Episode 121 - Female Athlete Series: Part 3: Relative Energy Deficiency in Sport with Dane Baker

Female Athlete Series: Part 3: Relative Energy Deficiency in Sport with Dane Baker

Relative Energy Deficiency in Sport or REDS. A syndrome that affects many of the body's physiological functions, our health, and athletic performance. As an endurance athlete, it’s really important to understand the signs and symptoms of low energy availability and seek support if you think this could be an issue for you.

Joining me to dive into the topic is fellow Sports Dietitian from Auckland, New Zealand, Dane Baker. He is an active researcher in the field of RED-s, lecturer at the University of Otago, and runs a specialist REDS clinic to help athletes recover from the multifactorial syndrome.

We dive into:

• What is REDS?
  
• What’s the difference between low energy availability (LEA) and RED-S
• Signs and symptoms to look out for to ensure you’re not in low energy availability for both males and females
• Tools for monitoring, screening, and diagnosis
• Treatment strategies
• Research updates in this space coming soon
• Where to get support if you think LEA or REDS is an issue for you

REDS can have serious implications both short and long term and it’s not something you want to go through. A must listen for any endurance athlete! Both male and female!

Links:

Read the updated 2023 IOC Consensus Statement on REDS HERE

Connect with Dane: LinkedIn

Website: danebakernutrition.net

Axis Sports Medicine: axissportsmedicine.co.nz

Check how well you’re doing when it comes to your nutrition with our 50 step checklist to Triathlon Nutrition Mastery: dietitianapproved.com/checklist

Start working on your nutrition now with my Triathlon Nutrition Kickstart course: dietitianapproved.com/kickstart

It’s for you if you’re a triathlete and you feel like you’ve got your training under control and you’re ready to layer in your nutrition. It's your warmup on the path to becoming a SUPERCHARGED triathlete – woohoo!

Connect with me: 

To learn more about the Triathlon Nutrition Academy, head HERE | dietitianapproved.com/academy

See behind-the-scenes action on Instagram: @dietitian.approved

Follow along on Facebook: Dietitian Approved

Join our FREE Dietitian Approved Crew Facebook group: Dietitian Approved Crew

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Episode Transcription

Episode 121: Female Athlete Series: Part 3: Relative Energy Deficiency in Sport with Dane Baker

Taryn Richardson  00:00

Welcome to Part 3 of my Female Athlete Series. Today I'm joined by fellow sports dietitian from all the way in New Zealand, Dane Baker, and he's going to shed some light on RED-S or Relative Energy Deficiency in Sport. It's definitely something that affects females. But we also do talk about the male athlete too because it is not purely females. He's worked for High Performance Sport New Zealand for 13 years now. He was on the New Zealand support team for the Rio Olympics back in 2016, the Gold Coast Commonwealth Games in 2018 and has had a long career in team sports. So he worked at the FIFA sports medicine facility as a sports nutrition specialist in Qatar. 

Taryn Richardson  00:46

He is currently the sports dietitian for Chiefs Super Rugby, the Black Ferns Sevens team, New Zealand Men's Hockey, and spent seven years working with New Zealand's swimming as well. He's also a lecturer at Auckland University and is involved in various research projects, particularly in the elite rugby space. I mean, talk about overachiever, I thought I was bad. This guy's busy. He also currently works in private practice in a RED-S clinic at Axis Sports Medicine in Auckland. So I'll link the details for that in the show notes.

Taryn Richardson  01:21

Like me, Dane is definitely a practitioner, and he's got some really practical tips if low energy availability or RED-S is something on your radar. What are the differences between those and some signs and symptoms to look out for? Plus, what do we do to make sure that we don't get into this rut of low energy availability for the female athlete, but also for the male. So let's dive into Part 3 of the Female Athlete Series all about RED-S.

Taryn Richardson  01:54

Welcome to the Triathlon Nutrition Academy podcast. The show designed to serve you up evidence-based sports nutrition advice from the experts. Hi, I'm your host Taryn, Accredited Practicing Dietitian, Advanced Sports Dietitian and founder of Dietitian Approved. Listen as I break down the latest evidence to give you practical, easy-to-digest strategies to train hard, recover faster and perform at your best. You have so much potential, and I want to help you unlock that with the power of nutrition. Let's get into it.

Taryn Richardson  02:31

Joining me all the way from across the pond in New Zealand is Dane Baker. Welcome.

Dane Baker  02:37

Hi, how's it going? Thanks for having me. 

Taryn Richardson  02:39

You're so welcome. Thank you for taking the time to talk to me. You're a busy man, you do so many things, and you got your fingers in all the pies. So it's an honor to be able to pick your brain all about RED-S today.

Dane Baker  02:50

No worries. Yeah. Let me pause up.

Taryn Richardson  02:53

Yew! All right. Well, let's get straight into it. For people listening that have no idea what RED-S is, what on earth are we talking about?

