How To Know If You Are In The RED-S

"Do you exercise?" asked the Doc.

"Yes, I try to do as much as I can.  I am training for my 5th marathon, take Pilates twice a week, kick box on Saturdays and on Sundays try to make it hot Yoga. I know I would do more if I did not have to stay at the office past 10 pm these past 2 months." answered the New York City business woman.

I emphasize NYC not only because this is where I live, work and play but also because the scenario above, while may seem a bit stretched in the sarcasm market, is actually not all that uncommon around these blocks. I have been there myself. Not to the extremes of marathon training and 7 days of structured exercise for weeks on end, but I can compare some of what we call in NYC "the hustle"  to that of an athlete's burnout.  Let me elaborate ( I promise I am great at it).

I moved to NYC in 2009. This was a good time to buy and rent as prices were low (but to me coming from Maine they were sky high.... my current view point of prices has changed since then- when did $7 beers become a great deal)?!

I lived in Park Slope, Brooklyn, which I knew nothing about except that it was just voted the number one city to live out of the 5 boroughs by New York Magazine and that the F train never followed schedules. I learned the word "schlep" and integrated it into my daily life of "schlepping" to and from NYU campuses, to volunteer, to work, to the grocery store, to the gym... you get the idea. My legs were my car, grocery bags and nutrition text books were my hand weights, and balancing everything I lugged with me was my ab work. But why stop there right? I was a New Yorker in training so I also added on yoga and Pilates classes, hip hop dance, ballet,  running, and strapping on Franco Sarto's new Fall season's high heels making pavement pounding a challenge for my poor feet. Add to this stress from grad school and paying NYC rent prices and you have a nice equation for mind and muscle breakdown.

I did not technically breakdown. Well, except that time when I thought I lost my 30 page document at Bobst Library at 1:00 AM. That was a different sort of breakdown though.

I did however lose weight unintentionally, and I was not working out to the extent that athletes do. Part of this weight loss was muscle mass, and even though I may have not realized it at the time, those sleepless nights and times of grumpiness may  not have been just from the loads of school work, but rather the loads of physical, mental and emotional work my mind and body was undertaking without an optimal amount of calories and nutrients. This is a classic example of how a non-athlete can dip his or her feet into the RED-S zone...

Fast forward 3 years. I am finishing up at NYU  and decide a great way to deal with stress is to run it out. So I say to myself "I am going to do the NYC Half Marathon in March this year." This was in June. I then started training in June because in my mind 13.1 miles was an eternity. This was far too early for me to start a dedicated training program and lead to me over training.  I ended cutting back on my training and took away a running day and added in a strength day. I personalized a program that worked for me. I completed the Half Marathon in 2 Hr: 2 Min: 22 Sec - not bad eh. Along the journey from June to March however I did experience interrupted sleep, an extreme urge for meat, which most likely was due to iron deficiency and some lost muscle mass. Another classic example of how an athlete in training dipped into the RED-S zone.

So what is all of this talk about RED-S? RED-S stands for  Relative Energy Deficiency in Sport. According to Mountjoy and colleagues in the editorial Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport (RED-S) this is a more  broad term of what was known as the Female Athlete Triad and refers to "to impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health."

Furthermore this article published in the British Journal of Sports Medicine explains that the underlying issue of RED-S is  an energy deficiency relative to the balance between dietary energy intake and the energy expenditure required to support homeostasis, health and the activities of daily living, growth and sporting activities.


So in other words there is not enough energy available either by food coming into your mouth or energy stores in the liver or muscle to maintain optimal health and carry out daily living activities to your greatest potential. Nor will your internal activities such as proper digestion run efficiently.

It does NOT only have to do with women either. This applies to men as well.


This is some serious stuff and new athletes or those who put themselves on very restrictive diets over a long period of time are especially susceptible.

This RED-S is also seen in those who participate in recreational exercise and who may not fit the category of professional athlete (think Zog sports or corporate teams and people who lead very active or busy lives, workout a lot and are very stressed- like our NYC business woman at the start of the post).

