possible without taking uncontrolled risks.”

That’s where things become a bit more difficult to assess. The best way to heal a broken bone is to have it placed in the right position in the event of a displaced fracture and allow it to heal in its own time. This process normally results in a stronger area of the bone due to an increased deposit of bone mass in the fracture site. However, it takes time, more often than not at least six weeks, which in the WorldTour is a lengthy period of time to not be able to train to your best potential or compete. There can be pressures for both riders and teams to get a rider back in action as quickly as possible. A very saturated race calendar with team rosters stretched thin can provide pressure on teams to have riders ready to race, while contract insecurities and a drive to win can also pile pressure onto the riders.

Surgery for broken bones has been used within cycling very successfully, but there are risks. In the event of a second crash and damage to the fracture site, the potential impact to the area will be significantly greater if the bone is still pinned, plated, and healing. This itself then has potential complications for long-term recovery. Does the risk outweigh the reward, or is it worthwhile?

Is there pressure, internally or externally, that riders race on with broken bones?

This brings us on to another interesting discussion, about who makes the decision of what processes and steps to take, and whether there is any pressure on the rider to make a rapid return to racing.

A good example of the rapid approach paying off is Annemiek van Vleuten, who in 2022 at the World Championships crashed in the team time trial and fractured her elbow. She then lined up for the road race a few days later, elbow heavily bandaged up, and went on to win the title with a searing attack in the last kilometre. It was a heroic victory and a true feat of grit and determination, but only because it worked out. Had she crashed and caused further damage, there would likely have been an onslaught of online discussion around the decision.

To get an opinion on the matter, I asked Droste about who makes the call on a decision to race with an injury like this and if there is any pressure on the rider from the team or vice versa to race? He was very open in stating that in these situations, he has never experienced it being one-sided and that at the team, they put a heavy emphasis on gathering as much information as possible and then considering that to make the best decision possible. A lot of elements need to be considered, such as how tolerable the pain is, whether it will have long-term negative effects, and does continuing to ride create risks for not just the rider, but other riders as well.

“It is crucial that all parties involved have the best possible information available to make a good decision that is right for this case.”

What long-term effects can these crashes have?

Going back to the rider in question and the specific injuries that they suffered raises the question about what long-term effects these injuries can have. Bernal has been fortunate to return to a competitive level in the WorldTour, although arguably not the same level that he once was. Chloe Dygert (Canyon–SRAM zondacrypto) is another example of a rider back winning at the highest level in the Women's WorldTour following her crash that saw her sever her quadriceps muscle during the 2020 UCI Road World Championships time trial in Imola, Italy. However, she is still hampered by this injury, notably needing to withdraw from the 2025 Tour de France Femmes due to the pain she was experiencing.

Meanwhile, Chris Froome (Israel-Premier Tech) has not come close to the form of his glory days, which won him four Tour de France titles, since his 2019 crash. In recent weeks, the 40-year-old was involved in another serious crash whilst out training, suffering broken bones in his spine and ribs as well as a life-threatening rupture to the lining around his heart.

The paper on polytrauma paints a fairly bleak portrayal of return to competition and form after severe injuries. Looking at 207 athletic individuals, although they were deemed ‘athletic’ by achieving a Tegner Activity Score of more than five, which is still far lower than the score of 10 deemed for elite-level competitors, it was found that after suffering traumatic injuries, most did not return to sports. In this case, the average ISS score was 22.8 compared to Bernal’s 41, and out of those 207 individuals, 59.1% did not return to sport at all, while 53% felt they did not return to pre-trauma levels of performance.

However, looking at the spinal injuries that Bernal suffered, at present, there is no documented case of an athlete ever making a competitive return to sport after injuries of that severity level.

What is the mental toll from these crashes?

Another element to these crashes and the recovery from them is the mental toll and effect that they have on the athletes. Ellen van Dijk retired in 2025 with immediate effect, citing fears of crashing and sustaining further injuries as a factor in her decision. German 21-year-old rider Louis Kitzki also made this decision to retire, after the deaths of Samuele Privitera and André Drege in races. For riders who suffer these horror crashes themselves, it can be a long road back to recovery and being able to put themselves in a situation where they may be susceptible to further crashes.

A study by Peter Hudson in 2021 looked into the impacts of crashes on cyclists, both physically and mentally. The key findings actually suggested that the greatest barrier for these cyclists when it came to a return to competition was a psychological one, with anxiety, sense of vulnerability, and a fear of crashing again as the main concerns, rather than the physical injury itself preventing a return to performance. A fear of cornering too fast, what other cyclists might do in the bunch, unknown road conditions and hazards, and not wanting to experience the pain of crashing and the labour of the rehabilitation process were all considerations when it came to why these psychological boundaries existed. It was determined that the best approach for these riders would be to seek psychotherapy.

This approach is also echoed by Droste: “I am a great advocate of providing athletes with psychological support in the event of injury,” although it depends on a case-by-case basis, as is much of the recovery process from crashes.

A good example of how this mental aspect of crashing can impact riders is Thibaut Pinot. After his breakthrough at the 2012 Tour de France, much was expected of Pinot, but one area where he lacked performance was his cornering. He was visibly cautious around corners due to a worry of crashing, and even went through the process of getting advice and instruction from racing drivers on how to improve his cornering. At the 2025 Tour de France Femmes, Sarah Gigante also showed that descending at speeds and cornering were not among her strengths, despite her exceptional climbing prowess.

This is mirrored by demon descenders such as Tom Pidcock (Q36.5 Pro Cycling), Matej Mohoric (Bahrain-Victorious) and others who appear able to descend far quicker than other WorldTour riders while using the same equipment, having the same grip, but able to push themselves closer to that limit with less fear of what might happen if they cross it.

Do riders have any contract security around crashes?

This is an interesting one, as the CPA (Cyclistes Professionnels Associés), who work to safeguard professional cyclists, have a document which details certain safeguarding measures for cyclists in the event of a crash. The minimum requirement from teams that employ athletes as riders for the team is to offer 3 months of full pay, followed by 3 months of half pay, as long as it does not dip below the minimum salary. This minimum wage for employed riders is €44,150/year and €35,721 for neo-pros – €38,000 for a Women's WorldTour pro and €31,768 for the equivalent neo-preo – but the injury pay for different riders at different teams will vary based on the contract. This is a minimum requirement to protect the riders.

