Episode 57A - What’s the nutrition roadmap for recovery from relative energy deficiency in sport (RED-S) | Bronwen Lundy

Over recent podcasts we've talked about this issue of low energy availability and the problems that can cause for athletes in terms of both performance but also health consequences and most recently in our last episode we talked about that specifically in terms of the risk of bone fractures. But what happens if you're in that situation now? You've got a whole of fatigue that you can't get out of or you've had multiple stress fractures or you've lost your menstrual cycle or there's something else going on or a combination of things perhaps. So today our episode is going to be dedicated to people that are in that situation and how do you get out of that? So what is the nutrition roadmap for recovery from relative energy deficiency in sport? Hello and welcome to the Long Munch, the nutrition podcast for runners cyclists and triathletes. I'm Ellen McCauvin and I'm Steph Gaskell. We're both the credited sports dietitians based in Melbourne and combined have over 30 years experience working with runners cyclists and triathletes to help them stay healthy and optimize their performance from complete beginners through to professional and Olympic athletes. Each episode we take a deep dive into the most common nutrition questions that runners cyclists and triathletes ask. Sort of stuff the people are talking about out on their run or ride in the coffee shop afterwards or jumping on Google to find out more information about it. So we'll take that topic, break it down and invite a guest expert in our A episode or a guest athlete or coach in our B episode to add their perspective as well. Today it's episode 57A. What is the nutrition roadmap for recovery from relative energy deficiency in sport? And our special guest is Bronwyn Lundy from Rowling Australia. But before we get to Bron, Steph, how are you going this week? I am going good out. I've been really enjoying the Matilda's The World at Our Feet which is a kind of docuseries on Disney Plus and really getting to know the players so much so that I've booked Tanya and I tickets to the game in July, early July, where the Matilda's are going to host World #5 France. It's going to be the first time they've faced this team on home soil. So yeah, I'm really looking forward to that. Otherwise just ticking along, doing some work, not getting weekends yet. I just like you, I think. How are you going? Yeah, good. I think there's a lot at the end of the tunnel and the work side of things. The semester sort of starts to wind down over the next couple of weeks, which is nice. But that said, obviously as a semester winds down in the work side of things, particularly over on the other side of the world in Europe, the sporting seasons really kicking into gear. So we're seeing lots of professional cycling, triathlon events, all sorts of things happening over at a stupid o'clock time zone for us here in Australia. And then local racing with one of my kids racing their school cross country or their inter-school cross country the other week as well. How'd they go? Yeah, they had a fun time sort of in the front 30th of the field I suppose. But yeah, I mean the main thing was his first time he's ever done a race. So just getting out there and enjoying it ran around with one of his mates. So yeah, that's good. Yeah, yeah, yeah. Updates and announcements from us, our so thank you so much for everyone that provided us feedback by our podcast survey. It was really interesting and we're taking on board that feedback. We will announce three people next week who are the winners of a free copy of our ebook which will be finished in a few weeks. 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So we're lucky enough to be joined by Bronwyn Lundy. Now Bronwyn is the nutrition lead for rolling Australia and a former high-level lightweight rower herself. And she's particularly experienced in this area of relative energy deficiency in sport. She's probably experienced it herself as an athlete, and particularly one who's competing in a weight category sport where she's had to do that. But she's also just recently completed her PhD in this particular area of reds and low energy availability. And I guess in terms of her work with rowing Australia, well, she doesn't work directly in running cycling triathlon. There are a lot of parallels with rowing, particularly around this area of energy availability and training load. Rowers have very high training loads, very similar to what we see in running cycling a triathlon. And she's spent many years working with rowers and other athletes. She's worked at the English Institute of Sport, the Australian Institute of Sport. And now with rowing Australia helping athletes to identify and recover from reds. And she's a real wealth of practical insights into how that recovery actually plays out, given that she works with the same athletes over a very long period of time. And she can look at the different approaches that can be taken to recovery from reds. And it's not just a one-size-fits-all. And I think that's what we're really getting into today is how you can recover from reds, but also the different strategies or approaches that you can take to that depending on your situation. Yeah, awesome. And I'm pretty sure she does enjoy getting out in the trails and having a bit of a run herself. So yeah, yeah. Awesome. Let's get stuck into it. Yep, let's do it. Run when Lundy. Welcome to the Long Munch. Thanks very much. Thanks for having me. Very welcome. So a large part of your work is working with elite level rowers. What got you interested in working with this sport in particular? Oh, look, it was the sport I always wanted to work in. I've worked across a range of sports before, you know, anywhere that nutrition can be of assistance. I've done heaps of rugby work like a lot of sport statutions would have done. But when the job came up with rowing, I was super keen to take it culturally. It's a really good fit for me. I started rowing when I was in high school as a school girl eight, which was a really great life experience. And I got to see bits of Australia that I otherwise wouldn't have at nationals. And you know, that kind of thing was quite exciting. And when I finished, I continued rowing for a few years as a lightweight. And that really sparked my interest in nutrition like how can you adapt your diet to change your physique to meet the goal that you need for sport? I was a heavy lightweight so I never bound for long-term success unfortunately, but it really gave me some insights into where the limitations might be in terms of what your body is happy to do and not happy to do and how far you can go with nutrition in those things. So maybe not the best healthy approach, but a really good way of understanding those things from the inside out. So love working with rowing in the diversity of it. Yep, yep. Besides working at that level, you've recently completed a PhD well done. And that was looking at energy availability. What were your main findings and how are you going to kind of put this information into practice, I guess? I think I was really motivated to do the PhD from my work in rowing. So I could see that bone stress injuries were a really important performance limiter in rowing and I was trying to dig into some of the reasons that nutrition could be a contributor or not to that. And the energy availability came out