Lets take a look at how RED-S may effect the body and mind:

• Immune System
• Menstrual Function
• Bone Health
• Endocrine- such and insulin and thyroid hormones
• Metabolic
• Hematologic
• Growth and Development
• Psychological
• Cardiovascular
• Gastrointestinal

So you get the idea- it hits at many different parts of the body and the mind- so how do you KNOW its effecting any of these areas? Here are some signs:

• Endurance performance has decreased
• Injury risk has increased
• Decreased adaptation to training- its not getting any easier
• Impaired judgement- you have a hard time making decisions and cannot think clearly
• Decreased coordination
• Decreased concentration
• Irritability
• Depression
• Decreased glycogen stores- some may call this ketogenic diet and in the SHORT TERM a variation of this diet while training may help performance but if you have other signs or prolong this diet it could hinder performance
• Decreased muscles strength 

New and improved calculations have also made it easier for me as a dietitian to pin point how many calories a person undergoing heavy endurance exercise should consume daily and then assure they are getting these in via real foods that are nourishing and not just empty calories. 

Nevertheless, we are NOT ALL BUILT IN A BOX- I am starting to think this is my tag line as I say it so often to my patients and clients. I can punch in numbers to my trusty calculator and get back a  target number range for caloric intake to prevent RED-S and this  is all fine and dandy. But without educating people about the best sources of foods to get those calories from and motivating one about how to adequately attain a healthy lifestyle among the periodical altered diets athletes and very active people undertake I am not doing my job as a dietitian.


My Takeaway:  

1) If you are undergoing endurance training, especially if you are new to this training, you are at an increased risk of RED-S. However this is preventable with proper awareness and education around caloric intake and the signs and symptoms that may be indicative of this issue.

2) A calorie is not a calorie is not a calorie- if you get your calories from bags of chips and swigs of soda these will  not fuel your fire the same way a whole potato will... a purple potato at that... an Okinawan purple sweet potato (Ok ok this is one of my favorites and its also a great source of glucose)!

3) RED-S applies to BOTH female and males. Whereas women are particular susceptible to low iron and calcium levels and disrupted menses, both sexes are susceptible to a plethora of physiological disruptions that may not only decrease performance but disrupt the activities of daily living.

Kelly Ahearn, MS RDN CDN is Owner of Indigenous Nutritionist, a private practice and consulting startup based in NYC. She has partnered with Running This World to offer nutritional education sessions via tele-health for anyone who registers for the complete package at runningthisworld.com - website is coming soon!





Reference:

Mountjoy M,  Sundgot-Borgen  J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport (RED-S) . Br J Sports Med 2015;49:417-420 doi:10.1136/bjsports-2014-094371

Hold The Carbs At Dinnertime? Wait. What?!

 

It's time to get serious... seriously trained that is.

For those of you who love to read anything and everything about food you may have recently read an article by Gretchen Reynolds of the NYTimes titled For Serious Training, Hold the Carbs at Dinnertime. The article specifically addressed a strategic plan around skipping carbs all together at the evening meal as it may improve athletic performance in events following the meal.  Sounds like a little too much planning ahead, a little too risky, or something that perhaps you are already doing? (You trend-setter you). Here are a couple of basic points from my professional opinion both in regards to this article and to sports nutrition in general.

                                                                             

• There is no ONE ideal sports diet- we are not all built in a box and whereas there are guidelines there are some flexibility within these guidelines in regards to the type of sport as well as the genetics of the athlete  

•  Some may think that dietitians advocate for “heaps” of carbs at the dinner table for athletes that is not always and necessarily true. Carbs are very important as they are the body’s first go-to source of energy, and they are also stored as glycogen for use of energy when blood sugar levels run low. Plus the whole carb loading concept, while it may have been something pushed by coaches in the past, may cause issues such as greater water retention and therefore temporary weight gain cramping your running style, digestive discomfort from high fiber foods and blood sugar changes, which is especially dangerous if you are have diabetes. 
  