But there is an important consideration here, and that is the term ‘employed’. The reality is that quite a lot of professional riders are actually self-employed and contracted by the team. This comes with a higher minimum salary of €72,404 and €58,582 for neo-pros in the men's top-tier, with self-contracted female riders earning €62,320 and €52,000 respectively. The reason for that higher salary, however, is due to riders needing to then cover their own salary if they can’t ride, and also needing to take out personal insurance in the event of an injury. In a sport such as cycling, where crashes and broken bones are not uncommon, this insurance will not be cheap.

However, if a rider is coming to the end of their contract, there appears to be no securities in place for these riders save for their insurance, either from the team or personal. A team is under no obligation to offer a rider a contract extension if they are injured during the final few months of their contract, but equally, there are no clauses under which a team can terminate a contract based on a rider's injury. It would require an amicable agreement between both parties. Additionally, insurance for the rider provided by the team is required to cover a minimum of €100,000/year of medical fees, along with a minimum of 12% salary for pension, and a €250,000 payout in the event of an injury that causes permanent disability or death.

Where does this leave us?

In a sport where such traumatic injuries occur, to the extent that they would be medically classed as life-threatening, it is truly incredible to see recoveries where riders can return to such a competitive level, over the span of comparatively short spaces of time. It’s a true testament to the healthcare professionals and medical expertise at the disposal of WorldTour cycling teams.

However, it does beg the question from a longer-term perspective, as well as a mental health one, of how these rapid returns impact a rider. Protections are in place for riders who are within the span of their contract, but for those nearing the end of their term, there are worries to be had. Add to that an increasing race calendar, relegation battle for points stretching teams thin, and a continual search for sponsors mainly reliant on race results, and there are pressures placed upon riders externally and internally to return to sport possibly quicker than would be medically recommended.

Teams take a rider well-being approach first, but there is a distinct lack of long-term studies looking at the effects of these rapid returns to sport after injury. Certainly, the mental component of the risk of these crashes has been a contributor to the retirement of several riders just this season.

The past few seasons have seen several high-profile professional cyclists open up about their struggles with mental health.

Mark Cavendish revealed he battled clinical depression following his struggles to regain form after suffering from the Epstein-Barr virus; Tom Dumoulin retired due to burnout, repeatedly stating that he was "mentally exhausted."

More recently, younger, less experienced riders have struggled earlier in their career too. Prodigious cyclo-cross star Fem van Empel is currently on a hiatus from racing due to mental pressure, whilst Leo Hayter stepped away from the sport and Ineos Grenadiers in August 2024, revealing a five-year battle with depression, anxiety and disordered eating. Positively, he’s now actively seeking a return to professional racing, appealing to teams to let him race the Chrono des Nations this October in search of a permanent place next year.

Given that those are just examples of riders who have spoken out publicly, just how deep are the mental health issues in professional cycling? And, in a sport that prides itself on self-flagellation, what’s being done to address the pain that lives with riders beyond a training session?

More shattered than collarbones

"If you’ve been racing for over 10 years, the chances of breaking your collarbone are around 25%. Is that the worst ‘injury’? Not when you take into account the lifetime risk of a cyclist suffering from depression. That’s around 27.8%." Those are the words of Professor Dr Michael Liebrenz, head of the department of forensic psychiatry at the University of Bern in Switzerland.

Liebrenz has helped to establish the Swiss Mental Health Hub, which offers confidential consultations and educational outreach. It’s targeted at the Swiss national team, but he helps riders all around the world, many of whom share common issues.

"In our systematic review, the rates of self-reported substance use or addiction-related behaviour among cyclists was around 20 to 22%," he adds.

What Liebrenz sees, especially in riders dealing with insomnia, anxiety or depression, is a pattern of reliance on prescription medications like benzodiazepines or Z-substances, particularly around multi-stage races.

"Anecdotally, there seems to be a fairly relaxed prescribing culture during long tours, often with limited explanation or tapering guidance. Riders may sleep better for a week or two, then return home and face abrupt discontinuation, rebound insomnia or even mild withdrawal symptoms," he explains.

"In rare but serious cases, this has evolved into longer-term dependence or combinations with other substances," he adds. "One case we reviewed involved both benzodiazepines and cocaine. But in most instances, it’s not about reckless abuse. It’s about small, cumulative coping strategies in a high-pressure environment where seeking psychological help is still seen as a sign of weakness."

Performance equals pressure

However the mental health disorder manifests itself – eating disorder, overtraining, substance abuse – riders often share an underlying neurobiology, says Liebrenz, especially when performance becomes the athlete's only strategy for emotional regulation. In that kind of setting, the slope is slippery.

"It’s a super performance-oriented environment, which places a lot of pressure on the rider," he says.

This could include earning a new contract, achieving the team’s race goals on any given stage, or sponsor exposure so the team doesn’t fold. Injuries are always a high-risk pressure, as are the extra stresses of a Grand Tour. That’s where Adam Hansen comes in. The Australian holds the record for the most Grand Tours in a row – 20 between 2011 and 2018 – and knows more than most about the oppressive environment it can be.

"Race the Giro d’Italia, Tour de France or Vuelta a España and you’re away from home for around four weeks," Hansen says. "You might arrive on the Tuesday before the race starts. During that time, you’ll have team presentations, media commitments, and time with the sponsors.

"As soon as you wake up, you might have 15 minutes free, and then you have breakfast. You’re then surrounded by people, which isn’t always great for many pro cyclists who are naturally introverts.

"You jump on the bus, again surrounded by people. As you leave the bus, everyone’s screaming at you, wanting attention. The quietest moment is actually when the race starts and is often the most peaceful time for a rider."

It’s a pressure-cooker situation, exacerbated by heat and increasing fatigue. But one of the growing issues is the modern phenomenon of social media.

"It comes with permanent insecurities and must be managed," Liebrenz says.

There’s also the growing understanding of neurodevelopmental disorders like ADHD (attention deficit hyperactivity disorder), which can lead to or exacerbate mental health conditions like anxiety and depression.

