E23 : Fueling for Performance: Debunking RED-S Myths with Dr. Melissa Lodge

Jimmy: Welcome to the Physio Insights podcast presented by Runeasi. I'll be your host, doctor Jimmy Picard. I'm a physical therapist, running coach, and team member here at Runeasi. On this show, we have real conversations with leading experts digging into how we recover from injuries, train smarter, and use data to better guide care. Whether you're a clinician, coach, or an athlete, we're here to explore what really matters in rehab and performance.

Let's dive in. Melissa, welcome to the podcast. Happy to have you here.

Melissa: Thanks for having me. I'm excited to chat.

Jimmy: Yeah. As am I. After talking to you before off air, we had a couple of mutual friends that I've had on the podcast in this space. So it's good to have your thoughts too to join the mix. But for the listeners who don't know you, can you fill us in and tell us a little bit about yourself?

Melissa: I'm Melissa Lodge. I recently got my PhD in exercise science and my research really sits at the intersection of female athlete physiology and relative energy deficiency in sport or REDs. And I'm also working towards becoming a registered dietitian so that we can design better interventions and help athletes stay fueled and performing optimally.

Jimmy: I love it. Yeah. And you have a pretty awesome Instagram where you're sharing a lot of this knowledge. How long have you been doing that?

Melissa: Yes. I have an Instagram page called Fed Collaborative. I've been running that for, like, over five years now. I started it during my master's work because I recognized that there was not only a research gap in women's health and in female athlete physiology, but also this knowledge gap or application gap where this information that we do have wasn't getting into the hands of athletes and coaches and and those who support the female athletes.

Jimmy: Yeah. Awesome. Before we dive into, like, what I wanted to talk about, which was one of your posts, what's your background with with running or athletics? Like, how did you get interested in this topic?

Melissa: Yeah. I'm primarily a runner by sports training. I did dabble in soccer and all of the others, like, team sports growing up, but really stuck with running through high school and college and still now post collegiately, so recreational these days. But I got into it primarily because my sisters were good at it, and it's fun to be good at something. And I also just do to this day, I still really enjoy it.

It's a great lifelong sport, but it comes with its unique challenges. Yeah. It's an endurance sport. So got high training loads and the sports culture around running. You're starting to see it shift, but it was definitely like now we're saying like fueled is fast.

Right? But there is definitely some body composition expectations when I was younger in the sport. So that's kind of what spurred me into this career path and looking at this condition of REDs and how prevalent it is in the female athlete population.

Jimmy: Yes. And how long did you run for? Like, did you run-in high school and then continue on after?

Melissa: So I started running probably about middle school more seriously. Throughout high school, I was doing soccer and track and field until I just decided in my junior I think it was my junior year to to start cross country and just send it on all three seasons. Ran all throughout college and then was racing competitively post collegiately for about, like, four or five years and just recently in the last couple of years decided to take a step back from running really competitively. Like, I'll still get out for my runs every day, but just more so for for fun and fitness rather than competition these days. Primarily, 1,500, five k.

I did run my first marathon this past year

Jimmy: Nice.

Melissa: Which definitely showed that I was more of a 1,500 meter athlete than a marathoner. But yeah, I love the mile has like my heart. So that's my favorite.

Jimmy: Was the transition like going from being competitive and post collegiately continuing to race to where you are now?

Melissa: It's definitely interesting transition for me. Like, I'm very competitive. So even though I knew I wanted to take a step back because that the PhD and all of the work that I had going on was just a lot on my body to maintain that high level of training. That being said, I'm still very competitive. So it's like a very interesting like, I'm not somebody who can just like hop in my local five k and be like, let's just do it for fun.

I'm like, no, I need to get the best out of myself. And there's levels to to all of that but I have like a very specific vision of what competitive running looks like for me at least. And so, I've had to really it's been humbling. I've had to like, really let go of some of those things and I haven't really been racing because to me, like, it's just fun. I'm I wanna keep it fun and just to get outside more than anything.

So it's been an interesting transition to navigate. Yeah. I think it's a really important topic across all sports really. Running's kinda unique and that you can continue to do it Yeah. After college.

Jimmy: Which is good and bad.