Dane Baker  03:01

Yeah, it's probably good question. I guess RED-S is like a syndrome that really gets underpinned by low energy availability. In simple terms, it's the physiological consequences of a prolonged period of being in a state of low energy availability. And then it has flow on a fix to different systems, different organs, metabolic rate, all sorts of different systems in the body. I guess RED-S has expanded from the original female athlete triad which looked at bone menstrual cycle, to all these other systems that we know are starting to get affected. And I guess the research is just evolving over time.

Taryn Richardson  03:01

Yeah, the more we know, like, the more we unlock around how it actually works, because it does affect so many systems in the body, doesn't it? It's not just those two things. And it also encompasses males which I think is really important. It's not just a female syndrome.

Dane Baker  03:55

Yes, yeah. And unfortunately, it's hard because so much of the research is focused on females, especially early on where a lot of that really low quality research around the female athlete triad and now just trying to expand that to males. In my experience, working with specialists, it's a lot harder to diagnose in males and males are a lot more resilient to low energy availability. But it definitely is something that can happen. The level of the effect on the system may be a little bit different.

Taryn Richardson  04:26

Yeah, why do you think that is?

Taryn Richardson  04:28

From what I've read, I guess there's the evolutionary protection of reproduction. So the stress response where this is not a good time to reproduce, whether it's in times of war, famine, or now we have other stressors and low energy availability from people just not eating enough. So maybe there just needs to be more research but we know probably bone density is particularly a little bit more in males from the research so far compared to females.

Taryn Richardson  04:54

Cool. So what is low energy availability? Like you and I, we really understand that deeply but a lot of people actually have no idea what that term means and how to identify if you are in low energy availability.

Dane Baker  05:07

Yeah, so I often talk to patients around, because I use energy availability every day. And the explanation is most of us have an understanding of energy balance, which is calories go in, calories go out, your body weight might go up or down. The problem there is that your metabolism is always in a state of flux. So your body can adapt to those calories, whether they're a little bit high, or whether they're a little bit low and this is where body weight can get quite confusing. And what energy availability is, it's this core amount of energy that your body has leftover that we can calculate by intake that has zero, but we were estimating how much energy from food your body's got leftover. And we use the kind of equation around calories leftover per kilogram of fat free mass or lean muscle. And so that fits a little bit more of a core, I guess, equation compared to energy balance. With energy balance, it's very hard to understand your metabolic rage, your non energy expenditure, thermal effect of food, all those things. They're always changing. And originally, a lot of the work was done in I think that's in birds in like success of like mating and reproduction, where they would use these kinds of equations to feed them and then understand reproduction. And that's when anilox kind of got a little bit deeper in using these formulas and stuff, the way that you can give an insight into energy, I guess in people.

Taryn Richardson  06:30

Yeah, so cool. It's really hard to calculate all those things, particularly for the listeners, they're all triathletes. So they're training for three sports in a week and you know, the energy availability, the energy intakes, or energy expenditure should be changing on a daily basis. And I know a lot of them count calories and track calories in and out which we know that there's limitations with both of those models. So I'm really pro, just getting them to understand how to periodise their food to training without having to do that, because it is gray. Like, it's so hard to do this stuff, even in a lab with a research study, where you've got someone in a tent, and you're getting them to breathe in and breathe out, and you're capturing everything, that's still going to change on a daily basis, and then throw three sports in the mix too, it's never a stable measure for a triathlete. And I think that's really important because as an endurance athlete, they are one of the key risk groups for low energy availability and therefore RED-S. So do you have any advice for somebody that is maybe trying to track calories or trying to understand what their overall energy in/energy out looks like in a week?

Dane Baker  07:40

Yeah, it's a good question. I think the first place to start is, if you are trying to track your energy availability, just know that there is a lot of error in that process, simply by how much you eat is hard to actually, there's probably a 20 to 30% error on that. So we're not thinking about the metabolic expenditure that's just going on at the time. And sometimes these devices pick that up as well. So it's typically a little bit lower. But coming back to your question, I think the key message is, we have these kind of so called thresholds around energy availability, which we can go into a little bit later, like the 30, the 45. But the only way is we really have those in detail are in really about 50 or 60 participants in really high controlled lab studies. So even those thresholds in real life situations, that doesn't mean you're in high or low, because your body is there's a whole lot of other factors as well, that's going into that. And that's what the latest sort of reviews are looking at is that you've got the additional psychological stress. You've got there's probably a genetic element to this. So there's going to be no cut off to say, hey, what do you do on your 29 kilocal per kg per day, you're on low energy.