Joey Pidcock, brother of Tom, who also races for Q36.5 Pro Cycling, was diagnosed with ADHD in late 2023. He was put on medication and began seeing a psychologist. "It was as if I suddenly stopped walking through three-feet deep water like I had all my life," he wrote on his Instagram feed. "Before, I always felt depressed and unmotivated."

The fast-paced, intense environment of cycling arguably attracts individuals with ADHD-like traits, such as hyperfocus.

"If properly diagnosed, a lot of cyclists would probably be shown to have some form of ADHD," EF Education-EasyPost team boss Jonathan Vaughters has commented in the past, while revealing that he was diagnosed with a form of Autism Spectrum Disorder in 2018.

"I suspect that up to 20% of the peloton could have ADHD," Liebrenz says.

High hours equals higher risk

Concussion could be another cause of mental health disorders, says Liebrenz, as could a rider’s training load. "We’ve recently undertaken research that examined if there is a link between hours trained and mental health," he says. "There is."

Along with a team at Harvard University, Liebrenz looked at 531 endurance athletes, across cycling, triathlon, running and skiing. They were assessed using the Patient Health Questionnaire, which screens for depression, and categorised their weekly workload into one of the following five categories: zero to seven hours; eight to 10 hours; 11 to 13 hours; 14 to 20 hours; and 21-plus hours. The results were stark.

"Under seven hours, around 5% displayed symptoms of a mental health disorder. Between eight and 13 hours, it was around 11%. Between 14 and 20, you’re looking at around 20%, which grew to 26% when training over 21 hours per week," he explained.

This is arguably every professional at the WorldTour level, where the women average around 25,000km and the men 30,000km.

"It’s clear, progressive rise in risk. When physical pain was part of the picture, too, that risk skyrocketed, with nearly one in two athletes above the clinical threshold.

"I don’t want to jump to conclusions about why this happens – there are likely multiple interacting factors, both physiological and psychosocial – but the trend is too strong to ignore," he adds. "My main goal here is to raise awareness: high training volume, especially when combined with pain, should be treated as a potential warning sign, not just a badge of dedication. We need to monitor athletes better, not just for overtraining syndrome or injury, but for the mental health risk that can build quietly under the surface."

Is that 21-plus-hour benchmark the cause or effect of that 26% figure? Are highly driven individuals, who heap huge amounts of pressure on themselves in search of the unreachable – peak performance – attracted by the huge volume of training? Or do the many hours of inflicting pain on oneself, with one’s own thoughts, take a mental toll?

Whatever the reason(s), one thing is clear, says Liebrenz: you can’t out-train a mental health disorder.

"Riders are used to suffering; they accept it’s something they need to do and think the torture is all part of the game. But those hard training sessions, those hard intervals, can delay them from seeking help. They believe that is how they should feel."

Assessing a rider’s mental health

What’s being done to address the issue? Like other sports, historically, there’s been a paucity of mental health initiatives across professional cycling.

"This was compounded by stigma and adverse sociocultural attitudes, often leaving riders exposed to psychiatric vulnerabilities during and following their careers," says Liebrenz. "Thankfully, progress is being made. The UCI now recommends that all teams screen their riders at mandatory medical examinations using the Sport Mental Health Assessment Tool. This directive aims to help facilitate early detection and prevention of mental illness in elite-level cyclists."

The Sport Mental Health Assessment Tool is based on three steps, starting with the Athlete Psychological Strain Questionnaire. This is the triage stage and features 10 statements. For instance, statement 1 is 'It was difficult to be around teammates', while statement 9 is 'I needed alcohol or substances to relax' The rider then responds from 1 to 5 – 1 being 'None of the time' to 5 being 'All of the time'.

The total score is calculated by summing the answers from the 10 statements, ranging from 10 to 50. A score of under 17 requires no further action; a score of 17 or more indicates an elevated risk of psychological distress.

This then leads to the Disorder-Specific Screening Questionnaire that digs deeper into factors like anxiety symptoms, alcohol misuse and disordered eating. If all the answers are negative, the administrator may refer the rider to 'softer' interventions like mindfulness and meditation. If one or more questions are positive, the administrator proceeds to clinical assessment and management, which would be the stage psychiatrists like Liebrenz are brought in, as the psychiatrist highlights with a recent case.

Successful case study

"A 20-year-old female Continental[-level] rider came to us," says Liebrenz. "She’d experienced a performance decline, fatigue, impaired sleep and inconsistent training. She was quite tearful, especially after transferring to a new team."

During the assessment by Liebrenz, she reported suicidal ideation and scored 31 on the Beck Depression Inventory (BDI-II), which translates into severe depression.

"She described how she’d be training, head into the woods, dismount and just cry. She’d be descending and think what would happen if she just rode into oncoming traffic."

The rider was immediately started on antidepressants (fluoxetine), before a period in psychiatric care. Slowly, her symptoms improved. After registering a score of 13 on the BDI-II, she transferred to another team "whose flexible racing contract was based on her mental health status. Today, she is doing well and is a strong advocate for mental health."

Thankfully, many riders don’t reach such dangerous depths, helped by a team’s psychologist, who might be full-time or used on a freelance basis. Liebrenz and his contemporaries fit alongside psychology and medicine, teams and riders tapping into their services if concerns tip beyond common issues like fitting into the team, as he explains.

"After diagnosis, I might see an athlete weekly during a crisis (usually anywhere between 60 and 90 minutes)," he says. "It might be monthly in stable phases or just twice a year for routine screening. During the race season or training camps, that might mean video calls, messages or a good old phone call.

"We often use cognitive behavioural therapy (CBT), so athletes have mental exercises or 'homework', just like they’re used to with training plans. This might include tracking sleep, reframing unhelpful thoughts or stress inoculation strategies. They’re receptive, as structure makes sense to them."

Liebrenz stresses that psychiatric care doesn’t happen in isolation.

"Our role is to guide treatment and shape the environment around the athlete, which means working closely with team doctors, coaches, agents, families and management," he says. "I routinely collaborate with cardiologists, for instance, when a patient might need medication that could influence cardiovascular function or heart rate under load. The goal isn’t just to treat illness. It’s to create conditions where mental health is protected, understood and actively supported. At Swiss Cycling, for example, we’ve created a confidential support hub for national-level riders. It’s open to anyone needing help."