as a really big one and not just in the ladies, but also in the fellows as well. So that really sparked the interest. I had three studies, the first one being really a descriptor of the rowing population and trying to find associations between nutrition factors and injury and we found that vitamin D and calcium and things weren't massive contributors in the rowing population. If you've ever hung out with any of them, they drink more milk than you can possibly imagine the dairy intake is really good and they get a lot of outdoor time to get double summers, Australia and Europe. So they weren't factors that contributed probably because they weren't limiting in that population, but the energy availability was a really big one. We asked a really basic nutrition question, do you eat as much as you want all the time? Do you modify your diet to achieve a body composition goal? Do you have to work quite hard at that or are you living off the smell of an oily rag and you're starving all the time? And even just that I modified my diet to achieve a body composition goal was associated with the greater history of rip stress, which is the main bone injury. that we get in rowing. So that really sparked a bit more interest for me in that space. And we looked at how to work out with male athletes whether there might be signs and symptoms of low energy availability. So we have some findings from that that we can apply. And then with the last study I've noticed that over a male role as career they tend to lose bone mineral density particularly in the hip. And I wasn't really sure why that was. And whether it's an energy availability thing or where it was coming from somewhere else. It seems like there's other contributors and we looked at calcium intake cutely before training sessions and whether that would promote or reduce the amount of bone breakdown that you might see over a typical training day. And that was a successful intervention. So I think the thing that I'm really happy with is all three of the studies are really practical and can be applied. And we've been applying them as we go along. And it's really answers to my clinical questions. You know, how do I manage this group that I got out of the PhD. So we're worth off from my point of view. Quick question. No, I think it's just as you're talking about that study around the calcium intake. We have chat with Luke Wilkins in the last podcast which was around bone health. But I'm interested in your take on this as well because you've been involved probably in in both of the studies that have happened here in Australia around calcium intake and sort of bone turnover during that specific session. Are you fairly confident that those changes in those bone turnover markers, you know, we talk about this with protein like you can measure muscle protein synthesis in a few hours period. But are we confident that that is reflective of what's going to happen to muscle over weeks or months if it's consistent? Are we fairly confident that that relationship holds for bone turnover markers as well in terms of what you see within that couple of hours of a study like that? We say, well, if you do that regularly, you are going to end up with better bone density. Can we be confident about that? You've gone straight to the heart of Ireland. No, no, really, we can't. Like, it's a really good piece of the puzzle that we got from the study. But we don't know how that applies and point of difference with the rowing study that I did compared to all of the earlier ones where we looked at two training sessions. So we looked at a training day and we had two supplemental calcium periods before two long training sessions and over the course of the day, the markers of bone breakdown were lower in the calcium supplemented group over seven, eight hours. So we can say over that period the bone breakdown was less. But what happens overnight? What happens when you put those days together and actually is dampening down the bone breakdown? Is that a good thing or a bad thing? Like, you need some bone turnover to build stronger bones. So are we causing maladaption as opposed to supporting it? So that we really don't know. There'll be some research coming out of Wendy Courts group over probably in the next 10 years to answer all of those questions. But she's picking up the research thread and definitely running with that. And she's done a lot of the earlier work in older individuals and cycling and running based athletes. Man, it's tricky because you obviously changes in bone density are so slow that you've, yeah, you've got to follow people for a really long time to figure that out, yeah. We were really lucky to be able to do the type of study we did in our Olympic growing group. I'm still quite believe that we managed to pull it off. But certainly those longer term studies are we'll be able to do in this population anyway. So yeah, back in episode 24A now, which is quite some time ago out. We had a sports dietitian researcher that you know very well, Bronn, Margot Rogers. So we had heron to talk about the question, can I underfuel my training? We discussed how to define adequate fueling for training. What happens if you underfuel? How do you know if you're eating enough? And we briefly talked about what to do about it if you're not getting enough. But we've wanted to go into this last part in a little bit more detail. So how can an athlete start the process of recovery from underfueling and more specifically relative energy deficiency known as reds? Sure. So yeah, so I guess before we get into the recovery aspect of reds, are you able to remind us what we mean by energy balance, energy availability and I guess the difference between the two? It's a really good thing to understand. I think it's the sort of core concept that coaches often have trouble getting a hold of and athletes too when you're talking about it. So energy balance is really energy and energy out to maintain the stable weight. And I think most people are around that kind of concept. That's what we've been taught since we're a kid. If what you eat is more than what you burn, then you put on weight if what you eat is less than what you burn, then you're going to lose weight. I guess energy availability is different from that. It's the energy that's left over for running your body systems after the cost of exercise is taken into account and the cost of day-to-day activities and things. Where energy availability can be different is you can turn down or turn off some of your body functions to save energy to put you back into energy balance. So you can be not eating enough and not losing weight. But there's still a cost to that. So your body's switched the process from weight loss to maybe not repairing your bones at the same level, maybe not adapting to training, maybe not looking after your gut so well, and maybe turning down or turning off some of your sexual reproduction functions. No point having a family if there's not enough food to go around, you can't support yourself, not trying to support a baby as well. So it's really you can be in energy balance, but in low energy availability and it's still not an optimal state of health and well-being. Yeah. And can you define I guess as well for our listeners what we mean by the term reds and how this links in with low energy availability? Sure. So low energy availability, not eating enough relative to the training mode that you're doing. That's something that might happen for