Melissa: Yes. You continue to do it and then your identity is wrapped up in it even more. Mhmm. Like, sometimes you don't know who you are without it and there can be new challenges that arise when you stop playing or stop racing. So I think it's definitely not my area of expertise in terms of research, but there's a lot of different avenues to look at retirement and athletics and the mental health of athletes and all of that.

So it's it's really important to talk about and to consider.

Jimmy: Yeah. Everyone handles it so differently. Touch on the topic I wanted to bring up which was your post which was 10 things everyone should know about REDs. Before we go through the list, I'd like to like just go through each one of these points one by one and hear you talk about them.

Melissa: Yeah. A lot of my page is educational and some of that is myth busting. And these are things that come up a lot around REDs that I found I get a lot of questions about or when I make a specific post about any one of these topics, it gets a lot of engagement from people asking questions or not quite understanding or, yeah, dispelling some myths that have been long standing in sports. Honestly, there's probably more than 10 things that I can be quite lengthy and chatty and it it was hard to compress it all into 10, but these were things that really stuck out to me of if people could only know 10 things, these would be the points of emphasis I would make.

Jimmy: Alright. Well, let's just dig in. So number one you had was a specific body composition does not equate with athletic success. Tell me about that.

Melissa: I think it's a pretty common misnomer that a specific body composition will lead to optimal performance in any sport really, but there's like a body ideal in each sport that people will talk about that coaches might subconsciously be thinking about that athletes aspire to based on what professional athletes look like or what their teammates and competitors look like. And really when we dig into the literature, there's no one body type or body composition that leads to optimal sport performance. And some of that is because if you look at a variety of professional female athletes across soccer and basketball and track and field, even all of the events within track and field, like, there's going to be a body composition where you can succeed. And typically, like the sport that you're good at kind of guides where you're gonna go and that's why you see similar looking bodies or that basketball players have really strong quads or really long femurs. Right?

Like these things make sense in terms of what you end up being good at in sport, but we don't necessarily need to alter or manipulate our body composition which is why I brought it up in the context of reds. A lot of female athletes feel the need to change their body and then manipulate their training or their eating to look a certain way. But really, fueled is fast, fueled is strong. So there's not one cut off that we found. Oh, if you're this body fat percentage, you'll be good at your sport.

It's not quite like that.

Jimmy: And so when we look at runners in particular, how does this relate to the runner?

Melissa: So the way that I like to frame it is if you focus on all of the other modifiable factors about your sport, your training volume and intensity, fueling around training, if you're getting enough sleep, if you're listening to your coach. Right? All of those things are gonna matter so much more than what your body looks like. And if you're doing those things right, your body will end up looking like what it's supposed to look like and that will be its healthiest form and its most optimal form for performance.

Jimmy: And so in the running world, the ideal or what you're referring to here is like the kind of the concept of like lean as fast instead of fueled as fast. It's like smaller is better, skinnier is better. Is that is that right?

Melissa: You hear a lot of lighter is faster. You used to. I think the narrative is shifting, and that's definitely a distance runner. It's like that's the culture that distance runners tended to grow up in is lighter is faster. And when you think about it from like a physics perspective

Jimmy: Mhmm.

Melissa: Sure, if like humans were just mass, but think about all the things that that your body mass is actually made up of. It's your organs, it's fluid, it's muscle, it's bone. So it's it's not as simple as just like this mass over this distance. And so I always try to break that down for people too. It's like, it would be lovely.

I probably wouldn't have even needed to get a PhD in physiology if the body was so simple and it was, oh, yeah, if it's lighter, it's gonna move faster across time and space. But that's just not how bodies work and if we're trying to fit our bodies to a specific composition, then we're probably gonna lose out on a lot of other great things that we need, like enough fuel and enough fat free mass to be strong enough to tolerate the training loads that we're trying to manage to be able to perform well.

Jimmy: Yeah, I can speak to this like personally during college, I was always like a more muscular runner compared to I ran five ks and 10 ks and compared to the other five ks 10 ks runners a little bit bigger. And there was a season where I thought smaller would be faster and lost some weight, got down, dropped like 10 pounds and immediately ended up with a stress fracture. And I personally saw it backfired. I do, I still think this is pretty common. Had a runner last week, 40 year old man, tell me he was trying to get down to one hundred and forty pounds because he thought he would be faster if he did that.