Young and old outliers

That help spans the full spectrum of experience, albeit bookended by unique vulnerabilities. Sir Bradley Wiggins' demons, exacerbated on retirement, saw him "doing shitloads of cocaine", while Marco Pantani and Frank Vandenbroucke died from drug use. A loss of identity and purpose are key dangers facing retired cyclists, which is why Liebrenz suggests that riders need a plan B – another project to focus on that’ll help the transition to civvy street – when they’re still riding. Hansen agrees.

"I was actually okay because my plan B was cycling," says the Australian, who helps riders in his role as president of the CPA (Cyclistes Professionnels Associés), a non-profit association that safeguards the interests of professionals. "Before cycling, I had a job in investment. It’s why, during my career, I invested in property. Many other riders laughed at me, but they spent their money. I’m doing okay, but that took sacrifice.

"I’ve had riders call me up and ask me how I handled retirement. They can’t get their heads around that they were treated like superstars, being transported here and there, cooked for… They don’t realise this is not normal. They don’t really understand what a nine-to-five job is. If they wake up one morning and they planned the night before to go training at 10, and they don’t feel so good, they can leave at 12, no problem, as long as they get their five-hour ride in. You can’t do that in the real world."

At the other end of a rider’s career, there are cases like the 20-year-old Swiss rider Liebrenz worked with. This cohort, he says, is of particular concern, especially with WorldTour teams seemingly seeking ever-younger recruitment in search of the next Pogačar.

"The teenage brain is still developing, particularly in areas related to emotional regulation, impulse control and long-term planning," he says. "Dropping a 16- or 17-year-old into the high-stakes world of professional cycling with contracts, performance tracking, and media exposure leaves little room for error, and essentially asks them to function like fully formed adults in a system that rarely tolerates vulnerability. That’s not just unrealistic; it’s dangerous.

"This isn’t something that a team psychologist or a motivational coach can solve alone. What’s needed is a more clinically grounded and proactive mental health strategy, one that includes professionals with expertise in neurodevelopmental disorders and complex psychiatric conditions. These specialists need to be available not only to riders but to staff as well. Professional cycling is an intense, travelling ecosystem. If no one on the bus knows how ADHD manifests under stress or what early signs of depression look like, those issues will be missed until they’re critical."

REACT professionally

To that end, Liebrenz is an advocate for the REACT framework in professional cycling:

• Routine check-ups. Mental health should be screened regularly, just like physiological parameters. Every six months, not just when there’s a crisis.
• External help. Not every athlete will want to open up inside the team. Make sure confidential, independent options are available outside the structure.
• Assess early, refer early. If there’s even a suspicion of trouble, act. Mental health is like injury management – earlier is always better.
• Collaborate with specialists. Especially for complex cases like ADHD or comorbid conditions, teams need sports psychiatrists involved, not just general mental coaches.
• Treat early, manage long-term. Mental health doesn’t end when a rider stabilises. It requires ongoing care, monitoring and support across seasons.

"The goal shouldn’t be to slow down talent development, but to balance it with appropriate psychological scaffolding," he says. "Young riders need space to be human, not just high-performance machines. Teams that recognise this, and act on it, will not only protect their athletes but also improve longevity and performance outcomes."

Despite their superlative levels of physical fitness and incredible focus, professional cycling is fraught with complex psychosocial challenges, be it competitive demands, weight-related concerns or injury fears. It’s a sport that lionises suffering and rewards pain tolerance. But at what cost to the rider’s mental health? On winning his fourth Tour de France title, Tadej Pogacar commented that he’s "already counting down to retirement".

It not only highlighted the Slovenian’s pragmatism but his acknowledgement that this sport chips away at you, even when you’re one of the greatest cyclists to have lived. As Liebrenz said, no matter how high your VO2max or peak power output, you can’t out-train a mental health disorder. But with the right support from youth to retirement, hopefully they won’t need to.

Heart rate and power data have been at the forefront of cycling performance data for many years, but there’s a cacophony of new wearables on the market which can track much more.

The peloton is awash with monitors which measure body temperature, hydration levels, sweat rates and breathing rates on the go.

Unlike heart rate monitors, these devices protrude out of jerseys, with many noticing that Pauline Ferrand-Prévot won the Tour de France Femmes while wearing a breathing sensor.

Team Visma-Lease a Bike teammate Jonas Vingegaard has also been seen sporting one, while Tadej Pogačar has previously been spotted wearing a body temperature sensor.

These new wearable sensors are now in the foreground and are driving a thirst for marginal gains.

UCI competition rules

Currently, the UCI allows several physiological sensors in competition, which include heart rate, sweat and breathing rate. All permitted sensors do not require insertion into the skin but instead sit directly on it.

The Tymewear breathing sensor was approved for use in competition just before the Tour de France this year. The sensor comprises a chest strap, a heart rate monitor and a strain gauge, which measures breathing rate.

Tymewear has a partnership with Team Visma-Lease a Bike, hence Ferrand-Prévot wearing its VitalPro strap.

"UCI were going to ban it, and then we were able to thread the needle because we're not directly measuring any metabolic markers," explains Arnar Larusson, co-founder and CEO of Tymewear.

"We're not directly measuring CO2, we're not directly measuring oxygen consumption, and we're not directly measuring lactate. We're measuring the ventilation, which is the airflow in and out of the lungs and that ticks all the criteria of not measuring any metabolic markers, which is according to the UCI rules. It just so happens that the airflow, that volume over time, is extremely representative of those things."

The Nix Hydration Biosensor was also approved for the beginning of the 2025 season by the UCI for use in competition. A non-reusable sensor, it provides insights into a rider’s hydration level and, according to its website, is used by EF Pro Cycling teams.

In 2023, UCI permitted the FLOWBIO sweat sensor, also driven by EF Pro Cycling. The sensor works by constantly capturing and releasing sweat, with a sodium sensor which measures the activity of the sweat and a skin temperature sensor.

"We worked with the UCI to get the sweat sensor recognised as an overall physiological monitor," said Stefan van der Fluit, CEO of FLOWBIO. “Through conversations with the equipment team, they saw that it's non-invasive and not like a glucose monitor, which has a physical needle in the arm, so they didn't feel that there was any safety concern warranted towards the device.

"The UCI were very proactive and willing to help because they could see that riders wanted to be able to use it, and they didn't want to, per se, be seen as getting in the way of the team.