  
   
  So when you burn out of carbs what is next in line? Fat. Which is preferred over protein as we want to hold onto that precious protein for other uses such as healthy hair, nails, muscle growth, and more (see my previous post How Do I Know If I Am Getting Enough Protein? for more information)
   

     Let us delve a little further into this shift from carbs to fat for fuel- particularly the main source of fuel for your body. When we do this we are forcing our bodies to completely undue their natural progression of burning energy for fuel. I am not saying this is wrong, and I am not saying it is right- I am just saying that it may be  person specific. Science is proving that  some diets work better for some then for others and are gene-specific as well as based on the condition of the person. I will comment that this specific diet manipulation may even be dangerous if applied long term as more studies are needed. On a lighter but nevertheless well understood note, without enough carbs you may start to get a little, ummm, hangry.

     But what is all this danger talk about you ask? Great question! The body just doesn't switch from burning carbs to fat and say “ok this is cool I will now use fat and no need for more carbs.” It has to train and get used to it. During this short term training it could be a drag for the bagel loving runner. Also, lets keep in mind that without that “quick energy” streaming through your body from a handful of raisins or a banana the more one may struggle to finish the race strong.

     The study that the NYTimes article was based on was conducted in Paris, France after researchers from the French National Institute of Sport, Expertise and Performance and other like-minded institutions got curious about the “sleeping low” sports diet where an athlete skips carbs at dinner time (see ya bread bowl) and trains with a low availability of carbs. It takes about 12 hours for the liver to run out of glycogen so when you pass on the carbs at dinner you are most likely past the 12 hour mark.

Here are some key points about the study published in the Medicine and Science in Sports & Exercise Journal:

• 21 experienced competitive male triathletes participated in the study 
  
• Subjects were tested via a simulated triathlon to test out their pace and fitness level
  
• 50% of the subjects were randomly chosen to eat a “standard sports diet” and the other half on a “sleep-low diet"
  
• The same amount of carbs were consumed over the course of the day (6 grams/kg of body weight for each person in each group -this means for a 170 (77 kg) person he is consuming 462 grams of carbs a day 

•  The distribution of carbs for the 2 groups differed by restricting carbs in the evening and piling them on in the morning for the sleep-low group vs equaling distributing carbs throughout the day for the control group.

    I think by now you are having an "aha" moment.Technically, the sleep-low group was not consuming  less total carbs in a 24 hour period, and it was that they were only restricting during one part of the day and making up for it the next morning.  

 Now back to the study.

• The “sleep-low” folks went through 3 trials of diet/training cycling interventions for 4 days a week for 3 weeks with low impact activities on the off days. The training sessions were completed in the afternoon to deplete carbohydrate availability before dinner.
• The first intervention included "train-high" interval sessions of high intensity in the evening with high-carbs after training
• The second intervention included the same type of training but this time with  overnight carb restriction ("sleeping-low")
• The third intervention switched from high intensity to  "train-low" sessions with a low amount of carbs available endogenously and exogenous-ly- that's science speak for low stores of carbs in the body in the form of glycogen and a low amount of immediate energy from carbs consumed during the training
• As for the control group they followed the same training program but with high amounts of carbs available at all times (6 grams/kg body weight/day) - no restrictions overnight and no restrictions during exercise

    The sleep-low guys ate virtually all of their carbs at breakfast and lunch. The control group  ate carbs at all meals with the key meal being carb repletion at dinner time. In the morning before breakfast the subjects  cycled for an hour at moderate pace.  The sleep-low group was pedaling away their little carb reserve and relying on fat whereas the control group had more carbs in the form of glycogen to depend on before transitioning to fat only utilization.