And he's probably five, ten or 11. So it's still out there.

Melissa: I try to take the attention away from from bodies. Like, I really do think that that can be a better approach. But even when you do like, it's hard to get away from it on social media and when you're at a race, you're looking around. The example that I like to provide, I don't like to point out any one athlete because you never actually know what any one person is doing. But if you look at some of the top female distance runners right now, the marathon championships or like track and field champs that's coming up in the spring.

If you look at them and think about or even go back and find pictures of them when they were in college or high school, like there are high school athletes right now that are comparing themselves to the best of the best and they're in their late twenties, early thirties. They've been training for their training age is so much older, it's so much more they're so much more experienced like they they're better not just because of what their body looks like, but that happened over ten plus years. And so that's where like fitting yourself into a mold that's not meant for you isn't going to lead to long term success. And then you also see younger athletes that might be lean on the start line and they might be faster than you right now, but how long are they gonna make it in sport? We don't know all of those things.

And so it's really hard because the comparison's out there and you can't just like close your eyes and pretend it doesn't exist. But I think if you can focus, bring the focus back to yourself and how you feel strongest, how you feel healthiest as an athlete, that's going to ultimately lead you to your best performances and your healthiest self.

Jimmy: Well, let's move on to number two, which is it's not just about health.

Melissa: This one, I find that most people think they tried to dispel all of what I'm working towards because I'm only talking about health and I don't care about performance. So this was this was almost like a personal twist on my my personal belief is that you cannot have optimal performance without optimal health and kinda goes back to what we were just saying about making sure you're in your healthiest body and if you're in your healthiest body, you'll be able to tolerate training and you'll be able to then make those adaptations that training is meant to provide and that will lead you ultimately to your best performances. But REDS is inherently a syndrome that describes impaired physiological function that results in decreased sport performance. And so, it is about health and that is really important, but it sometimes can be hard to get people on board if it's only about health. Yeah.

And so, it's not. It's not just about health, it's about your performance. It's about making you the best athlete as possible and we can't then put health on the back burner because it's gonna come back to bite you. You're gonna, like you said, end up with a stress fracture, you're gonna end up on the sidelines, you might be sick before championship season and miss training because of that. And training is the stimulus to provide adaptation to get better.

So all of these things, they play into each other. So it's not just one or the other. In fact, you need both to be able to sustain health and performance in the long term.

Jimmy: Yeah. It makes me think of Ryan Hall and kind of his journey like you're have you seen like Ryan Hall's transformation if you will?

Melissa: Mhmm. Yeah.

Jimmy: Probably because of that, it's like a happy middle ground, been a little bit healthier. Could he have run even faster? Would his career have been even longer?

Melissa: Yeah. And people might not like me for this, but so be it. Most people aren't gonna be elite athletes or Olympic level athletes. Right? So

Jimmy: Mhmm.

Melissa: Like elite sport is probably not always the healthiest thing. There's elite athletes aren't elite athletes their whole life. Do I think we can make it healthier? Absolutely. But I also think that people are drawing comparisons towards the Ryan Halls, the Sarah Halls, the Just Tons of the world.

And unfortunately, they'll never be that good. So I think the barometer like the it's different. Like, if I don't judge myself against the same measuring stick as I did five years ago because five years ago, I was trying to run the fastest I ever have and now I'm not. So I'm not gonna train like I was training back then. I'm not gonna eat necessarily the same exact way that I was because I was doing more training back then and all of these things matter.

And so it's not to say that we can't glean meaningful insights from elite sport, but I also think people need to reflect and be like, is that actually like, am I running am I running close to an American record? No? Okay. Then I should probably measure my approach here. And I think it's important for everyone to care about their health, but especially when your performance isn't your paycheck.

Jimmy: Alright. So it's not just about health. You're saying, if we can maintain good fueling habits, we will also perform better. If we don't get into the fueling strategy. Do you want to maybe talk about that real quick?

Because I think it ties in here with like, he was feeling quite a bit.