"The Tour really pushes people to move quickly, and because EF wanted to use it, the emergency protocol was issued within three or four days."

Notably, the UCI continues to ban metabolic sensors, including the Abbott Libre glucose sensor and those which measure lactate. In 2023, Kristen Faulkner was disqualified from Strade Bianche for wearing a continuous glucose monitor during the race.

How the peloton uses these sensors

These new sensors offer valuable insights into a rider’s condition, and access to data like sodium levels and airflow, which was previously much harder to establish or simply not possible during a ride.

According to FLOWBIO, riders from seven WorldTour teams use its sensor.

"It's mostly one or two riders on the team who initially have been identified as high risk of dehydration,” said van der Fluit.

"Jack Rootkin-Gray (EF Education-EasyPost) had massive issues with dehydration, Pavel Sivakov (UAE Team Emirates-XRG) came directly to us and bought the device from us, as did Wout van Aert (Team Visma-Lease a Bike), and that’s how we got into the team.

"Some riders are always looking for an edge, and they find us. We're seeing a lot of growth in the pro field now, and have athletes reaching out to us. For example, we've been working with triathlete Lucy Charles-Barclay because she's had a lot of issues with heat."

Another popular sensor in the peloton is CORE, which provides thermal data through measuring skin temperature, heart rate and heat flux.

"We did a count last year and two-thirds of the riders were using CORE between men's and women's,” said Ross McGraw, Global VP and Head of CORE. “We’ve seen this number increase, and there are more women in that count in the WorldTour.

“The value is both the performance benefits of heat training or cooling strategies pre, post and during races, as well as the safety side when looking at how warm some of these races are getting."

It’s a similar story for Tymewear, too, with the brand saying that most of the top 10 teams have now purchased their own breathing rate sensors and are starting to use them.

The data gained from these sensors has huge value for coaches, too, thanks to the new datasets.

"As a coach, I’ve always relied on power and heart rate data, but these only tell part of the story,” said Jakub Novak, former pro cyclist and cycling performance coach at Pro Cycling Coaching.

"Breathing, hydration, and sweat analysis give us a direct look into the body’s internal state, how it's coping with the demands of training or racing in real time," added Novak. "They’ve made it possible to move beyond guessing about things like dehydration, fuelling, or respiratory strain, and start making decisions based on hard data.

"Hydration sensors can help quantify sweat loss and electrolyte depletion. For longer rides or hot-weather races, this has allowed us to dial in hydration and sodium intake more precisely, reducing cramping and performance drop-offs. It’s especially useful for athletes prone to over- or under-drinking during training."

Banned sensors

As mentioned, the UCI currently does not allow metabolic sensors in competition, and hesitation around these devices centres on practicality as well as data accuracy and usage.

Those on the market currently are invasive as they work by inserting a microneedle into the skin.

As of yet, there aren’t any non-invasive direct metabolic measurement devices on the market; the closest purports to be one called IDRO, although details are scarce.

"On scale, people aren't going to be stabbing themselves with needle-based devices to get data," said van der Fluit.

"I think the challenge for the industry when it comes to biomolecular data is how to get that non-invasively for the consumer. If you wanted lactate and glucose data at the same time, you'd have to wear two sensors on your arm, and I don't see that kind of a platform scaling."

"Perhaps if you had this direct metabolic information, you could somehow manipulate the rider’s intensity in a way that was conducive to better race performance,” said Larusson.

"Though I'm extremely sceptical of that, as if someone is better prepared than you for a race, then they're going to win, and no amount of metabolic data is going to change that on race day."

For some coaches, the prospect of lactate monitoring would be welcome.

"Real-time lactate monitoring is one of the most exciting developments on the horizon,” said Novak. “Being able to track lactate continuously during a ride or race, without needing finger-prick blood samples, would unlock an entirely new level of insight. It would allow us to pinpoint an athlete’s metabolic thresholds with extreme precision, monitor how they’re responding to intensity in real time, and make on-the-fly decisions about pacing or fuelling."

More data, safer riders

In the UCI’s decision to permit sweat sensors in 2023, the organisation acknowledged that these devices offer useful information "for optimising the recovery process, especially after a race in high temperatures, and prevent the risk of hypohydration and injury due to heat."

Heat exhaustion and dehydration-related withdrawals in WorldTour races are not uncommon. Antonio Tiberi withdrew from last year’s Vuelta a España after suffering in the heat during stage 9. Mark Cavendish reportedly suffered in the heat at last year’s Tour de France, while his teammate Michele Gazzoli also had similar issues.

"I think we need more metrics to truly understand the human body," said McGraw.

"The more continuous data points you have, the more accurate your assessment will be and whether the UCI or any other governing body chooses to intervene, there will at least be tools that can provide more insight into what's going on with that human.

"There are doping controls, but are there any controls to make sure athletes aren't collapsing on the side of the road?"

Speaking of collapsing on the side of the road, another consideration is the impact of a wearable on a rider who crashes.

For comparison, in Formula 1, driver clothing is classified as a safety device, and drivers can only wear FIA-homologated clothing, which guarantees protection against heat and flames. These principles extend to wearables.

"Any wearable biometric device intended for use in a race environment must also undergo FIA homologation,” said Xavier Mestelan Pinon, Chief Technology and Safety Officer at the FIA. “The homologation process must demonstrate that the device does not introduce any additional safety risks to the wearer."

For example, any device must be crushable, and the battery must be able to withstand heat and flames.

"As driver clothing is considered a homologated safety device, the FIA sets a strong example of how state-of-the-art sensors can be integrated without compromising the wearer’s safety,” added Pinon.

The possible impact of a wearable on a rider who crashes at high speed may well be why the UCI has so far only permitted wearables which sit on top of the skin rather than subcutaneously.

Accessibility to data

Hydration, thermal, sweat and breathing sensors are not cheap, which raises questions around fair access to this data. A CORE device costs £264.95, FLOWBIO £295, Tymewear €299, and the Nix Hydration Biosensor £149 for 4 patches.

"It becomes an uneven playing field when you have teams that are so well-resourced [that] they can pay for all those data points," said Janelle Chubey, director of OEM at 4iiii and sports data expert.