      Put back to the test of the simulated triathlon and the sleep-low group showed improvements in both cycling efficiency during moderate cycling and to exhaustion. Futhermore they performed 3% better during the 10K run. Over a minute faster at finishing the race vs the control group! Last, but not least, the sleep-low group lost more body fat vs the control group.

So what does this all mean to the athlete who is looking to improve performance, or perhaps to lose greater amounts of fat mass?

• Strenuous exercise in the afternoon followed by deprivation of carbs ( I know I am already crying) and then waking up to a casual training session followed then by a carb heavy breakfast (now I am happy again) does show some promising results to improve endurance performance
  
• In 3 weeks it appeared as though athletes were able to access fat for fuel, which allowed them to work harder, condition better and gain more speed

This next insert comes directly from the  NYTimes article itself that I want you ALL to pay special attention to:

“Such a rigorous routine is not for everyone, of course. Those of us not training for a marathon, triathlon or similar event probably would not enjoy or benefit from sleeping low. Even serious athletes should thread the approach into their training cautiously, Ms. Marquet said, beginning a few weeks before a race and easing off in the days just before the event, when they should down carbohydrates at will.”

Ms. Marquet, the leading researcher in this study, also gave word that MOST of the athletes have now integrated this sleep-low diet  into their training. But before you run off (literally and figuratively)and start making reservations as steakhouses for dinner here is the final conclusion from the researchers themselves:

"Short-term periodization of dietary CHO (carbs) availability around selected training sessions promoted significant improvements in sub-maximal ( cycling at less then their best) cycling economy, as well as suprea-maximal  (cycling faster then before) cycling capacity and 10 km running time in trained endurance athletes.” 

Yes, parenthesis were  added by moi.

......and now some poetry in motion, all pun intended.

 

Carbs were restricted at dinner only
But without these carbs the athletes felt lonely
However, their performance improved, deeming them the winners

But it was still hard foregoing those carbs at dinner.

All joking aside, here is....

My Takeaway:  

     We must always use common sense and just because a study is highlighted in a very well known publication it does not mean that all people training for a strenuous event must now follow the no-carb-at-night-tactics because it is may not be the best fit for everyone. This study had some limitations as all studies do. Only males were included in this study and they were already endurance trained athletes. The intervention blocks were only 3 weeks in length which brings to question if this diet is even attainable over a longer period of time. This is important to note since training periods for triathlons and marathons are much longer then 3 weeks. This kind of diet may be better when done towards the end of training. Finally, the nutrition intervention, although given in specific directions, was self reported by a detailed food diary the subjects kept with them. This is a common limitation to many studies and does not make this study dis-credible, only one to have an open mind about before committing to it.


    I recommend that athletes work with a Registered Dietitian-Nutritionist who specializes in sports nutrition if they plan on implementing this diet into their training for optimal safety and greater personalization.

Kelly Ahearn, MS RDN CDN is Founder of Indigenous Nutritionist, a private practice and consulting startup based in NYC. She has partnered with Running This World to offer nutritional education sessions via tele-health for anyone who registers for the complete package at runningthisworld.com - website is coming soon!

References:

Marquet LA1, Brisswalter J, Louis J, Tiollier E, Burke LM, Hawley JA, Hausswirth C. Enhanced Endurance Performance by Periodization of CHO Intake: "Sleep Low" Strategy. Med Sci Sports Exerc. 2016 Jan 7.  [Epub ahead of print]        
                     

Reynolds G. For Serious Training, Hold The Carbs At Dinnertime. March 9, 2016 5:25 am New York Times Well. Accessed March 16, 2017.

How Do I Know If I Am Getting Enough Protein?

    Recently an old friend from college texted me this question. If you are a dietitian reading this I am sure you have been asked the same or similar regarding protein. For the rest of you I would guess that you have perhaps wondered the same, especially in light of all of the media hype centered around protein in addition to fads old and new such as Atkins and Paleo.