Melissa: As far as like we know based on the reports of what he was taking on in in the race, there's about a 115 grams of carbohydrates per hour which is really pushing the upper limits of what we thought especially runners like cyclists have been taking on a lot of carbs for a while but they're not pounding like their bodies aren't like sloshing around the same way that runners are when when we when we run. So I think he really tested Sawi, showed that, oh, actually this is really possible in running with the with with his performance, but also what researchers had modeled before he ever did that was if we can tolerate taking on more carbs during a run, then we're not gonna be able like, we're not gonna have to dip into our stores. Essentially, what we should be doing in an ideal world is burning carbohydrates and fats for fuel. And the longer you go, the more likely your body is to use fats because you're inevitably gonna run out of your carbohydrate stores because your muscles can only store so much at a time. Now that's why we take on carbs during any endurance effort, but let's say in the marathon, right, so that we're actually not burning out of carbs and then having to use fats.

So the further that we can make it, the more carbs that we can take on, the less likely we are to have to dip into and change that fuel source. So that's sometimes why people feel pretty nasty and they feel that like bonk or that dip in perform or like pace during a marathon. And then also fats are more energy dense, but they aren't as efficient of a fuel source. So you're not able to hold the same paces or intensities. As as you're taking on more carbs, you basically prevent that crossover point from happening.

And as you saw with Sawi, he hopefully did everything else correctly and shoes and carbs and all of these factors that played a role, great weather. But that was part of many puzzle pieces that led him to the best marathon performance we've ever seen.

Jimmy: Number six, which was Yeah. Elaborate.

Melissa: Yeah. So so back to our macronutrient one zero one. We have our carbohydrates, our fats, our proteins. In an ideal world, we're not actually using protein for energy. We can, but what I always tell people is if we're tapping into our protein stores, that means that we've used up our carbs, our fats, and we're likely starving into territory where we need to break down our fat free mass, our skeletal muscle, our precious muscle that we spent time training for to to produce energy because we've run out of everything else.

So you really don't wanna be that low in energy where you're tapping into protein for energy. Now carbohydrates and fats are gonna be the two main macronutrients that contribute to our energy goals. But we need everyone like general Americans but especially endurance athletes are gonna have most of their energy coming from carbohydrates. So it would make sense that if you're not eating enough, you're probably not eating enough carbohydrates. So a lot of the times you see low energy availability and low carb availability happening together which can compound the effects of what we typically see with low energy availability like poor bone health, menstrual dysfunction, endocrine dysregulation.

But we've also seen early evidence to suggest that if you're getting enough energy and you're not getting enough carbs, so you might be meeting your overall energy needs by getting more fat and protein than recommended and less carbs than recommended, you're actually gonna see some similar effects in terms of low energy availability. So that bone, the dysregulated metabolism, like your metabolism is gonna suppress. You're gonna get immune dysfunction, all of these things that we're trying to again avoid because they can impact your ability to perform are gonna show up even if you're getting enough energy but not enough carbs.

Jimmy: What is it what is it that's so important about carbs?

Melissa: Carbs are our best friend for so many reasons. One, they're our preferred fuel source of energy especially at intensities greater than 70% of our v o two max. So anytime that we're trying to perform optimally, they're going to be our go to. Carbs play a really important role in our hormone function. So I think typically you think of fats as helping form the basis of our hormones, which is absolutely true, but carbohydrates help us have enough, especially for females of estrogen, which is protective for bone and that's also going to help with your immune function, not necessarily estrogen, but your IGF one and these other regulators of immune function.

So you start to see more upper respiratory tract infections if you don't have enough carbs or energy in general. So carbs play a really important role in not only keeping you healthy but performing optimally as well.

Jimmy: Mhmm. Why why did they get such a bad rep?

Melissa: You know, that is the million dollar question. I do think that especially from a perspective we always talk about a knowledge gap. Like, I think sometimes people just don't really appreciate how many carbohydrates they need and what that looks like in practice. On top of that though, we have seen that female athletes, even if they know their needs, aren't necessarily meeting them because they're afraid of carbohydrates. And that could be just because of, you know, disordered eating tendencies, what they're being shown online.

They tend to think that they're gonna make them fat for lack of a better word. And, I think that, again, that mixed with the the culture of what should my body look like and wanting to control things, they tend to restrict carbs. It doesn't like protein, know is becoming really big these days. This was a problem before that, but protein feels a lot safer. Mhmm.