"A very intense level of data and science costs, not just to have the devices for each rider, but having the right people able to interpret the data. At what point do teams who don’t have the same level of finances as someone like Visma request a form of control on this?

"My sense is that it will become like in other sports where they enforce salary caps across teams to make sure that they're even-ish."

To this point, CORE has chosen to support more women’s teams in an effort to make its devices more accessible.

"Women's teams have a history of being underfunded and can't maybe make these purchases," explained McGraw.

"We were working with Human Powered Health in the beginning and looking at how individual the data was for their riders and on menstrual cycles and how that impacts core temperature and their training.

"We understand that not every team can afford it, and we do our best to balance that."

Playing chess

The UCI currently only permits the rider to view their data from these wearables; live monitoring in team cars is not allowed.

"It could potentially be valuable to see data in the car if there's a health consideration," said McGraw.

"I could see a future where there's an ability to flag potentially dangerous levels of core temperature or heart rate data. There isn't a way for anyone else to monitor this data aside from the rider, and just like any athlete, seeing a number and deciding to slow down or stop is not really in their DNA, but how do you draw the line, right?

"You don't want the whole thing predetermined by a computer and a car. It dehumanises the sport. I can see a desire to not have a full data stream of every single rider in the team car, such that it becomes like playing chess."

A desire for data and integration

Demand for these sensors and more performance data shows no signs of slowing down.

FLOWBIO says its sensors are always sold out because there is so much demand; in fact, its devices sold out within the first two months of this year.

The UCI is evidently mindful of this data hunger with its adherence to pushing through non-invasive wearables, where it deems necessary and where there is pressure from teams.

When you include heart rate monitors in the mix, there are a lot of sensors on the market, and currently, you need to wear several to get all the data, which leads to the prospect of sensor integration.

"Eventually, I see all of these being integrated into a single multi-sensor patch or smart textile, tracking lactate, glucose, hydration, and even respiration in real time," said Novak. "That level of insight would allow us to coach more precisely than ever before."

CORE users have to wear both a heart rate sensor and the brand’s sensor.

"There's always a conversation about combining the two,” McGraw. “That would be ideal."

FLOWBIO is exploring partnerships with sports tech brands so users will be able to see their sweat rate and sweat sodium on their bike computer, and hopes to release a new version next year.

"Convergence is definitely where the industry is going, or consumers will have to change fundamentally a lot of their behaviour around wearable technology because people don’t want to wear 100 wearables," said van der Fluit.

"That said, I would still rather have two devices if individually they're the most accurate."

Why do we ban certain substances in sports and not others? It may seem like a technical question, but the principle behind it underpins the core values of anti-doping.

A substance is placed on WADA’s prohibited list if it meets two of these three criteria: it enhances, or has the potential to enhance performance; it may pose a risk to the athlete’s health; or it violates the ‘spirit of sport’. The third criterion is nebulous, but the first two are factual.

Health alone was once the solid footing of anti-doping, and prominent Grand Tour champions will still cite health concerns as proof of their aversion to doping. However, sports and medicine have changed dramatically since the era of doping tragedies such as Tom Simpson. Most recent doping controversies have unveiled intricate systems powered by close medical supervision, and infamous abusers of banned substances live out their retirements in seemingly enviable health.

Doping is also, unfortunately, a widespread phenomenon in professional sports, with historical data (2011) suggesting up to 60% of athletes dope, while a more recent study (2022) in Frontiers cut that to a still high 21%. The medical fallout of that endemic use is not overly obvious.

Nothing frames the confidence with which some athletes are open to embracing doping more than the mooted Enhanced Games, where drugs on the WADA (World Anti-Doping Agency) Prohibited List will be allowed.

Posing a threat to athletes’ health is certainly the most concerning aspect of this would-be event, especially when you reflect on, in our case, cycling’s dark past.

So is the willingness to dope a reflection of pure brazen ambition, or a reflection of a landscape where the health risks aren't as frightening, or perhaps the data no longer suggests the health risks are there?

Revisiting doping's dark legacy

In 2007, research in the journal Sports Medicine revealed that “EPO use is a suspect in nearly 20 deaths in four years in European cyclists”. Between 2003 and 2004 alone these allegedly included eight deaths including 21-year-old Belgian amateur Johan Sermon, who died of a heart attack and 16-year-old Italian Marco Ceriani, who experienced a heart attack during a race, fell into a coma and never recovered consciousness.

As William Fotheringham wrote in the Guardian at the time, "Although there is no evidence directly linking the recent spate of fatalities to banned drug use, a similar cluster of deaths – mainly in the Low Countries – in the early 1990s is now held to have marked the arrival in cycling of the banned blood-booster erythropoietin (EPO)."

Despite Fotheringham suggesting that "there is no evidence directly linking the recent spate of fatalities to banned drug use", the EPO link seemed tragically persuasive, especially as deaths like these are rare in cycling in 2024 – we can’t list one such cardiac attack in the sport in the year – with much of the credit down to the Athlete Biological Passport, which has been used in cycling since 2008.

So what is the actual evidence that substances like EPO are dangerous and should be on the Prohibited List? When it comes to EPO, hold that thought. We’ll come back to that. For now, let’s take a bird’s eye view of doping and examine the evidence. And, in all honesty, it doesn’t look that clear from up here…

Certainly not when you read 2023 research by Jo Morrison, professor of kinesiology at Longwood University in America. The title of her study, featured in the journal Performance Enhancement & Health, says it all: "Lack of evidence that doping is harmful to the health of elite athletes."

A snapshot of Morrison’s research…

"There is evidence that the pattern of banned substance use in elite athletes is high, yet morbidity and mortality of elite athletes is not greater than the general population, and former elite athletes live longer and healthier lives than age-matched controls."

"This sweeping claim [that the use of performance-enhancing drugs (PEDs) is harmful to the health of the athlete] assumes that PEDs are specifically harmful to athletes, despite many of these substances being approved for human use in patient populations that are of less robust health than athletes."

"While anti-doping authorities often rely on the mantra that PEDs are dangerous and can harm the athlete’s health, this is a claim that’s based on anecdotal reports of misuse, absence of qualified medical guidance, black market PEDs, and preferential selection of substances that have not been approved for human use but are easier for the user to obtain and may have a better chance of evading anti-doping testing. The assertion that PEDs harm the health of the elite performers who are subject to testing and sanction is not evidence-based."

