Rugby to RED-s: Part II

Written by: Dane Baker

In my previous article (PINES e-News May 2022), I discussed my transition from working in professional rugby as a sports dietitian, to now working in a clinical setting with patients diagnosed with hypothalamic amenorrhea / RED-s. In this article, I’ll share my insights into working with this patient group. It is important to emphasize that I work in a unique position in a multi-disciplinary team with sports physicians and reproductive endocrinologists who do a full clinical work up and diagnosis prior to my meeting with the athlete. My role is to assist their recovery through optimizing diet and fueling strategies to restore a regular menstrual cycle. Follow-up is assessed through blood tests and specialist consultations. 

In New Zealand, patients receive no government subsidy and this is a user-pay process. My consultations are one hour in duration, where I assess dietary intake and exercise output, and then educate around the concept of energy availability and how this will be incorporated into their periodized nutrition plan. I create a plan based on the information obtained in the assessment. The plan is designed to create structure and routine across multiple days of training or exercise situations, with energy spread across the day to ensure they reach optimal energy availability. I focus on portions at main meals, fueling during exercise, recovery options, and consistency in snacking. As a practitioner, my focus is on changing behavior by changing beliefs around nutrition to get the patient on track as soon as possible. Often due to cost, I only have one session available to achieve this. Ideally, I review the patient numerous times across their recovery journey, however my initial goal is to provide an in-depth plan for the coming months of training. 

Below are my key tips and insights I have gathered along the way. As we know there are many limitations and grey areas in the field of energy availability1. However, I have learnt with these patients using the concept of energy availability in nutritional planning can be a powerful and pragmatic approach to recovery. 

The concept of energy availability works with patients.

Many patients diagnosed with RED-s have restrictive eating patterns. They have removed food groups due to perceived intolerances and allergies that show up in gut issues (a common symptom of RED-S 2.) Combined with their concerns about body image, carbohydrates, and potential health issues related to dairy and animal protein, for me to simply provide generic advice to increase carbohydrates, add meat to your diet, or just eat more is not going to be an effective way to increase energy availability in this group.  I spend a lot of time educating patients about the concept of energy availability and how down-regulation of key metabolic systems is affected by low energy availability (LEA). This buy-in is vital to convince the patient to follow an often-challenging energy intake.

 I am an avid reader of Professor Anne Loucks work, her latest chapter in Endocrinology of physical activity and sport 3 is great reading and an example of the formulas I use in prescribing energy. I talk to patients over and again that their energy intake needs to be periodized across the week, just as their training is. Having a strong concept of fueling adequately for performance and underlying health is a vital part of buying into the nutrition plan. 

Energy distribution is so important.

Many patients have poor energy distribution; most train fasted for every morning session. Minimal or no fueling during prolonged exercise sessions is common practice. Creating consistency and routine with their pre-, during- and post-training nutrition is a common priority for most patients. Artistic athletes such as dancers, gymnasts, and divers often spend 4-6 hours training with minimal energy consumption. I have been surprised many times that simply inserting small snack breaks or fuel during the session (with easily digested forms of carbohydrate) has improved their reproductive profile when their total energy intake still appears deficient. I often reference the information in Fahrenholtz et al’s 4  work about the importance of energy distribution to patients; this is a key area for recovery. 

Gut symptoms are real

As I alluded to in my introduction, many patients present with GI distress and IBS-like symptoms. Many have gone through a journey of trying a fodmap diet, excluding food groups such as dairy, going gluten free, or trying a strict vegan diet. Many times, they are unable to pinpoint the cause. In a lot of cases, these symptoms first appeared when energy availability was most compromised. This can make it challenging in providing a nutrition plan adequate in energy and nutrient density. I try to work with the patient with foods they tolerate initially to increase their energy intake. I also discuss the association between LEA and GI symptoms to provide confidence of re-introducing certain food groups as they progress in their recovery. 