Dane Baker  08:50

So you're looking how your body is responding. And that's that's what you're probably doing with your coach, how are you responding to the training, how's your fatigue? How's overall, like injury, illness, sleep, all of these things may be kind of saying. And the key one, which we can discuss, obviously, is tracking menstrual cycles. That's probably what we're doing and exactly what you talked about is having these good nutritional interventions around keeping it simple. Unfortunately, the area when I work with patients, I'm working with patients that had been in a real energy deficient state for a long period. So we actually tried to educate them around what they need. So that's a little bit different than, yeah, if we've got an athlete, that's healthy competing well, we just want them to be eating well, really.

Taryn Richardson  09:35

Yeah. Amen. I'm glad you're on the same page as me with that. Thank you for backing up my messaging that I've been talking about for a long time. Yeah. So we can dive into those cut offs a bit later. But firstly, like if somebody is worried that they might be in low energy availability, what are some of the things that they can look out for or signs and symptoms that they may not be eating optimally to support their training? 

Dane Baker  10:00

Yeah, so I guess if we start with the female, obviously, the key thing is a regular menstrual cycles, or absence cycles or a prolonged period without a period. So in New Zealand, our first point of call is the GP, that's the first place to start. And the challenge there is that athlete or patients on no contraceptive pill, then that will be masking your cycle, so that's the challenge. So that probably rolls out like 50 to 60% of a lot of athletes. Then the other signs to look at as obviously, like, I guess, excessive fatigue, not responding to the training, there's also been evidence around sleep. So sleep can be a factor. These often tie really closely with probably overtraining, there can be an element of just overreaching, and it doesn't mean that you've got RED-S. And that's probably where a lot of the information now is trying to get people to have context, it's this exposure to low energy availability that can long term cause a down regulation.

Dane Baker  11:01

And then in New Zealand, we would then if there is a concern would be then scaled up to a experienced sports dietitian or reproductive endocrinologist, because there may be other reasons why there's a menstrual cycle that's irregular, probably polycystic ovary syndrome, there could be other more nasty things at play. So you really need to exclude all of those other things. And that's what I talk about as a diagnosis of exclusion because essentially, you're excluding everything else. And you need blood levels, you need an experience clinician to be able to do that. But I don't think it hurts if you are concerned with that, that you're addressing nutrition, I think that's going to go hand in hand anyway. But I think it can help not to just think that it's RED-S because there's an absence cycle. I've seen that enough now that you, you really want that sort of followed up with your medical lead.

Taryn Richardson  11:49

Yeah, it's a bit like gut things. It's a process of elimination. It's not this. It's not this. So it must be this in a way.

Dane Baker  11:56

Yeah, it's a good point, because gut has another symptom. So Kathryn Ackerman's research they did, I think they surveyed about 1,100 patients at their sports medicine clinic. And there was almost a double prevalence of gut issues in patients at risk of low energy availability. So I'd say probably half the patients I see that are diagnosed will have had quite significant GI issues. A lot of them are unresolved, like IBS diagnosis, they've had colonoscopies, all sorts of investigations. And often it's a low energy availability thing. 

Taryn Richardson  12:27

Yeah, because it does affect all of the systems on the body. And if things aren't working properly, then you're gut's not working properly, either. And it's often one of the things that happens with endurance athletes or triathletes, in particular, you sought out somebody's fuelling and get that better, and they kind of miraculously disappear.

Dane Baker  12:43

Yep, exactly. And that's why I guess our approach is to try to use the energy availability concepts to get them to buy into that, because it's quite hard if you've got someone that's having a lot of GI issues and use your answer as just you need to eat more, that's often, that's not going to go too well. So I guess you need to kind of get them to buy into why they need to fuel more. And I think having that understanding of you're in a state of low energy availability, your gut's down regulating this is also affecting other systems. That's what we've found that actually is almost like a bit of a light bulb moment that they're like, oh, okay, I'm willing to try this. And then we often see there's a period of probably more bloating. There's a few things you can do to prevent that a little bit. But ultimately, it's your need to kind of get through that initial stage. And that's when all patients start feeling a lot better.

Taryn Richardson  13:32

What sort of things can you do to prevent that or minimise that extra bloating that might happen in that transition phase?

Dane Baker  13:38

I'm probably just referencing other people. But I'm a big fan of Dana Lis' work. And I've seen her present a lot of times, and I'm not experienced that around the FODMAP, but not doing the full exclusion. She talks about the offenders of like FODMAPs. And maybe we just look to reduce those. So I find probably 95% of patients have already excluded gluten, you're probably already included dairy and the devil, right? Yeah. So maybe you keep those things out but I try to educate that as you recover, your gut will be able to tolerate these things. And so it could be lactose free milk, it could be like sourdough bread, it could be low fiber options. The sweeteners, they're often a real risk, like their protein bars and protein powders. In most cases, they're the main offender, I've seen a lot of cases. So it's just finding better options or taking those out, spreading out the intake is obviously a key one. Yeah, I think a lot of people end up having less and less so they don't actually fuel before and we know that having something in the gut and hydrating is going to be beneficial. 