a couple of days and that might not have any great impact on your body systems or it's a small deviation and you readjust relative energy deficiency in sport. The syndrome is where that exposure to low energy availability really results in some outcomes that you can see. So it might be oligo menorrhea or amenorrhea, so not having a regular menstrual cycle or it might be where you have poor bone healing and turnover and you're more prone to injuries and things. So the low energy availability is the it's exposure. So the thing that's happening and the reds is really the outcome of that. Okay, let's talk about now the I guess the recovery from reds, which is really our topic today. So let's say we've got a runner or a cyclist or triathlete and maybe it's been diagnosed with having relative energy deficiency in sport, low energy availability. I guess the first and obvious question is you know what do we do or where do we start sort of on that road to recovery? So what is kind of the recommended treatment for reds from our nutrition perspective? The recommended treatment in theory is really simple. You just have to eat more, you have to you know have more energy available to to turn things back on to get them running properly. So that seems really simple right? But you know how do you do that within the context of a competitive season? You know so if you have a in you know in my situation if I had a lightweight rower that had to make weight and they're in low energy availability, showing signs and symptoms of reds, am I going to feed them more two weeks before they have to weigh in and then they can't go to a world championship. So do you have to try and schedule that in? Like how do you manage the recovery? As a contrast if I have a male open weight rower whether body weight issue isn't a big thing and they're fatigued and they've got world championships coming up, I would get them to eat more of the actual body weight doesn't make too much of a difference in in that setting. So it's really different things for different people and it probably depends on what the reasons are that you ended up in low energy availability in the first place too you know if it's I accidentally didn't need enough during this hard training block that's a pretty simple kind of fix and sometimes my nutrition prescription is as basic as have a second dinner or add you know 500 calories you know that's in the context of a very big calorie intake obviously for the guys but other times it can be really titrating very small amounts of energy over very prescriptive periods of time so there's no weight change but the energy intake is creeping creeping back up. Yeah and that was something I was going to ask you about actually was that eating more can mean different things as you said you can slap on an extra 500 calories a day over night or you can slowly you know add in like an extra 100 calories a day for two weeks and then after that add another 100 calories a day until you've got that sort of 500 over a period of maybe a couple of months or something and I know that was really popularized probably five or 10 years ago in like theoretically at least in the recovery from bodybuilding where they you know really drop their body fat significantly go into really low energy availability and they talked about they were they called it reverse dieting this kind of slow stepwise increasing calories afterwards to try and that theory anyway was to try and restore those metabolic functions and bring that energy availability back up in a way that minimized the gain in body fat on the way back up. Do you, I mean obviously that's a very different population, but do you see that in the athletes that you work with as well in terms of the amount that you increase it and if you increase it slowly you can kind of bring that energy availability back up without as much body fat gain because I guess that is for a lot of athletes that's kind of the big fear is I don't want to gain weight as a result of fixing my energy availability. Absolutely like if there's any concern around weight gain or body fat or you know how that all influenced performance or if there's you know body image concerns that would preclude that as well or make that much more difficult than yeah yeah I sort of talk about like sneaking it in you know if it's 100 calories you can sneak it in under the radar or anybody doesn't notice and you wait till it's gotten used to that and then you sneak in a little bit more and eventually you get to a point where you're eating pretty well and things are running the energy cost of being you is back up to where it it should be and you know happy days I often find I think it's a little bit unfair between men and women are often fine between my male athletes you can put 500 calories in and sometimes it goes straight to muscle mass and you don't get anybody fat change or very minimal it sometimes seems to depend as well on how severe the energy gap is so if someone's been really I'm not eating enough by a large degree for a long time you're more likely to get a body fat gain if you put a lot in if it's a pretty minimal you know short term thing or a smaller gap then you can put more back in and it seems to go in the system without causing the same body fat changes yeah okay and I said dead like 100 calories just as a sort of a hypothetical is that kind of the level of increment if you're trying to do that sort of slow gradual increases that the kind of increment that you'd be thinking about yeah for for a female athlete concerned with weight gain yeah absolutely that's that's kind of what I've gone with I think is it's a nice round number and it's worked with everyone that I've done that with I think the research in this space is pretty limited there are like refeeding studies but they generally use you know in the set calorie blocks for everyone like they haven't hasn't been a dose response or or anything like that and I think each athlete situation is so you know you really need to come up with a solution that fits it yeah and I think 100 calories as you said is a nice round number but I think two in terms of how that translates into food there's probably a lot of like little snacks and things that are around 100 calories plus or minus 20 so you've got lots of different options you could say just have one of these extra and that's all you have to do and it makes it simple as well yeah absolutely yeah yeah okay and obviously you know you mentioned before that people can develop low energy availability either because of unintentional under-eating in other words their training volume's gone up and they just haven't eaten enough to compensate for that or it could be deliberately restricting what they eat either because of body image disorder leading that side of things or simply because they're trying to lose weight quote unquote does the approach that you take change depending on which one of those it was in the first place yeah absolutely you know if it's an accidental training era feeding training era I spent a lot of time looking at the training program with the athlete and working out what's changed and where they might be under fueling and trying to work out how to target that better because that's part of their understanding of themselves and their tolerance of the training and how to do better next time you know not not run into the same same problem so that's it's kind of easy if that's the case it's a practical problem you find a