    Let's start with the basics. What is protein? Protein is one of the 3 macronutrients that our bodies need to thrive. The other two, carbohydrates and fat, are equally as important and have both been under fire in the past while protein stays gleaming in the spotlight. First it was no or low fat, then no carbs, and now it's mega protein. In hindsight protein is the first macronutrient in which the American culture has pushed MORE of instead of less of. Why is that? The answer is multifactorial, and here are 3 key points to know about protein:

1. Proteins are made up of essential amino acids - meaning we can only get them from FOOD- these amino acids are building blocks that have various functions in our body
2. Proteins have many functions and some of which are to make other types of proteins-

• Enzymes (type of protein)
• Hormones (some are a type of protein such as insulin and growth hormone)
• Functions as an energy source for liver, muscle and intestines
• Metabolic signaling 

3. Protein helps maintain….

• bone health
• body composition (percentage of fat vs muscle)
• Blood glucose levels
• body weight

So you get the idea. Protein does a lot and is important for us all. There are some rare genetic disorders where one must be very careful with the amount and kind of protein they ingest (phenylketonuria for example) and for other populations a bit more is necessary (pregnant women, athletes). There are 3 components of protein that we can all take into consideration. The kind, the time we consume and how much we eat.

The Quality:

Protein is separated into animal protein and plant proteins. A complete protein is one which has all 9 essential amino acids, and an incomplete protein does not have all 9, or is very low in one or more amino acids, hence it is incomplete. Animal sources are complete protein and although most plant proteins are incomplete there are some exceptions. Hemp protein is a vegan source, which DOES have all 9 essential amino acids. Quinoa, buckwheat, soybeans and even blue-green algae are also considered complete.  Legume are as well, but they are limited in two specific ones- methionine and lysine,l ow in leucine AND are not always well digested by all. Some common legumes are alfalfa, peas, beans, lentils, carob, soybeans, peanuts and tamarind.

I will cut to the chase now and provide you a list of high quality proteins and complement proteins- those that when consumed together make an incomplete protein complete!

High quality proteins:

• Animal protein- best to stick to lean cut meats, fish, cottage cheese, strained yogurt, milk (goat’s milk is better tolerated if you have some lactose intolerance), and eggs
• Hemp protein powder or hemp seeds
• Legumes- but remember, it may be a complete protein but are limited in some amino acids
• Buckwheat, Quinoa, Soy

Complement proteins:

• Rice and beans
• Whole Wheat pita and hummus or other bean dip
• Baked beans and Cornbread
• Peanut butter sandwich

    Protein is a ubiquitous macronutrient in that it plays a diverse role in the body. It helps keep out skin, nails and hair healthy, and is responsible for making some enzymes and some hormones. The last thing we want it to take charge of is being used up for energy. Hence, this why the athlete's buddy carbohydrates are protein sparing.

The Timing:

There is a rhyme and reason behind timing when and how much protein you consume. What is super cool is that we are human and we are adaptable so if there happens to be one day once in a while that you are crazy busy that you do not eat at the exact time you usually do after a workout or miss lunch (insert scream sounds here)  YOU WILL BE OK. Just do not make a habit out of it as this will not only affect your running performance but also your mood, blood sugar levels and energy.

Here are some general guidelines around protein for the general population:

30 grams, 3 times a day, so that's about 30 grams at breakfast, lunch and dinner.

So now lets personalize this a bit for the runner:

1. Eat more than just 3 times a day- your appetite will grow the more you run. Snacks are important for the athlete and this who are very active.

2. After a run the best time window to consume protein is within 30 minutes- 20 grams of protein in a post-training session is a good amount to aim for.

3. The guidelines for runners according to the International Society of Sports Nutrition are 1-1.6 grams per kg body weight - example to follow! ↓

Joe Shmo is 150 pounds, which is 68 kg. He needs approx 70-110 grams of protein a day.  