Dane Baker  14:41

But I do think it was interesting the female health conference, they were talking about now with the younger athletes avoiding those exclusion diets because it is quite triggering. That's yeah, I agree that's the other thing. 

Taryn Richardson  14:41

Yeah. 

Taryn Richardson  14:55

Yeah, it's just another thing to control when you potentially already have a restrictive diet in the first place.

Dane Baker  15:01

Yep. I see maybe it's just the New Zealand thing, but I see a lot of patients go through the FODMAP experience, but they don't actually come out of it. They just keep everything excluded. They don't recharge.

Taryn Richardson  15:13

Yeah, that happens here as well. And that's just education. They've done it by themselves, or their GP said, go and do this diet, look it up online, then have no idea about the impact of the long term implications of excluding all of those foods, because they're so good for our gut. 

Dane Baker  15:29

Yep.

Dane Baker  15:29

And I think I can't remember the paper, but they did some research and understood that the your gut microbiota changes with two weeks of the FODMAP diet. So it's not a long term thing. It is really just a test diet that you do for a short period of time, and then you want to get off it. But yeah, very common for me to see that over here as well. And globally, people get thrown on it, have no idea how to do it properly, because they're not working with a sports dietitian, and then just stay on it forever.

Dane Baker  15:55

Yeah, yeah. And we I think we see a disconnect, too, from the dietitians prescribing that there's a pretty clear and obvious low energy availability thing going on here. When got a 16 year old presenting with stress fractures, no period, and then FODMAP diet, because the gut health you're like, well, we put a lot of work into GP education. So hopefully, it's getting better.

Taryn Richardson  16:17

Yeah, awesome. And so that's the females. What about the males? What are some signs and symptoms a male athlete could look out for to make sure they're not in low energy availability?

Dane Baker  16:27

Yep. So I guess similar, probably from a fatigue perspective, I guess all that markers of your wellness type markers you're looking at with training and trying to understand if it's excessive, and they're not responding to the training. Especially our testosterone, like mood, and enjoyment is a big one that can be picked up, potentially a bit of body language with experienced coaches. Also, a lot of works been done in sort of hormones and around morning erections those things so it's a little bit, I don't think Greg Shaw's done a bit of work in that, and it's... 

Taryn Richardson  16:59

Yeah, Coxy?

Dane Baker  17:00

Yeah, it is, I hard yesterday of those discussions. But I think one of the best things I've heard those guys talk about as if you've got young guys, and they're not going after life and getting out there, and there's probably a bit of a warning. So if they're severe, and you can test testosterone, and I've seen many who I've talked to many specialists and seeing the present around the challenges of is a lot of reasons why the testosterone might be low and some of that supplementation and some of it can be steroids. So there, it's not a clear, and sometimes the testosterone is really low. So it's a little bit more challenging to get the actual diagnosis in the males.

Taryn Richardson  17:39

So just feeling tired, fatigued, not really absorbing in training and reduced sex drive?

Dane Baker  17:45

Yeah, and I guess if you are going to measure those hormones, try to do it with the specialists so they can understand the context of the time of the day, what this actually means, what could be affecting those numbers. And I guess, obviously, injury history, illness, that might play a bit of a part as well, like maybe soft tissue injury, all those kinds of things. And I guess just like male adaptation as well, but just not adapting, like to the training, and having them look their nutritionally to see if there's anything that can be helped.

Taryn Richardson  18:12

Yeah, it's not like one thing's gonna fix it. Is it? It's definitely multifactorial. And like you do in clinic, working with that person understanding what's actually going on first, and everyone can probably do with a little bit of understanding, feeling better for their sport, I would say.

Dane Baker  18:29

Yep, yep. In some forms, as well. I've seen like, maybe not so much of the endurance athletes, but fighters in particular, it's like the continued weight cuts in the hands. 

Taryn Richardson  18:38

Yeah.

Dane Baker  18:39

The body just stops responding. So they're not losing any weight. They're not losing, they're not changing body composition, yet they're just on a minimal intake. So that's kind of warning signs your system's starting to get affected. Pretty cool. 

Taryn Richardson  18:50

So there's some good things to look out for if you are listening, and you're like, holy crap, I'm worried but it's okay. Work with a sports dietitian and understand how to fuel yourself properly for your sport.

Dane Baker  19:01

And one other thing as well as there's been a bit of research around cholesterol levels. So that's often what we see as the cholesterol is abnormally high for an athlete. So that can be a bit of a sign as well, more than every one. But that does appear quite often.

Taryn Richardson  19:16

Is that because the body's releasing it into the bloodstream for fuel?

Dane Baker  19:20

Not sure that I think it's a cardiovascular response. There's evidence showing now that there's increased plaque in the arteries from states of low energy availability. So again, it's affecting different parts of the body. And I use as well, the the arteries, the endothelial cells, all those can be affected by low energy and protein synthesis as well. 