practical solution and a way if it's a deliberate weight management kind of strategy change body composition change weight you might consider how long it is tolerable to be in that state or how much problem it's causing and whether recovery periods might be and and also just checking and challenging what the goals are and whether they're necessary and whether they're really what the goal should be whether they're realistic and then you know trying to come up with a food plan that matches the training as well as possible to minimize any any issues there's some thinking that carbohydrates particularly important in the energy availability piece and it and may even be carbohydrate rather than energy that's the core constructs so typically I'd be trying to prioritize that to keep the training quality in there and to to make sure that that's as adequate as it possibly can be if there's issues around body image and food restriction and and challenge with the choices then that's obviously a little bit of a different thing be trying to reassure and provide structure in a plan progression and use some objective tools to show that progress is being made I'm really lucky in my sport we have great access to psychology and athlete health and wellbeing providers so we we have a lot of ways of supporting athletes through through change with that as well but having a having a way of measuring that it's working that it's that it's needed that it's working and also being able to provide reassurance that'll take longer but we can do it without any weight change if we need to yeah yeah okay and I think you're just picking up on your point there around the carbohydrate side of things I guess that was going to be my next question is okay so we decide that you know eating more energy more calories is the important part but that could come from protein fat carbohydrate the timing of that across the day could vary or we just putting it anywhere in the day or we putting it specifically at a certain time of the day you know before during or after training talk us a little bit more through that in terms of you know whether we choose to add on more carbohydrate or more protein for example or you know well maybe do that first and then we'll come back to the timing as well yeah sure I think you know I always look at the athletes hold diet rather than say I always do carbohydrate or I always do protein or whatever but look at the whole whole diet and look at the energy adequacy and then I'd look at the timing of or the the quantity of the carbohydrate relative to the training load and that's generally where I prioritize first and it also depends on the degree of restriction as well so if I'm just saying add an extra dinner at 500 calories then I'm not always very directive with where that comes from like if they're kind of you know meeting their training goals or in the sessions they're doing and I just need more energy then I'll just say extra dinner and I know that their dinner's come with a good portion of carbohydrate as part of that yeah yeah I was going to say because you do see those differences don't you there some people that are actually probably fueling appropriately for training that is not eating enough calories across the whole 24 hours overall and so it doesn't matter so much where it goes whereas there's other people that are probably under fueling their training either before or during in particular and so that's obviously you know the obvious place to start is to better support that and you get the calories as a bonus almost also you know if you have someone who has some concerns around carbohydrate finds it challenging to think about eating more of those then I might go you know a really small amount of higher fiber lower energy density kind of carbohydrates and add some protein as well if the protein is you know more accepted so I might be working towards the increased carbohydrate but I might not start there if that's that's more of a challenge yeah yeah I think I've had a few athletes where I thought actually maybe the protein is a little bit underdone at certain times in a day as well and so maybe I've actually started with that and then got that right and then worked outwards from there and with with the carbohydrate yeah has there been any times where you've thought actually their protein needs are kind of met their carbohydrate needs are kind of met they're just lacking in energy so actually adding more fat because you get more calories or kilojoules per gram of fat is actually a more efficient way of doing it I don't think I've prescribed that individually very often that certainly we're really lucky here at the wrong sheds we have a kitchen that the athletes eat from and we're well supported to provide food in that and I think initially I I didn't want to buy full cream milk and I didn't buy butter and you know I limited the amount of cheese and whatever and through experience and working with a spot I don't do any of that anymore I only buy full cream milk unless we have low weights in and I you know we have oil we have avocado we you know I've really pulled the limits on those kind of things and I I'm not generally concerned about fat intake at all in that population anyway I understand it's different in other sports yeah yeah yeah yeah okay and you talked about you know calcium and vitamin D before obviously was rolling that's not so much of a concern but more broadly for someone who has reds where maybe those things are and not as clearly covered in terms of meeting their needs already maybe they're eating is a bit more restrictive and so they're not getting that amount of calcium or something like that do you think these nutrients are going to be important I mean obviously they're associated with bone health but are they going to be important in that sort of recovery phase from reds or as an issue it's just so specific to energy it's like those things are going to have such a small difference it's not going to really matter anyway oh they're definitely on my checklist so if someone has reds then I'll be making sure that that's okay in in mine it's kind of like an exclusion is it okay yes it is moving on yeah those things in isolation won't protect if there's not enough energy so you're still trying to solve the energy piece but you definitely want to tick them off to make sure if you've got low calcium intake you you're not going to be able to have good bone health yeah yeah fair enough and I guess yeah as you said you know you can have energy that will help the to go into depositing minerals, but if the minerals aren't there to deposit, then that's not going to be helpful. Absolutely. Yeah. Okay. In terms of that recovery from reds, obviously energy availability is the energy intake side of things. We've talked about, you know, how to increase the calories in what you're eating, but the other side of it, of course, is the exercise energy expenditure, so the training load as well. At their times, where, you know, between yourself and the coach, the decision is made actually might be in conjunction with eating more, but actually the approach is actually to train less. I mean, obviously it's not for a lot of athletes. That's not going to be an attractive option, obviously. They don't want to train less for these reasons, but has that ever been an approach that you've taken or felt the need to take? No, actually, I haven't taken that approach. I think there would be situations where it would be