Jimmy: Yeah. I feel like people are not afraid to like Right. There's like

Melissa: Taboo. Yes. Definitely. That's like the what we've seen in the literature. I'm sure there's other theories as to why this is, but I would say like a lack of education first and foremost, and then also those disordered tendencies and fears around carbs, which are unwarranted.

I will say that. Like, I mean, I understand how people can get there, but it's not we shouldn't we shouldn't be fearing them. I think people do but they don't need to.

Jimmy: And so when we go into this like idea of low energy availability, low carb availability, your number nine on your list, yeah, was you may be getting too much fiber. I feel like this fits in good.

Melissa: It really does. And this one is like people feel very passionate about this one. And I think in part because generally speaking, Americans aren't getting enough fiber in their diet.

Jimmy: Wait, time out. I feel like every podcast I listen to now is now like pitching a fiber supplement right now.

Melissa: Are they? Yeah. Well, probably because Americans traditionally don't get enough fiber. And this is the thing, this is another piece of education that's important is public health messaging is not always meant for athletes. Because what is needed for public health is not the same.

Like almost 90% of Americans don't meet their physical activity guidelines. That's not the athletes that we're talking about here. So honestly, I mean, I would say there's a lot more inexpensive ways to get your fiber. If you are just like a general healthy American, you don't probably need a supplement. You probably just need like a banana and an apple or some fruits and vegetables in your day and you can ditch the supplement.

But that actually like this is why there is you we see excessive fiber intake in athletic populations and female athletes in particular is because if you think about it from the perspective of like, okay, where do we get our fiber? We typically get from fruits and vegetables, whole grains. Those are very what we like would call quote unquote safe foods for athletes. Like, they don't feel the need to restrict those. And I'm not saying restrict.

I'm just saying, if you eat a high fiber diet, you're probably going to increase your satiety, making it more difficult to meet your overall energy requirement. So if you it's like what we call volume eating. You're gonna have a salad that's gonna make you feel full. It might not satiate you in the long term, but it's also going to be filled with, yes, nutrient dense options. Like, you can have the salad and maybe something else to help meet your energy needs.

Mhmm. Because what then is going to happen is you're going to then not meet your protein, fat, carbohydrate goals and you're gonna stick to things that are more fibrous, that are feel safer and it's mostly permission to eat a variety of foods to get away from only feeling like you can have like fruits and vegetables and whole grains. And the other thing on top of that of just not being able to meet your overall energy needs is that if you have too much fiber, can actually reduce your estrogen reabsorption. And so that which we talked about before is important for not only maintaining a normal menstrual cycle but also bone health. And so there actually is like, there can be too much of a good thing.

And so it's all about making sure that we're getting everything in the right ratios that we're meant to get. And I'm not saying eat a low fiber diet by any means. I'm just saying meet your fiber goals, meet your fiber needs, and leave it there for the day. Don't feel like you can only the only way to meet your carbohydrate goals is to have fiber rich foods. Like, you can have a piece of white bread, it's really gonna be okay.

Jimmy: Yeah. Your statement there was you may be getting too much fiber. Is there a way for an athlete to decide if they are getting too much fiber or is it more just habits that they're doing?

Melissa: I would say the reason why we've observed it is primarily because of their habits. Fiber is actually one of the really a really easy nutrient to keep track of because it's a pretty baseline recommendation and it's just grams. It's not individualized to body weight. You typically see a recommendation of about 35 grams of fiber. There's obviously, there's a range under a little bit over that, but it's on the side.

Fruits and vegetables, don't necessarily have like a nutrition facts label to go along with it but you could easily Google like how much fiber is in a banana or if you're looking at the side of your whole grain bread, just take a glance at, oh, how much fiber is in this piece of a whole grain bread? If you have two pieces of bread in your sandwich and it's like a banana with lunch, how close to that 35 are you? And just kind of look at it that way. It's not something I I wouldn't say you have to like be overly analytical about it. If you get 25 one day and 45 another and you're getting close to thirty five every day, it's more so trying to recalibrate, like, an athlete's mindset around, okay, I can have other things and that will inevitably kind of even itself out if you will.