Taryn Richardson  19:40

Cool. I didn't know that one. If somebody does suspect that they're in low energy availability, and they are presenting to a doctor, presenting to sports dietitian, what are some of the things that we can use? What are the tools that we've got in our tool belt to then diagnose it, which is really difficult?

Dane Baker  19:56

Yep. So I guess the key message is you're not going to diagnose someone with RED-S for a dietary assessment. It can be a good educational tool. I guess one of the things you often see and I've done this when I've worked in elite teams is well, about 10 years ago, you measure what they do, you measure what they expend, and be like, Oh, they're all low on energy and it's just because it requires a terrible doing the diet. And you need seven days of data and reviewers, like we have seven days and you're like, well, I've got four days. And that was enough before they all wanted to punch me because they're getting sick of it. So yeah, everyone will act differently across different days. And you'll typically just see everyone's in low energy availability, because they're under report.

Taryn Richardson  20:34

Yep. 

Dane Baker  20:35

So the key thing is for a diagnosis would be if there is a high level of a concern to go through the GP and then do a battery of tests before clinical examination with someone that's experienced in whether that's a sports session, or an endocrinologist. And then, what we're looking at doing a DEXA diagnosis where they'll go through exclude all the other things that it could possibly be, then we're working on the energy availability, to start returning that athlete, whether it's female to having regular cycles. In the clinic I work in, they'll use a lot of blood work where every six weeks, the patient might do a repeated hormonal test. And we can actually see those different with the estrogen, the ideal where it just slowly starts to go up. And then it goes up to a certain level and then that patient might have if it was period, and then the goal from there is trying to get that cycle within that sort of 28 to 35 days.

Dane Baker  21:32

And so they'll do test as well, the formulations occurring. And that can be a process. So it can be we often say it can be 12 months, it might even be 24 months before that cycle's really regulated. And that level will depend on the patient if there's a strong I guess, the sort of eating element to this, then we need sort of specialist services around that. It can also depend on how long they've been in low energy availability, if they've just kind of dipped into it recently, they can typically get out a little bit quicker. But there's a lot of factors at play, stress, how much training you're doing. I can show them what fuelling looks like, but if their training is high intensity all day, every day, you've got a lot of other things going on there with regards to the stress. It is a challenging piece, but I definitely say diagnosis needs to be specialised, I guess.

Taryn Richardson  22:26

Yeah. And you may never get a diagnosis necessarily and have that written down on a piece of paper. But it doesn't necessarily mean that it's not you or you're not affected by low energy availability. So going through all of this stuff is still really useful. 

Dane Baker  22:39

In the challenge, we have in New Zealand is that it's private health care to see these people that's not covered by ACC, which is our government sort of insurance. So it does often involve quite a bit of cost. And we know we're missing a big chunk of the population that don't have access to that resource really. 

Taryn Richardson  22:56

Yeah, I think that's really important. So what are the some of the things that you do with somebody that you would see in clinic then to help them through low energy availability or RED-S? Like let's get practical. That's my happy place.

Dane Baker  23:10

I'm really passionate about the concept of energy availability, because I think it's a really nice way to educate athletes, patients around putting their different days together, their weeks together, rather than just like a nutrition, have this much of your carbohydrate, this much protein. You get into those real emotional debates around carbohydrates and sounds like okay, that your body needs a certain amount of energy. It might not need all this, it might need some, what, how much do we need to get? I do a full hour consult, trying to understand their training week, the different days of training, what they're currently eating. We don't try to analyse that from a calorie perspective. It's more like an assessment or interview.

Dane Baker  23:50

And then I'll go away and put that up, what do I think is the negative energy availability, it might be that they need to recover from being in a RED-S for six months, and that in that regard, we're trying to get to those higher thresholds, it may be someone looking to reduce body fat, and maybe we want to do that safely and still use energy availability to ensure that there's enough baseline energy but we're just kind of minimising it. But I don't get anyone counting calories. That's that's the key, but I'm using kind of structure to go okay. This is the reason why I'm trying to get you to eat this much. And then there'll be a real visual plan around That's breakfast lunch then as snacks. That's a really easy way to put the pieces together. But the framework is around different days of training getting the energy right but then getting the distribution of the energy right. That's the key.

Taryn Richardson  24:41

I'm the same and I don't get people to count calories actually did a whole podcast episode around why I don't think it's very useful for triathletes to count calories for so many reasons. Some of which we've touched on today. So it's nice to see that the New Zealand sports dietitians are on the same page as the Aussie ones.

Dane Baker  24:59

There's something like, all the case studies, and I'll get challenged on it, we've actually just about to publish research on 55 recovered RED-S patients around there, facilitators and barriers to increase energy availability, and increasing energy intake and increasing meal frequency causes. There was a causes anxiety, yeah, but there was also a relationship with knowing what they needed to eat reduced that anxiety as well. So often, the thing I often hear from my patients is everyone's told me, I've had RED-S, they just told me, I need to eat more, but I never know how much I need to wait. And that

Taryn Richardson  25:38

Just stresses me out the whole time. So hard.