appropriate. They just haven't come across my path. I think it would be a hard sell with the coaches to train less. If it was a severe energy deficiency and it was causing strong signs and symptoms, I think I could get it across the line if I needed to, but usually we've been able to eat enough to compensate, and it's been okay. Growing is definitely a volume sport, and they don't usually do any extras above what's prescribed. So you're really getting into the space of negotiating with a coach to change their training programming to a downward region, and that's quite a hard sell. We'd certainly be trying to change the food first, but it is an option, and if there was a lot of additional training that wasn't needed for the performance in the sport, that definitely would be something you could do. We have, having said that, we've taken commuting out for a couple of people, so one of the things in our current training program is that we get the guys to ride to the Sheds and back, and it's not training, but it sort of is. And the energy cost of that, it can be an extra 600 calories a day, and if they're down and back and down and back, but they don't count it, so that's something that we've changed on occasion. But core training, growing out on the water, not a chance. Yeah, yeah, yeah. And that might be different for maybe recreational athletes as well, absolutely. And also, I guess, in some cases, it might be a bit sort of self-limiting in that if you're sick all the time, you'd probably not training as much, and if you've got an injury, you're not training as much, or if your performance is just like, you're just not recovering, and you're feeling terrible, you're not able to do the sessions to the extent originally prescribed, so you're kind of, you're pulling back anyway without intending to. Yeah, absolutely. Yeah. Okay. And I guess some people might think about sort of medication, pharmacological kind of treatment options. And I guess historically, particularly for female athletes, maybe if their menstrual cycle became irregular or stopped completely, there might have been a use of oral contraceptives and things like that to assist. Where are we at with that currently? Is that a practice that still happens, doesn't really happen any more? Where are we at with that? I think the practice still does happen a bit, but it's not particularly effective. And I think it's kind of where you're getting medical support a little bit outside the elite sports space, maybe the knowledge hasn't quite caught up. Definitely, their energy is at the core of it and taking an oral contraceptive pill isn't going to fix the problem. Provide some of the hormones associated with the reproductive cycle, but it doesn't fix the other hormones and things that are affected by having low energy availability. There are some clever things that endocrinologists are doing around hormones to support, recover recovery, but it's not a take this and it'll fix it. You have to fix the underlying problem, which is the low energy availability first and that can be an additive, but certainly the traditional OCP doesn't get you very far at all. Yeah. Yeah. Now, obviously, if someone goes down this path and then they start having more energy in their diet, hopefully things start to improve, what do you see as kind of like the time course of how things start to improve? Is it very a lot from person to person? Is it pretty similar between people? Then are we talking like a few days, a few weeks or a few years in terms of that recovery? Yeah. That's a great question too. It really depends how long it's been a problem and how severe the problem has been. I have people that have worked with where we're talking about five and six years and not fully back to a normal menstrual cycle, but that's because there's still barriers in the eating behaviour. I think even if you're able to change things as much as you need to, if there's none of those kind of roadblocks to it, if you've never had a normal menstrual cycle, it can still take a few years to get back there for the people who have made a training error and maybe over the last month they've underfueled. Really the signs and symptoms are pretty minimal. You can turn around that around just as fast. If you're using resting metabolic rate as a marker of whether you've gotten back or not within a month, certainly you can make a big difference in that, but that's for someone who hasn't had a prolonged suppression beforehand. Yeah. Presumably, also, we think about the different components of reds. There can be the performance aspects, maybe the mental health aspects. Some of those things might turn around a bit more quickly, whereas obviously bone health is still going to take, like if someone's, you know, osteopenic or something, it's going to take a while to turn that ship around. You may never be able to fully turn it around, that's the unfortunate aspect of it. Sometimes people have low bone density now for something that happened when they're a teenager, but you can certainly stop bone loss and that can be really encouraging to show someone. You've got this line going down with the bone, dropping off and dropping off and then flatlines and that's reassuring as well, you know, if you can maintain for a long time, that's still an absolute positive. Yeah. Yeah. Okay. And do you see anything in particular that tends to predict how quickly people are likely to recover or what might hold them back in the recovery process? Certainly, the body image, disordered eating barriers to changing food behaviour, that's probably the biggest limiter, and, you know, coming back along the spectrum a little bit with that. Sometimes people have a really set idea of what healthy eating is, so it's not disordered eating, it's not necessarily strongly body image related, but, you know, I've had a lot of people say to me, I can't just eat rubbish, it's like, well, it's not rubbish, if it's the fuel that your body needs to do the training that you're doing, and, you know, usually that's around drinking, extra juice or having flavoured milk or something like that to add more calories in. The mindset of that is that it's sugar and it's bad for you, it's bad for you if you don't need it, but if you actually need it, it's good for you. So it's sometimes getting those shifts in thinking can be a challenge and actually believing that there's an issue and you have to resolve it, can be part of it too, because we're so programmed that Liner is better, and, you know, if you're a proper athlete then you're being careful with your diet and you're only making healthy choices and you're keeping body fat as well as you can, there's some elements of truth in that, but you take it too far and it becomes definitely damaging. And then, yeah, it's just the severity, so the bigger the deficit for the longer the time, it just takes a little bit longer to turn everything back on. Yeah. Yeah. Okay, yeah. We had a couple of podcasts ago, we had a topic around, you know, should I eat like professional athletes and we talked to Jeremy Peacock, who's a paratrice athlete now, who sort of started out as an age group and then went down that sort of elite pathway in paratrice law and he talked about the fact that as an age group, he's perception of what elite athletes did was very different to the reality and that probably speaks to exactly what you're saying here. Yeah. Kind of like, I'm an elite athlete, so I have to or I do eat a certain way