Jimmy: Yeah. I'm thinking, I don't know if this is right and maybe this is a sensitive subject. It's like people who would intentionally eat a huge salad right before dinner to fill them up and then they're gonna kind of eat less. Is that what we're talking about?

Melissa: Yeah. Volume eating is kind of that strategy. What you're eating has a lot of like a salad, like it takes up a lot of your plate or bowl, but it doesn't necessarily provide a ton of energy. So, you feel full but you just like you didn't necessarily have a meal that was energy dense. And so, it's not necessarily always a bad thing, but if you're doing that all of the time and using it as a strategy to then not eat your Yeah.

Energy like dense meal, that's where we wanna explore that behavior. Yeah. And and really thinking about the healthy thing to do is make sure you're meeting your energy needs and there's a place for that salad, but it's probably in the context of a more substantial meal.

Jimmy: I'd like to take a moment to thank our sponsor, Runeasi. Runeasi is a running and jumping analysis tool that helps provide objective data on things like impact loading, dynamic stability, and symmetry. I've been using it in the clinic for the past three years and I love how easy it is to add to my evaluations. Not only that, but it backs up my clinical reasoning and helps me with my decision making process when I'm doing exercise prescription. So if you're a physical therapist or running coach, book a demo.

If you're lucky, it will be with me. So that ties into number seven, which is this idea. Athletes have a hard time adjusting their energy and macronutrient intake based on their training.

Melissa: Once again, we're thinking the most about carbs in this picture. Mhmm. Because when we look at sports nutrition recommendations, our fat intake recommendation doesn't really change. Our overall energy intake is going to and fat is a proportion of your overall energy intake. We say about 20 to 35% of your total energy intake.

So of course it will end up scaling but it always looks about the same proportion of your of your plate or your meals. Then protein, even for endurance athletes is going to increase slightly. And I say it slightly because what people on the internet will have you believe right now is that you really need to be eating so much protein way more than you might need. So that usually looks like about 1.2 to two grams of protein per kilogram of your body weight. So these are where those individual recommendations come in where it's a little bit harder to gauge like, am I eating enough?

That's why working with dietitians is really helpful because they can help you sort through this in a very individualized in a way. If you are training more than like two to three hours a day, that's where you're really going to start to see that protein intake increase. But still it goes from 1.2 to two to 1.7 to 2.2. So there's overlap there and like if you're meeting your protein goals on the average across a day, you're probably doing a pretty good job depending like, regardless of what you're training that day looks like. And then carbohydrates is where it really changes the most because with an easier day of training, like low intensity, less than sixty minutes, you probably need about like three to five grams per kilogram of body weight of carbs.

That can go all the way up to eight to 12 grams per kilogram of body weight for endurance athletes training, like, two to three hours a day. They might be training at a higher intensity. And so that's, like, a huge difference and that's when athletes don't do a good job adjusting their needs. A lot of that is again coming from not eating enough carbs to be able to support the training that they're doing that day. And part of that is again, I think education, a lack of knowledge, a lack of appreciation for what one training session means compared to another.

Another piece of it is that athletes aren't eating enough in the first place. So if you're not eating enough on a day where you require a little less energy, then you're probably not gonna be eating enough when you do a hard training session. There's also like appetite regulation like exercise can high intensity exercise especially can suppress your appetite. So it's important to listen to your body, but also it's important to just eat before and after training even if you don't necessarily feel like you can stomach something, that's where liquid calories can become really important or getting like a smoothie in while you're making a meal that's more substantial. And yeah, I always like to try to remind athletes it's not so much about fueling less on your easy days, it's about coming up with a really good plan that you're meeting regardless of your training day and then adding to that when you have a harder day of training.

Jimmy: Yeah. What do you think? I feel like I see this a lot where people will try to adjust calorie intake, carb intake on their easy days primarily and don't think about the big days. So it's like they're more focused on lowering it on those days than increasing it on the big days.

Melissa: Right. And I think that that's a mindset that we need to get away from Yeah. Personally. Because I think, again, that could come back to like they would prefer to eat less on their easy day. Like, their framing of it is such that it's coming from more of like a restrictive mindset.

Jimmy: Mhmm.