Dane Baker  25:41

So it's like, Okay, here's a framework. And then I kind of present that as this is a blueprint for the next 12 weeks. And it's like, Okay, hopefully in that time, we'll have to repeat a blood tests. And maybe we need a bit more energy, maybe you don't need all this and you start doing pretty good. But it creates that kind of structure and routine. And often, that's another thing, they benefit as having the structure and like the structure in place, and that's a big part of that with energy availability with around appetite. So we know appetite. reducers. So sometimes as simple things were a lot of athletes can easily implement those in low energy availability, that their appetite's dysregulated. So giving them some kind of what's the good structure, in actual amounts can be quite helpful. But again, the amounts is just food, it's just options. So it really is food and not eating calories, but is a rationale to why you're eating those kinds of options.

Taryn Richardson  26:36

Yeah, sometimes you just don't need to tell everyone all the detail that goes into a plan.

Dane Baker  26:40

Yeah, yep. Yep. And I'll talk to that as well. Yep. So every patient that I feel like if there was a young patient with the appearance, also if I'm talking about calories, does that cause any stress? And they're just like, nah. Like, one thing I've learned from clinical psychologists as they like, they'll know it anyway. So you telling them is like, that's only an hour more disordered, so I guess patients. And the specialist will do that review and if there is a high level of disordered eating, and we'll use clinical eating, the sort of services for them to start working on different ways of eating.

Taryn Richardson  27:14

Yeah. And a message to that type of person to eat more is not going to land well, either. Like it's not useful, it's not helpful. It's not going to actually change things.

Dane Baker  27:23

Yeah. And what we've found is we often see a lot of those patients as they come back from those services. And they want to return to sport. But they've got a limited plan, I guess. So we're trying to give them more, a lot more variety and a lot more, keeping the structure but just opening them up to eating a whole range of different foods.

Taryn Richardson  27:43

Yeah, it does take a multidisciplinary approach, like working with triathletes. It is, you know, the sports physician and the psychologist and the sports dietitian and the coach and all the things to make sure that all bases are covered. It's not just one person trying to work with an athlete, it needs to be that same message. And everyone helping all the different components to help somebody get their body working properly again.

Dane Baker  28:07

Yeah, exactly. And that's where I'm lucky with where I work, because it's all sort of clinical based and private health care. It's a really stimulating environment, but quite fortunate, because everyone's on the same page. And that's why it's been so interesting coming from sport, where you have certain situations where you go great environment, and then you have another environment, which is just, you know, this is going on. But it's really hard for you to get that athlete to buy into it, because just don't have the consistency and the voices. If there's been the diagnosis, there's been a whole process before they see me. And they're like, right, tell me what to eat. I've kind of got over that base now.

Taryn Richardson  28:48

Yeah, that's good.

Dane Baker  28:49

So that's good. So that yeah, so the way I work is, is in a different setting. I guess I try to emphasise that to people I'm kind of working in the recovery space. I'll see a range of athletes, but that's kind of my sort of focus all the time.

Taryn Richardson  29:02

Yeah. But we've talked about some of those things to identify it, which I think is really good. Can you touch on for me the continuum of low energy availability or RED-S, like in the different kinds of levels that we have? Because it is important to understand that you're not in low energy availability, or you're not. It is a continuum. And we have some good information around that if you can dive into that a little bit for us Dane. 

Dane Baker  29:25

Probably the biggest term I think is the best term is a  problematic low energy availability. So I think that's something we should all have a good understanding of is at different times of the day or waking up in the morning, you're in low energy availability, you haven't eaten all night. That's not going to really make any difference. But it's the exposure to the low energy availability at an individual level. So you might have someone else that's exposed the same low energy availability, but their system doesn't seem to be as impacted. So that's also hard for patients to understand and beat. That's because there's a genetic element, but it's also the psychological stress or the situation's someone's in. And that's also then having a fixed cortisol levels, which is further suppressing estrogen. 

Dane Baker  30:08

So, to go back to your questions, the different thresholds really come from the work of anilox, who use those numbers to start to quantify. If I feed someone this, and I do this really well controlled study what starts to happen? And so it's just like a dose response, I guess of energy availability. And what they found was, once probably they go below that 30, that reproductive system starts to unravel within about 24 to 48 hours. For just a real crude example, you've got someone that's 60 kilograms, and they go for a 40 minute run. Maybe they expend like 400 calories in that run. And so if they're eating, let's say, 2500 calories, they've got about 2000 calories left to their system. Depending on the size of their body mass, then is probably going to be pretty close to 45. If they go into low energy availability, if they're eating sort of 1600 calories a day, that might mean they've got about 1100 calories leftover. So you can kind of think about as how much leftover to the system.