or, you know, consume certain things, but actually that's not necessarily what happens. Yeah, just the other week, I made pancake butter for the guys, they had a really heavy week and they had two sessions back to back. I knew they weren't going to be able to adequately fuel in between without a bit of help. Carbohydrate was what I was focusing on, so I did four bowls of pancake butter and some blueberries and some with bananas and made it all appealing and put out all the toppings. And we held a meeting in the kitchen while they were cooking and eating and one of the staff said to me, ice cream and breakfast, like seriously, and I was like, yeah, absolutely. But it's just that mindset, you know? Yeah. And particularly with, you know, as Jeremy said, and I think you're alluding to he, like if you've got multiple set training sessions in a single day with a short recovery period, if you're going to try and get that in from like, you know, brown rice and quinoa and multi-grain bread and stuff. Good luck. Yeah, good luck. Exactly. Yeah. Either not going to get it in or you're going to, it's going to come back out once you start that next training session. Or is that any gun making you uncomfortable? Yeah. Exactly. Yeah. For sure. Okay. I guess the final thing around this, you know, we sort of talked about the recovery side of things, but obviously prevention is better than cure. So if we're thinking about, you know, planning out, you know, athletes got a season coming up and obviously they might have in their minds and body composition goals and, you know, we've had other podcasts about whether that's appropriate or not. But I guess thinking about that, what's your approach then, I guess, you know, as you said, like the last thing you want to do is be in low energy availability and then having to try and add more calories two weeks before, you know, your major event of the year or something. So I guess, you know, some planning can go a long way in this. I guess the first thing is, and we spoke to Hillary's telling worth about this a while ago, you know, there's that case study where she sort of dropped weight heading into sort of the key competition. and she actually said, "Yes, I lost my menstrual cycle for two or three months during that, but then every time afterwards, I'd make sure my energy availability came back up." And I sort of recovered from that. Do you guys do that with your rowers in terms of planning across the season? Like, you know, this period is a big training block and it's not a competition phase. So really, we just want to focus on energy availability as kind of king and getting that training in rather than trying to optimize quote unquote body composition. But now we've got to this racing block. That's when we need to focus on it. And then we can kind of figure out what period of time we need to achieve that. Yeah, definitely. So at the start of the season, when we do screening reviews, I'll talk about training weight and racing weight. Or I'll get them to talk about it with me, so I understand that. And then really, we're trying to maintain in those weight ranges. I think for the rowers, they eat so much all the time that when they get to racing and that pressure is alleviated, they're happy to go with it. So people have asked me, you know, how do you stop them gaining too much weight when they taper? I've never seen it. I've never, never, never gained weight. It's not a hard thing at all. But I know in other sports that needs to be planned a little bit more carefully, I think. Oh, I will send messaging like I look at the training program and talk to the coaches about what's coming up. And I'll say this next three weeks is a massive block. It's going to be tough. These are some of the things you can try and do. This is how I'm going to try and support you. And then these are some ways that you can monitor yourself. So I'm just trying to get the thinking in the right headspace. We actually, it's probably a bit controversial, but we get them to record their weight, theoretically, you know, when they do, you know, set out accessions and things. I just write it down on a piece of paper and I have a look. And it's not from a point of view of, are they getting too heavy? It's, it's always, are they maintaining okay? You know, it's, yeah. And if I know someone's a bit lower than that training range, I'm just say, how are you going? I know, I noticed you're a bit light today. Is that just today or is that been over the last few weeks? Is it backsliding or are you, was it just a, you know, didn't drink enough or today? I was busy or whatever it was, you know. So it's trying to find multiple angles for supporting them to monitor themselves to keep on track. Yeah, and the weight one's an interesting one because I think, you know, as you said, it's been quite controversial in recent years of, you know, whether it's appropriate to weigh and measure people in terms of body conversation, but I guess it's the context in which it's done and the value that he's always placed around it that that's the bit that's potentially a problem rather than a natural number itself. Yeah, it's not me standing there with a clipboard writing it down and then commenting. So they weigh themselves and they write it down. And also that they understand why they're weighing and how it's going to be, how that information will be used, who will be shared with that kind of thing to alleviate the perceived pressure around that. Because, yeah, I mean, obviously I do a lot of hydration research and that's another area where if you don't have weight, it's very hard to work out what's happening in terms of sweat rates and things like that. So how do you calculate someone's fluid needs without standing on a set of scales? Yeah, but it's the context and it's the application, yeah, for sure. And then if you're planning for someone, you know, as you said, there's like training rate weight and racing weight. And so as they get towards a competition period, if racing weight is lower than training weight, is there, and there might not be a simple answer to this, and it might be a silly question, but I'm sure there'll be people, you know, listeners that are thinking it, they might be thinking, well, is it better to lose that weight slowly over, you know, a 10, 15 week period, or go short and sharp, like three weeks, because yes, it'll be a bigger energy deficit, but I'm only exposed to that energy deficit for a quite a short period of time. Do we have any information to understand, you know, whether one of those is going to be either practically easier or kind of safer from a reds health point of view? I think you'd really have to look at the context of that as well. I know if you have a very small energy deficit and you lose weight very slowly over a long period of time that doesn't tend to, that kind of sneaks under the radar a little bit, but then I knew underfueling key training sessions over a bunch of months, maybe not putting yourself into a low energy availability space, but maybe just not quite getting the quality, not having the output that you need in that session because you're a little bit underdone. I think the short sharp can be good if it's timed in the right way and having just a short exposure to low energy availability doesn't seem to have the same impact. There's a study just out in the last few weeks. I think it's Louise's book's group, being at that specific question, and there's other studies too. I