Melissa: But I think that if we can, again, feel really good about what we're doing on like that easier or more like in running. Like, for example, you might just have like regular runs more often in a week than you have your long run or your harder workout. And those are like if you can nail it five days out of the seven days of the week and then you're actually just needing to make smaller adjustments when it comes to a long run or a workout, then that's also way less brainpower. That's way less like recalibrating every day that you have a training session. So I think it's also like coming back to that mentality of like fueled as fast and we shouldn't necessarily be thinking about it from a perspective of restricting.

We should be thinking about it from a place of abundance and and fueling and having enough energy to support training and recovery. Yeah. So I think that it's more so about fueling more, not trying to eat less on those easier training days.

Jimmy: Yeah. So it's like having a healthy baseline that gets additive based on training volume, not subtract.

Melissa: And I think that, like, training volume is huge, but the the thing that we've noticed athletes are not great at is intensity. Oh. Because usually, if you have a high intense workout, like if we stick with running and you go to the track and you're doing you might not be running as much total time, but it's more intense. You're running faster than you usually do and that increases your demand. Like that increases your training load, that increases your energy demand, that increases your carbohydrate needs.

And so, there's definitely a lack of appreciation. I think there's I don't know what it is but athletes tend to recognize when they're training volume increases. But they're not always great at adjusting for the intensity piece and so that's something to look out for too.

Jimmy: He's ran super hard.

Melissa: Yeah. Not a research term but I always call it tempo tummy and it Yeah. Like you're you don't necessarily like feel like your regular options feel as good or you could even stomach them. So that's where I'm always like chocolate milk, smoothies, something easy. It doesn't have to be, you know, it can be simple.

Like, I usually like a piece of toast and like cinnamon sugar before run, but I can also always stomach that like that. There's never a time where I can't at least get something like that down. And so, if you have to, like, keep it simple while your stomach kinda calms down, like, that high intense high intensity exercise does decrease your appetite and and that's not a reason to fuel less. It's just it's important to acknowledge, but we do have to work through some of that GI distress and getting something in will still remain really important. So this is kind of similar to what we were talking about with the low carbohydrate availability because we're looking into what that energy looks like across a day.

So you might have heard of like backloading your calories or, I mean, like in the eating disorder space, some people might call that bingeing. Backloading, I think sounds a little bit better because What is backloading? Always basically, when this is actually something that male athletes do more than female athletes is like That

Jimmy: sounds like something I've

Melissa: Yeah. Yeah. Yeah. You won't eat enough throughout the day and then you get to dinner and then you might have like two times the amount of dinner that you'd have because you're like making up for not having lunch or something.

Jimmy: So in college, I had my two main injuries. I had a sacral stress fracture and a bunch of a couple tibial stress fractures. And I had a lot of GI issues and my primary eating habit became early early breakfast, big.

Melissa: Yep. So that sounds like you were you were probably reaching backloading territory, which I we wanna try to avoid, but I don't fall athletes, especially because you brought up a good point around practice time. And so this does make it really challenging. But essentially, we call this within day energy deficits. So if you when you calculate energy availability, it's based on one day.

And so or it could be like the average of many days, but it's essentially what you had per day. If you look at that number, you could be meeting what's considered like adequate. But if you do the back loading and then you didn't eat enough during the middle of the day or even like some people who don't eat before their first training session, like if you do train early in the morning and you had dinner and then you go to bed and you slept for hopefully like seven to eight hours and now you're reaching like ten plus hours of not having any fuel in your system, you're gonna be in a within day energy deficit. And like low carbohydrate availability, we see very similar effects with the within day energy deficit. Like, there's going to be greater perceived exertion during training, potentially adverse training consequences like you're not gonna be able to train as hard during your sessions.

You see similar effects to metabolism and estrogen, higher cortisol. So that kind of makes sense like you're you're stressing your body out. And then impaired we do see impaired bone health. And then again, I do try to take the focus away from body, but sometimes this helps athletes who are stuck in this mindset that we've seen in gymnasts, if they're exposed to within day energy deficits more often, have higher body fat percentage, which you kind of think it should be the opposite. But essentially, body's gonna hold on to what it has because it doesn't know when it's getting its next meal.