Breakfast - 20 grams

Snack 15 grams

Lunch: 20 grams

Snack- 20 grams

Dinner 20 grams

Snack: 15 grams

This is just an example and there is some wiggle room here. If Joe ate 25 or 30 grams at a meal no biggie here,  but research shows that over 30 grams at one time is not really anymore beneficial in how the body utilizes it. However, nutrition science is ever evolving and more genetic focused studies are under way so maybe for some people it may be helpful, and maybe for others more harmful. For now, be rest assured that you do not have to fill your plate with a protein on top of protein on top of protein at dinner time.

    For a post-run recovery intake at least 15 grams of protein intake is my recommendation. A ratio of 3:1 or 4:1  of carbs:protein is efficient  depending on your goal for weight. Because we are not robots (yet) and we eat food and not numbers I put these numbers into food for you:

10 grams of protein looks like: 1. Cups of Soy Milk

15 grams looks like: 4 ounces of cottage cheese

20 grams looks like: Eggs Sandwich with 2 eggs and 2 pieces of whole wheat bread

30 grams looks like: 6 ounces Strained yogurt such as Greek or Skyr mixed with half cup chicken for a nice little chicken salad

The Quantity:

So just how MUCH do you need? This is the part we have been waiting for!  Well... I do recommend you see a Registered Dietitian Nutritionist (RDN) to find your optimal intake as we are not all built in a box. Here is some background on protein recommendations in America.

• The Recommended Daily Allowances (RDA’s) for protein were developed for most healthy people and covered the MINIMAL adequate amounts needed
• The Dietary Reference Intakes (DRI’s) are more broad and range from the adequate intake (RDA) to prevent nutrient deficiencies to the upper limit (UL) which is the amount one can consume without it actually being toxic
• The Acceptable Macronutrient Distribution Range (AMDRI) is a value for a macronutrient (a carb, fat or protein) in percentages- for example the AMDRI for protein is 10-35% of a person's daily calorie intake- no worries about getting into the nitty gritty details of calculating this out (again, that is part of what dietitian can do for you when necessary).

So confused yet? Yea, sorry about that- but it IS a good idea to get a sense of what are all these numbers on a nutrition label. The takeaway here is that any dietary recommendations set forth by a committee to meet a very large population of people are not set in stone and instead are guidelines to ensure people are not under doing it or overdoing it. When you work with a dietitian he or she can fine tune these recommendations to better fit YOUR needs based on not only your height, weight, goal, and activity level, but also support any current medical complications you may have and most importantly PREVENT disease by taking special consideration of family history, environment and genetics.

Remember all that talk about essential amino acids and how some foods have more of one and lack another? There is one in particular that is especially important to us all, and more so for athletes (drum roll please) it is  leucine. Leucine is key as it helps to make proteins in the body by triggering the metabolic pathway ( think of the domino effect) signaling that the meal just consumed was adequate enough to grow muscle tissue- how cool is that? It's like food is talking to our muscles and telling them to grow (less room for fat)!

I'm a dietitian, I love food, I promote REAL FOOD- and there is a time and place for supplements, however they are to SUPPLEMENT your diet and nothing that a healthy individual should rely on- furthermore you get so much more out of food than you do from a pill. So instead of running to your local drug store and looking for leucine in a box eat more of these high leucine foods:

• Beef*
• Chicken*
• Pork Chop*
• Tuna*
• Milk
• Peanuts
• Lentils
• Egg
• Almonds
• Soybeans
• Asparagus

*One serving of these is 3 ounces, which is about the size of a deck of cards.

Now that we have all that taken care of get out there and start running! Remember when you finish you have 30 minutes as the optimal time to get in a snack with  at least 15 grams of protein. Want to give your chocolate milk a nutritional kick? Try goat's milk with raw cacao or carob powder and a little honey, mix well and pour over ice. Not keen on goats milk? Hemp milk is also a great alternative. No supplements needed, just good ol’ food.

Reference:

The Role of Protein in Overall Health: Quality, Quantity, and Timing Considerations. Seyler, J, Layman D. SCAN's Pulse. 2012, Vol 31, No.3 

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