Dane Baker  31:12

And then those really well controlled lab studies, they found within about 48 hours, if they can get that threshold really accurate, that reproductive system, like insulin, estrogen within 24 hours starts to reduce. So there's real clear signs that it's impacting. Where the challenge has been is they've replicated these studies in real world situations where they've done food diaries, and they don't see the thresholds is clearly and that's probably just because there's a bit of error. But even in those studies, I think there's a 50% chance of quite significant menstrual disturbance at below 30.

Dane Baker  31:48

The other interesting part is it's kind of body system dependent as well and that's where the bone and the anilox's work, the bone actually started to downregulate as soon as you went below 45, which is quite interesting for adolescent athletes. So at that age, you're just trying to build tissue, and you don't want to compromise really anything. So that's another reason why low energy availability and adolescence is really can be quite problematic. So that's how it works. But again, it's at an individual level, it's there's no sort of black and white here. And there's going to be your if you analyze that. So that's what you're looking at from a health perspective as like not diagnosing it but, are you healthy, are you getting through training, are you having a regular cycle, then you know, your energy availability is adequate. And with our elite athletes, we can start looking a lot closer was different monitoring tools around the length of the cycle, how they respond to training. But from a general population, we're just looking at, are you healthy, are you having a regular cycle, are you getting through training? Those are the kinds of things we're gonna look at it.

Taryn Richardson  32:53

Yeah, I think that's really good to highlight.

Dane Baker  32:56

But I guess, as well, like coming back to the problematic LEA, we know there are nutrition interventions, such as carbohydrate restriction for pseudo trainings, and it doesn't mean just because you do that once a week that you're gonna start getting an LEA, you need to monitor it. And that's where the elite environments with Olympic had these monitoring systems in place. But the challenge is when you go and do that without that physiology support, without the medical support, things can start to slip and a lot of those studies like Lewis's and John Holley's work, they're actually ISO energetics. And they still got the same energy, they're just changing the carbohydrate and the fat.

Taryn Richardson  33:34

Yep.

Dane Baker  33:35

But when someone goes away and does it, they often just take a whole lot of energy out of it, though.

Taryn Richardson  33:40

Yeah. 

Dane Baker  33:41

They don't just start massively increasing their fat intake overnight.

Taryn Richardson  33:45

Yeah, it's important to highlight that it is a short term shift to like a day or two or three is enough to drop your cycle out for that month. So it's something you have to be on top of relatively quickly. And prolonged, low energy availability is not what we're aiming for. But short term, maybe a little bit of advantage, as long as it's well supported with nutrition.

Dane Baker  34:04

Yeah, yeah. I think that's what your guys work in AIS, I think there's a really nice information that just came out recently around body composition and when you should look to do interventions around how much support you have the age of the athlete. I think that's a really nice way to put it, where, if you are in these really well support environments, you can do it in a safe way. But when you don't have those resources, that's when things go. And there's toxic cultures that's just a recipe for the energy availability stuck in compromised pretty quickly.

Taryn Richardson  34:36

Don't get me started. Don't get me started.

Dane Baker  34:38

I've never worked at triathlon. But yeah, we see we see a lot of triathletes. 

Taryn Richardson  34:42

Yeah, I'm really passionate about just getting them to fuel training and understanding their periodisation of that, which nobody knows how to do unless they've had some support, but they all want to lean up. Everything, a lot of them. Yeah, like one in 100 doesn't. So they're constantly trying to cut back calories, trying to scale back to drop some body fat for an event, but then putting themselves into low energy availability and basically trying to push it uphill, because they've affected all of their body systems to the point where it's just not working. So yeah, I see that really commonly, which is why I built the Triathlon Nutrition Academy to teach triathletes how to actually eat to support their training so that this doesn't happen. Because it's very, very common.

Dane Baker  35:25

I guess, for you guys is what we see. Because a lot of the referrals I'll see come initially through the stress fracture injury. Yeah, just how catastrophic that is, once you've had one rescue of another one, and it's just like.

Taryn Richardson  35:36

Do you know the percentage? I was trying to think of find out the other day, there's a percentage of like, once you've had one your incidents of having a second is high.

Dane Baker  35:44

Don't quote me, but I think it's as high as 30 to 50% of the rate risk. Yeah, a lot of that would be from just the behavior, I guess, as well. Like, if it's caused by low energy availability, it's not like they're just going to snap out of that, typically. So it's here. It's devastating. We work quite a few athletes have progressed to the college system in the US, and then you'll see the stress fracture appear again, and yeah.

Taryn Richardson  36:10

Yeah, it's disappointing, because then you're not training and then you're not racing. So let's not get to that point people, I hope that's it before that point.