Morrison also cites a 2019 review that examined the "evidence of performance enhancement of the 23 classes of substances on the prohibited list and concluded there was no evidence of performance enhancement for the majority of classes of substances on the list. Either there were no studies available or studies showed no positive effect. For the five classes of substances that did show performance enhancement in trained athletes, the evidence is based on 11 studies with 266 participants."

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The study, which featured in the journal Sports Medicine, was co-authored by Jules Heuberger, of the Centre for Human Drug Research in Leiden, Netherlands, where he undertakes clinical trials for pharmaceutical and biotech companies for developing new drugs for diseases. We contacted Heuberger to reflect on his findings that not only looked at the performance-enhancing aspect but the potential health risks, too.

"My CEO and I thought that the drugs on the Prohibited List are obviously pharmaceutical drugs, intended to help some kind of disease, so it’d only make sense to apply the same reasoning, the same scientific rigour, to drugs like these to test whether they actually enhance its performance or whether they are harmful," he says. "To apply the same standards as we do for drugs that we take to the market, as if we were testing a treatment for a disease called cycling slowly!"

When it came to the health-risk aspect, the paper suggested that while any substance can jeopardise an athlete’s health and that there could be side effects to all substances, the "requirement that a substance specifically may affect the health of an athlete is not supported by evidence."

And without scientific evidence, the application of this criterion is equally arbitrary to that for enhancement.

Why Meldonium?

"One of the problems is that the process WADA follows is not transparent," he says. "After a series of discussions and meetings, it’s decided to either put a substance on the list or to monitor it. But the whole process and what evidence is required is muddy."

And political. "In that paper, we wrote about meldonium," he continues. "It was put on the monitoring list because there was a large proportion of Eastern European athletes allegedly using it. It sounds like there was much lobbying and it finally hit the prohibited list."

Meldonium is used to treat ischemia: a lack of blood flow to parts of the body, particularly in cases of angina or heart failure. It’s manufactured in Latvia and only distributed in Baltic countries and Russia. WADA found "evidence of its use by athletes with the intention of enhancing performance" by virtue of carrying more oxygen to muscle tissue, while a 2015 study showed that 17% of Russian athletes (724 of 4,316) tested were found to have meldonium in their system. It was banned in 2016, and classed as an S4 substance under the WADA code, which addresses hormone and metabolic modulators. In that same year, tennis player Maria Sharapova was banned for two years after testing positive for meldonium at the Australian Open.

"But if you look at the scientific evidence behind what meldonium does for treating disease, that’s almost non-existent," says Heuberger. "That’s why it’s not authorised in Western Europe or the United States [by the Food and Drug Administration]. So, if there’s little evidence in a medical arena, there’s certainly less evidence of improving performance of it being detrimental to health.

"Our point is that it’s not clear how a substance ends up on the Prohibited List. Of course, if you take too much of a substance, it could be unhealthy and dangerous. If that’s the case, you’d have to put sandwiches on the list as too many of those can be unhealthy and harm your health!"

The drugs don't work

We couldn’t discern if Heuberger was being flippant with that last point. But if the perception is that there’s an arbitrary nature to substances on the Prohibited List, the scientific rigour and openness Heuberger questioned is arguably constrained by the WADA Code and regulation 19.5 that states, "Research efforts should avoid the administration of prohibited substances or prohibited methods to athletes", while 19.6 reads, "Adequate precautions should be taken so that the results of anti-doping research are not misused and applied for doping purposes."

So, don’t test on athletes (makes sense with the elites as they could then be banned) and, if you do, don’t publicise the fact. Of course, research still happens, including ground-breaking and headline-making research by Heuberger and Professor Adam Cohen in 2017 when a study of theirs featured in The Lancet Haematology.

In that study, forty-eight participants were injected with EPO or a placebo for eight weeks, during which time they completed seven endurance tests in the laboratory. They then faced the final challenge, a 130km rider that finished with a race up Mont Ventoux in the summer of 2016. The winner, a lawyer, took an hour and 12 minutes to reach the summit. On average, riders on EPO were 38 seconds slower than the control group.

The study's findings that EPO didn’t super-charge cyclists swept the internet like worldwide wildfire. "It’s indisputable that the new red blood cells spawned by EPO increase the body’s maximum oxygen uptake (VO2 Max)," Cohen said at the time. "But such an increase may not boost cycling performance." In long-distance races like the Tour, he argued, riders rarely performed at maximum uptake. Yet in a review of 13 previous EPO studies, Cohen found that all focused on VO2 Max instead of performance. Critics argued this was too simplistic, that EPO’s a proven performance-enhancer and not just because it raises VO2 Max.

But were there health consequences in the study? "There were two markers in the blood that were elevated, both tied in with coagulation," Heuberger says. "But we didn’t observe clinical side-effects, so we couldn’t conclude that there’s an absolute health risk.

"However, we do know in patients with low haematocrit values – for example, kidney or cancer patients – that are being treated with EPO to boost their red blood cells, if you try to push them to normal haematocrit levels, the incidence of stroke and serious cardiovascular issues increases. 

"So, one part of the answer is it depends on the dose, but something like EPO is not immediately dangerous, otherwise we wouldn’t have been able to do the trial. And we wouldn’t have done it if we didn’t think it was ethical."

Clearly, the dose is important. The higher the dose, the higher the potential benefit, and the higher the health risk. But, certainly with EPO, there’s evidence that even slight skews in blood levels can cause health problems.

A 2012 meta-analysis into the adverse effects of erythropoiesis-stimulating agents, including EPO, found an increased risk of stroke, venous thromboembolism and mortality in patients treated with these agents, particularly when used to achieve higher-than-normal haemoglobin levels.

There’s also evidence that EPO stimulates the growth of cancer tumours; can lead to the body’s immune system attacking red blood cell precursors, resulting in anaemia; and increases the chances of hypertension.

For Heuberger, there are substances "I’d think twice about [taking]. That includes growth hormone and drugs that influence the immune system. Then you have drugs like anabolic steroids that have clear side-effects detrimental to health."

With over 400 substances on the Prohibited List, that’s not a lot, which is Heuberger’s point. For too many of the substances, he says, there simply isn’t evidence of performance enhancement or health risk. 