Appetite comes back

Appetite can be suppressed during times of energy restriction, so simply following appetite often results in many athletes being under fueled. As these patients recover, they often tell me their appetite has normalized, and they become far more comfortable consuming their prescribed energy intake (as compared to when they started). They now look forward to eating; achieving their required energy intake becomes much easier. Often the first few weeks are the hardest, so this takes trust in the process that appetite will get better and bloating will subside. Again, an important role of the practitioner is to instill confidence in the patient that they can achieve their recommended intake. 

Watch out for significant energy expenditure / exercise addiction

The latest research by Fahrenholtz et al 5 suggests a positive correlation of exercise addiction and LEA. These patients (athletes and non-athletes) are very high energy burners. They are often avid walkers outside of training, to and from school, during their day on campus etc. During the assessment, understanding their day-to-day movement as well as their training schedule is crucial. There are obviously limitations in assessing and calculating this, however ultimately the plan is to increase their energy intake. Each day can vary significantly with energy expenditure, so my goal is to provide a clear structure to fuel those different training-day scenarios and urge on the side of higher than lower energy intake.

Isn’t optimized EA just good fueling and adhering to sports nutrition guidelines?

Yes! When I put these plans together, each week’s energy needs get prioritized around and during training. Macro nutrient balance is also a key to optimize energy intake. These active patients require calories in the 2,800 – 4,000 mark, so removing food groups makes this intake very challenging. As I have alluded to earlier, many patients have strong beliefs in food groups and their perceived effect on their health and body image. I have found using the concept of energy availability and calories as a tool for food choice and portion size rather than a focus on food groups or macronutrients has been more impactful on changing behavior. As a caveat, I do not work with patients with clinical eating disorders. (They are referred to eating disorder services through the clinical diagnosis process.) Yet, I will ask patients during the assessment if my talking about calories creates anxiety. If yes,  I color-code nutrition plans rather than identify calorie targets. 

Good one Dane, but where’s your evidence??

What I have told you is completely anecdotal and based on the patients I have seen over the past 4 years. Research focusing on the recovery of athletes with RED-s is scarce. We are currently in the process of retrospectively surveying these patients to learn the barriers and facilitators of dietary change in their recovery process. This research is being conducted by the University of Otago and Axis Sports Medicine. We hope to have more evidenced based information to share with you all by the end of the year!

References
  1. Areta, J. L., Taylor, H. L., & Koehler, K. (2021). Low energy availability: history, definition and evidence of its endocrine, metabolic and physiological effects in prospective studies in females and males. European journal of applied physiology, 121(1), 1–21. https://doi.org/10.1007/s00421-020-04516-0 
  2. Ackerman, K. E., Holtzman, B., Cooper, K. M., Flynn, E. F., Bruinvels, G., Tenforde, A. S., Popp, K. L., Simpkin, A. J., & Parziale, A. L. (2019). Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport. British journal of sports medicine, 53(10), 628–633. https://doi.org/10.1136/bjsports-2017-098958
  3. Loucks, A.B. (2020) Exercise training in the normal female: effects of low energy availability on reproductive function. In: Hackney
  4. AC, Constantini NW (eds) Endocrinology of physical activity and sport. Springer International Publishing, Cham, pp 171–191 https://link.springer.com/book/10.1007/978-1-62703-314-5 
  5. Fahrenholtz, I. L., Sjödin, A., Benardot, D., Tornberg, Å. B., Skouby, S., Faber, J., Sundgot-Borgen, J. K., & Melin, A. K. (2018). Within-day energy deficiency and reproductive function in female endurance athletes. Scandinavian journal of medicine & science in sports, 28(3), 1139–1146. https://doi.org/10.1111/sms.13030 
  6. Fahrenholtz, I. L., Melin, A. K., Wasserfurth, P., Stenling, A., Logue, D., Garthe, I., Koehler, K., Gräfnings, M., Lichtenstein, M. B., Madigan, S., & Torstveit, M. K. (2022). Risk of Low Energy Availability, Disordered Eating, Exercise Addiction, and Food Intolerances in Female Endurance Athletes. Frontiers in sports and active living, 4, 869594. https://doi.org/10.3389/fspor.2022.869594