Dane Baker  36:18

Oh, yeah. And we have these conversations regularly. Because I think for most probably like triathlon would be in that category as well, like strength, strength power, and like power to weight ratio, it's, it's often the lowest hanging fruit is like let's reduce body composition. But I think the thing is, if you take the low hanging fruit, there's a 50% chance that you could bring the whole tree down. And then once you start getting into that real problematic LEA, it can be a 12 month process. To get them back and get the body comp right as well, that can be two years. So we've seen that in patients. You're just really risking things if you're not doing it with good support, good monitoring. And that's the hard part to those modern those like systems.

Taryn Richardson  37:01

I love that analogy, like bringing the whole tree down. I think that's a good one. I'm going to use that.

Dane Baker  37:05

Yeah, I'll just be thinking about that. Because I use conversations all the time, because it's what most people go for they'll all, will get you leaner, will get you faster. It's like, yep. But there's been a three year history of stress fractures and LEA. So I think everyone comes to the table different in that situation.

Taryn Richardson  37:21

I agree. I agree. So many gold nuggets there. What's just general advice for somebody to make sure that they aren't heading along that continuum? And if they think that they are, what are the best places to get some support? 

Dane Baker  37:35

It goes back to what you were saying, I think if athletes are actually getting really close to those recommendations from the IOC, that a lot of the work that's done around carbohydrate availability, protein, when those admit they're in a really good state of energy availability. So having that awareness, and I think the best place to often start pre, during, and post, if you start working on those and you start training more, you'll naturally start to get better. And along this can come down to the gut and being able to tolerate more that.

Dane Baker  38:02

I think you need to have the awareness of those quality sessions of you know, when the intensity is getting higher then we need that carbohydrate and when you think about recovery. But then we need to also think about it's not just, you know, 150 calorie protein shake with water, it's like, okay, you'd be on a bike for four hours, how are we going to start to get that energy back in the system when you're training again in 24 hours. So those are the kinds of things I think you need to consider. And like if you are an athlete, just knowing that you should be periodising energy across different days, you know, and that could be framed around your exercise. But also just having that awareness that if you're in the same thing every day, but you've got huge train demands one day to the next, you're going to be up and down. And not only your performance, but long term, your energy availability might start getting compromised. I

Taryn Richardson  38:47

Couldn't have said it better myself, Dane. So carbs are your friend my friend. Don't be afraid of carbohydrate.

Dane Baker  38:54

Yeah. Now I guess there's a law that was written in BGSM a couple of weeks ago, which really sort of alluded to female athletes in particular around carbohydrate and isn't potentially another mechanism at play around LEA. And it's, again, there's just more stress hormone, there's more cortisol. So maybe a lot of that work we just haven't done in females around carbohydrate periodisation. And it's just something again, to be aware of that it might not be as simple as what we've seen. 

Taryn Richardson  39:24

Yeah, we're getting there in that space, aren't we? Slowly, slowly. It'll be another 5 to 10 years, but we'll have all the magic answers soon.

Dane Baker  39:31

Yep. 

Taryn Richardson  39:32

Well, thank you so much for diving into RED-S with me, giving us a bit of an update on the new things that are changing and what somebody could actually do if they were worried about being in low energy availability. It's been awesome. I didn't want to do this episode myself. So I brought in the big guns to give us the lowdown. If people want to find you, Dane, what's the best way to do that? 

Dane Baker  39:54

Yeah, go to axissportsmedicine.co.nz. There's lots of information on the clinic. We can see people all around the world or the country and also try to keep active on LinkedIn. I try to update a few things. I'm not too good on the other social media pieces.

Taryn Richardson  40:07

I was trying to get you on Insta.

Dane Baker  40:10

I go on there but I look at fishing tips rather than nutrition.

Taryn Richardson  40:14

It's a beast either have to like fully commit to it or don't because yeah, it's huge.

Dane Baker  40:20

Yeah.

Taryn Richardson  40:21

I'll link those things in the show notes if somebody does want to look you up. Can't find you on Insta but can find you on LinkedIn. Does anyone use LinkedIn?

Dane Baker  40:28

I don't know. Probably not. But you've got to the website, we have a good database of patients and physios. So we're always trying to put out blogs and the latest information to keep people abreast of what's going on the space.

Taryn Richardson  40:41

Okay, cool. Awesome. Well, thank you so much, Dane. Thanks for your time.

Dane Baker  40:44

Cool. Thanks, Taryn.

Taryn Richardson  40:45

And I'll talk to you soon.

Dane Baker  40:47

Cheers.

Taryn Richardson  40:48

Thanks for joining me for this episode of the Triathlon Nutrition Academy podcast. I would love to hear from you. If you have any questions or want to share with me what you've learned, email me at [email protected]. You can also spread the word by leaving me a review and taking a screenshot of you listening to the show. Don't forget to tag me on social media, @dietitian.approved, so I can give you a shout out, too. If you want to learn more about what we do, head to dietitianapproved.com. And if you want to learn more about the Triathlon Nutrition Academy program, head to dietitianapproved.com/academy. Thanks for joining me and I look forward to helping you smashed in the fourth leg - nutrition!