It’s something we posed to WADA, a spokesperson responding: "The inclusion of ‘it may pose a risk to the athlete’s health’ as one of the three criteria speaks to a central element of WADA’s mission to lead a collaborative worldwide campaign for doping-free sport. A key feature of our work is to monitor scientific and medical developments in sport with the aim to safeguard not just the level playing field but also the health of athletes.

"Not all substances and methods that are included on the Prohibited List necessarily pose a risk to the health of athletes, which is why a substance/method will be included in the List if it satisfies any two of the three criteria."

As a reminder, the other two criteria are the potential to enhance performance and violating the spirit of sport. Seen through an academic lens, this makes things even blurrier as Heuberger’s paper revealed that there’s limited evidence behind many of the Prohibited List’s substances’ performance benefits. If there’s little evidence of a health risk, too, that’s not violating the spirit of the sport. Then again, you might ask, why would an athlete take a substance that didn’t benefit performance?

A decent reason not to dope

But would you risk it? Let’s take the substances Heuberger would think twice about: growth hormones and drugs that influence the immune system. According to the Mayo Clinic, side effects linked to human growth hormone may include pain in joints; cause diabetes; increased heart size in a condition known as cardiomegaly; raised blood pressure; and lead to eyesight problems.

A 2008 review of the growth hormone athletic literature showed that lean body mass increased in growth hormone recipients compared with participants who didn’t receive growth hormone. On the downside, "hormone-treated participants more frequently experienced soft tissue oedema and fatigue than did those not treated with growth hormone."

Further research referenced by Harvard Health Publishing, albeit in older individuals, showed that growth hormone recipients experienced a high rate of side effects, including fluid retention, joint pain, breast enlargement and carpal tunnel syndrome. The studies were too short to detect any change in the risk of cancer, but other research suggests an increased risk of cancer in general and prostate cancer in particular.

Heuberger would also veer away from drugs that influence the immune system. According to Heuberger’s 2019 paper,  one example is glucocorticoids, which "act on metabolism and the immune system, and, through that mechanism, potentially affect performance."

There’s clear evidence that prolonged use can damage health with a 2013 study in the journal Neurohospitalist revealing an increase in osteoporosis, osteonecrosis (death of bone tissue due to the interruption of blood supply) and even heart disease.

Beyond the dangers of health, there’s also the riders’ ethical responsibility to not cheat. In ethics, the concept of fairness involves treating everyone equally and impartially.

‘Fair play’ is usually understood to mean using only tactics that are in accord with the spirit of the sport. That’s on a human level. But on a formal level, that’s where UCI and WADA rules come in.

Again on a human level, it does beg the question: why do athletes dope? Michael Joyner wrote a piece in 2013 suggesting that one of the reasons is down to game theory. Athletes are in a game with one another, the piece argued, each vying for the best result and highest salary. If the athlete feels testing and enforcement are lax, the risk of being beaten by a doper is perceived to be larger than the risk of getting caught. In short, doping becomes the optimal strategy for victory.

An Enhanced free-for-all?

Now, let us return to the Enhanced Games, namely the safety aspect that they pay great credence to on their website. "Athletes competing in the Enhanced Games will receive free medical screening prior to competition, which will ensure that they are healthy and able to compete,” it reads. “The screening will involve an echocardiogram, blood tests and genomic sequencing, in order to build up a full picture of the athlete’s health, and allow athletes to make an informed decision about whether they are safe to compete."

Then, "The Enhanced Medical Pre-Screening Protocol, which is still in development, will allow athletes to track their biomarkers prior to competition, creating a blueprint of athletic excellence that could be used to inform performance therapies, diet, sleep, and training."

Safety, if you believe the marketing, is paramount at the Enhanced Games. But which doctor would prescribe therapeutic drugs for performance reasons without risking being struck off?

"That’s what we’re arguing," says Brett Fraser, chief athletics officer of the Enhanced Games and two-time Olympic swimmer. "We’re looking to create an environment where we’re using the best doctors and scientists in the world to understand and optimise sporting performance in a safe manner. This is all going to be done with the focus on the safety of athletes. That’s the most important thing."

One of Fraser’s hopes is that they’ll learn what doping products today’s current athletes might be using and feedback to WADA so that they can improve their testing protocols. Whether that’s philanthropy or simply a safety smokescreen, well, we’ll leave that hanging. What’s clearer is that Fraser feels the Prohibited List has become bloated based on little empirical data.

"You’ll find some pretty interesting substances on there," says Fraser. "And there’s an inconsistency. Why would they be allowed in training but not in competition, for example? What is the rationale behind some of these substances being on the prohibited list? They’re not studied enough and could be perceived as being arbitrary in nature."

This has clear parallels with Heuberger, so what does Heuberger think about the Enhanced Games? "I don’t think it’s something I support as it seems too extreme," he says. "However, it would be interesting to see what’s possible with pharmacological enhancement, but this isn’t the best way to investigate it because it’ll be difficult to do in a balanced and well-controlled way that protects the health of the athlete."

Will the Enhanced Games happen? If PayPal co-founder Peter Thiel has his way it will. Thiel was revealed as an investor in a multi-million-dollar seed round in January for the Games. 

Where does that leave us? Substances like EPO and steroids have sufficient empirical and anecdotal evidence behind them to suggest that they’re potentially harmful to health, certainly at reasonably high levels. Whether that’s enough of a deterrent to an athlete depends on their motivation, desperation and moral compass.

But there’s a clear feeling that many of the substances require further research to quantify the potential risks and how much of a performance enhancement they’ll deliver. If you can prove that they don’t enhance performance, of course, then that will arguably be a greater deterrent to an athlete taking it than the health-risk aspect.

Heuberger suggests restructuring the setup so that you focus on the drugs that you think will have a big performance gain, undertake proper tests or trials for that, and then put those on the list and develop very sensitive tests to detect them. He also feels that WADA should drop the third criteria for placing substances on the List, the ‘spirit of sport’, because of its problematic fuzziness. 

As stakes become higher, technology becomes better, and medical knowledge becomes deeper, the challenge of anti-doping will become greater. In a future where athletes aren't concerned with health risks, we can only hope that ethics is front and centre to the principles of our sporting stars.

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