think that can be quite an effective strategy, but you just need to pick the timing of that relative to the other things you're trying to do. If you're trying to freshen up then and show, give yourself internal confidence that you've got the performance in the bag and you're also trying to cut at the same time, you might not see it, you might not freshen up at the same rate. There's other factors to consider too. That's a good point. It's not just a physical adaptation to training. You're better to slightly underfuel 15 weeks of training rather than dramatically underfuel three weeks, but it's also, as you said, that psychological element particularly coming into competition. And just wrapping up, Ron, so for any of our listeners who may be concerned about flu energy, availability and reds, are there any useful resources out there that you can recommend? Definitely chatting to a sports tradition to get your tailored advice. The AIS has the female performance and health initiative, which has some really good information on menstrual cycle and monitoring your menstrual cycle and energy availability and things. It's quite female specific, but Dr Nikki Key in the UK has a bunch of different resources that you can look up as a blog on training peaks that's got a really nice summary of it. I want to take a look at that. I've struggled to find something specific for the fellows out there, though. I don't know if you guys have seen anything. Everyone? No, not specifically. There've either been generic or, as you said, female specific. Yeah. We are now going to go into the bonus round, Ron. So this is where our listeners get to learn a little bit more about you. If you could do anything other than your current career, so it sounds like you really do love it, what would it be? I think in recent years we've just moved out to the bush. We have a little bit of land on a pretty, pretty little bit of bush. And I think if I wasn't doing my current career, I'd hang out there and grow veggies in my garden and have been learning some practical skills. I'm the only female in my household, two sons, my dad and my husband. They've been teaching me how to chop things down and drill things and whatever. So I don't think I'd want another career. I think I'd be quite happy just to hang out there. Some great trials and things around too, it's lovely. Sounds good. And then what is a sport you've always wanted to try apart from what sounds like wood chopping, but have not yet had the chance? I mentioned my history as a raw way back in the day. And I've always loved running and trail running, but I'm a bit limited with that at the moment. So for the last few years I was trying to teach myself to swim and to open water swim, but I'm like the most chicken person ever. I always end up swimming too close to the shore and we got anything in the back of the wave breaking things. And just the other week I made myself swim out deeper and I was feeling all, you know, pleased with myself and good. And then I then I see these little fishes like all around me and I was like, ooh, I was a little fish and I know a little fish. And then I was like, oh my god, I'm a bait ball. I'm in a bait ball. Yeah, still alive, the shark didn't need me. So it's all green fog. That's my greatest fear is I watched too much of chores when I was younger. And so I just won't go in. So yeah, very brave from. Again, quite a few points just from the adrenaline few factor. And favorite post exercise snack or beverage and why? I really love a good coffee and something carb-y, blueberry bagel or some nice pseudo toast with apple and a poached egg. I could eat that every day, I think. So not just one, but a few. And one of the things on your bucket list that you haven't yet done. I don't actually have a bucket list. I don't really get bucket list. You think of things and you do them. I think of things that I do with my canyons. Yeah, that's good. What is your most prized position and why? I actually got a new car just when I finished my PhD. My husband bought it for me as a surprise. And I'm like totally not a car person. I really, really love it. It's great. Yeah, I think. Because we're living out in the bush and driving a little bit more and it's just been really nice having a pretty car that does nice things. But it's just super comfortable. Yeah, that's probably up for the moment. What about if you were travelling and you had to go on, yeah, you're on a flight? What's the thing that you just have to take with you will have with you? Probably good headphones, I can't be dealing with the airline headphones and I have my own movies on my iPad and my own headphones and playlists and that pretty much does me put the eye covers on the earplugs in you know, you're helping out that way pretty well, yeah, yeah. Alright, well thank you so much for your time, Bronn, it's been great to have a chat to you learn a bit more about the recovery side of reds and the different options or all different ways that you could potentially do that so you're all done PhD-wise now. Yeah, I just handed in my clean, accepted changes copy you've last week. Yeah, so you're just going to get the hat now. Yeah, I'm waiting for them to say thanks very much for doing that and you're all good to go, but yeah, Louise has signed off on it so it's good, yeah, excellent, excellent, alright, little while to go then you get to, yeah, we're a big floppy hat and get a certificate on today, so, yeah, awesome, awesome, awesome, thanks so much for your time, yeah, thank you. That was great, thank you very much, Bronn, now to our lovely summariser, Owl. Yeah, so our question today was, what is the nutrition roadmap for recovery from reds? So reds, I guess is the consequences of low energy availability, so it's the combination of things that can potentially go wrong both from a performance point of view and a health point of view as well, so I guess the solution regardless of all those to get out of that state of reds is, as I said, improving the energy availability, now sometimes people get prescribed things like the oral contraceptive pill, that doesn't resolve the issue, it kind of just covers over the cracks in terms of menstrual cycle in particular, but it's not going to address the underlying issues that are being caused by the low energy availability, so really in terms of a roadmap for recovery from reds, it has to be centered around improving the energy availability, there is no other option, it's more about the nuances of how you do that over what time frame and what sort of choices you make in terms of how you add back more energy or more energy availability, so in some cases it might be that someone would decide, okay, I'm going to train less, but that's not an attractive option in the majority of cases, and so most people will look to the calorie intake side of things, so increasing how many calories they eat rather than reducing the amount of calories they're expending through training, but in some cases as Bron said, you can consider things like incidental activity, commuting in terms of bike or running, for example, or extras that people are doing in training, and if those things are adding value in terms of improving fitness or performance, but they are increasing your energy expenditure, then they might be things that you could consider reducing to try and make things a bit easier from the eating side of things to increase your energy availability, but if we think about the eating side of things, because that's how most people are probably going to address this issue, depending on, I guess, a lot of the reasons that people ended up with low energy availability in the first place, so if it was simply unintentional, I up my training volume, but I didn't realize how much I needed to eat, simply just adding an extra meal or a high calorie snack in addition to what they're already having is all it takes to correct that issue, but for some people it can take quite a lot more calories than that, and so it might be beefing up multiple meals, multiple snacks, that sort of thing, one of the things I guess, then we have to consider is how fast do you go with that, and so some people have a fear of body fat gain, and so in that case, as Bron said, maybe an incremental increase, you know, increasing by just a hundred calories a day for a period of time, maybe a couple of weeks or something like that, which is just one extra snack or one addition to a meal for a period of time, and then if body composition doesn't change, then you go to the next step, and what you can see in that case is often as you increase the energy intake, the expenditure increases as well as the energy availability improves, and so actually you increase the energy availability for no change or very little change in body composition or weight. I guess either approach can be helpful, but then in terms of whether it's carbs is a protein that you add and where you add it in the day, as Bron said, probably the first priority would be carbohydrate around training, particularly before and during training to ensure that the training is optimized from a fueling perspective, you might as well optimize how you're fueling training as well as increasing energy availability sort of two birds with one stone. For some people, it might be that they're lacking protein throughout the day, and you can go back and listen to our episode around protein, I can't remember off the top of my head what number it was, I think about 18-ish episode 18, and so that might be something you can address, and that will get some more calories in. But if those kind of fundamentals are addressed, someone is generally speaking fueling well before and during training, they're meeting their protein needs, then where those calories fit into the day doesn't matter as much, or the type of calories whether it comes from protein fat or carbohydrate is going to be less important. If it's a subtle restriction due to a specific view of what is healthy eating or clean eating, then we might have to consider the food choices or the types of foods that people are eating, so is it that they're eating excessive amounts of fiber or very low energy density foods. So again, referring back, episode 40A, where you'd Steph talked about is fiber, my friend or enemy might be a useful one from that perspective. And so sometimes more processed refined carbohydrate sources are necessary to meet the demands of a high training load within the limits of your appetite and preventing gastrointestinal issues as well. And I guess our reminder here that we assume because eating less can be difficult that eating more must be easy, but in fact, eating more is just as challenging for most people as eating less compared to what they used to. If it's an issue around disorder eating or eating disorders, that's a very different story we need to think about. So in that case, we definitely recommend professional advice and help for this, and a really individualised approach needs to be taken in those cases because we're dealing with a mental illness essentially. Now finally, in terms of the time course of recovery, that does vary a lot depending on how severe the energy deficit was in the first place, how long they're in that energy deficit, and also I guess the perspective of the athlete to how they're going to eat more calories or increase their calorie intake. So if you've had unintentional low-ng availability for a relatively short time frame, then often you can see you turn around in terms of performance in particular within just a few weeks of that. And I've worked with quite a lot of athletes where that's been the case. If there's a particular fear of body fat gain or body image concerns, then you might have to go slower with how you increase those calories. And so you would expect the recovery would also be slower. In some cases, it can be months. In some cases, as Brian mentioned, it can even be years as well. In terms of resuming a normal menstrual cycle, if that has been lost, well that partly depends on how long it was absent for. And so the return is usually proportional to how long it wasn't there. And so it can be anything from a few weeks to a few years depending on the person, then depending on that scenario. And then finally, as Brian mentioned with low bone density, that is a very slow process. Turn over a bone is extremely slow. It can take years to turn that ship around if at all, unfortunately, which does mean that if someone is in that state of low bone density already, that's an ongoing stress fracture risk that has to be managed for the foreseeable future for the sort of the short to medium term definitely and possibly even in the long term. So I guess just to finish on a bit of positive spin there, recovery is certainly possible in reds. And we do see that. It does vary from person to person. But I guess if you're really stuck on what to do or how to tailor a solution to your particular situation, we suggest you contact a professional for advice because there can be a bit going on here with reds and how to recover from it. Awesome. Good summary now, as always. Next episode, we are up to episode 57B. Same question. How do I recover from reds? And we are joined by who, our? Yeah, we're joined by a former British distance writer and podcast host herself, Tina Mua. So she's created a whole bunch of really great resources around reds on her YouTube channel. Has her own podcast, as I said, and we had a really great discussion with her. Although she's from the UK, she lives in America these days. So we had a chat to her from America about her experience with reds and her recovery process as well. Yeah. And just finally wrapping up a reminder that if you do have a question that you would like answered on the podcast, you can contact us at the Long Munch on Instagram, Facebook or Twitter. Thank you to those who have left ratings and reviews on Apple podcasts and Spotify. We appreciate that. And remember also that there's now more than 57 previous questions we've already answered. So if you're new to the podcast, welcome. You might like to check out the back catalog to see if there's something there that will be helpful to you. Most podcast apps owning show you the last few episodes. But if you click back, you'll find the rest of them there going back to November 2020. If you want to be notified every time a new episode is available, you can hit subscribe on the podcast app that you're listening to this on. And if you do have your friends asking about particular nutrition issues for their training or racing and you've heard it on the podcast, then you might like to refer them to here. Otherwise, as always, we will love and leave you and wish you all the enjoyment with this beautiful, wintry weather that's coming at least in Melbourne and we'll see. Let's go say the other half of the world it's the sun. I know, lucky bogus, we'll see you next time. See you then. [BLANK_AUDIO]