And so that's a source of energy for it. So it's gonna kinda try to keep it so that it can use it if needed. And so I I think that, again, that challenge you brought up a really practical challenge with fueling and I personally hate an afternoon practice time. I fell into that trap in college too where, okay, what do I eat at, like, lunchtime so that it doesn't disturb my stomach for when training's coming up at, three, but then training's from three to five and then you don't necessarily get out of there at five. So now it's dinner time and you like missed a whole snack window in the afternoon and you didn't have like a normal type lunch.

And so I do think it's really hard for athletes to break that down. And I have a couple examples on my Instagram about what you could do if you have a morning practice versus an afternoon practice. I am partial to a morning practice or just a morning workout because I find that it's much easier to just get up, try to get something in before my run, and then just feel normally the rest of my day and not have to think about if it's gonna disrupt my stomach. But I also think we think of we talk ourselves into thinking that we can't have a lot of things that we like, three hours is enough time to, really digest and be able to have whatever before a run. So yeah, just making sure that you're not only paying attention to getting enough during the day but throughout the day as well.

It fits in like squarely with within day energy deficits because the longer you're going, the more like or the less reliable your body feels like to be able to get enough energy in. It doesn't necessarily like trust that the next meal is coming if you will. And then also if you go into your training sessions under fueled, then you're not gonna be able to maximize the training that you're doing during those sessions. And so I think that a lot of people actually like unintentionally end up in like an intermittent fasting situation if they train early in the morning and aren't eating beforehand. But that's where it's good to just get like an applesauce packet, white toast with cinnamon sugar.

Like, there's a lot of sports nutrition products like honey stinger waffles or any like anything like that before is really good just so that your body is not going into that training session under fueled and that's yeah. If you're doing if you prescribe to any type of intermittent fasting, like that you're just gonna be in a within day energy deficit and that's gonna have similar effects as I mentioned to low energy availability. So to me, it's like, What's the point? It used to be more popular. Like, I feel like I was talking with athletes five, five plus years ago, more so about that.

And now it's like the protein and the supplements and I also think sometimes it's I mean, to be honest, the social media influencers nowadays like they know how to market things and so sometimes I'm like, we just have to come up with a better marketing strategy because we call it within day energy deficit and maybe they're like, they don't know what that means or they don't recognize that as being tied to intermittent fasting. And so, I think that we have we have a PR problem sometimes.

Jimmy: Yeah. And it makes a lot of sense the way you present it. I like that a lot. Do you know is there a difference between the way men tolerate it versus women tolerating it?

Melissa: I have to be honest, I'm so in my female athlete silo. A lot of the times that I what I will say across the board with some of the low energy availability research is that men are more resilient to shifts in energy availability than females. So we might see the consequences come online a little bit faster for females than males. In terms of intermittent fasting, I have heard some people suggest that, you know, like, works for women and or it doesn't work for women but it works for men. And I would say, like, it kinda doesn't work for either

Jimmy: For anyone.

Melissa: And that females might have graver consequences but I wouldn't go as far as to say that I would recommend it for men and not for women.

Jimmy: Sure. Yeah. No. Yeah. Fair enough.

Alright. So next topic, you can't screen females on hormonal birth control the same way. We talked a little bit about this off air. I'm very interested in this one. So yeah, go ahead.

Melissa: I'm really interested in this because I obviously exist in the female athlete research space and a lot of the times we're focused on rightfully so, there's not enough information on women as a whole. But when we talk about women, we're like, oh, so let's talk about the menstrual cycle. Well, when we break it down, about fifty percent of female athletes are on some form of hormonal birth control. And then if you break it down further, again, these women can intersect both of these categories but then you have women going through pregnancy and postpartum. You have women in the menopause transition.

You have youth or teenage athletes who haven't actually experienced menarche or their first period yet. So when you really break it down, we're focusing our attention on menstrual cycle research which accounts for less than fifty percent of the female athlete population. So I think that in and of itself, there's more to be done from a research lens. But this one is particularly important I think for clinicians and the female athletes themselves to recognize because clinicians don't always catch this. And I think it just has to do with this is a newer area and this is not how clinicians were trained or they don't talk a lot about female specific considerations.

Essentially, the menstrual cycle and in particular the period because it has that visual feedback of the bleed is such an important vital sign especially in the context of REDs. So if you have a female athlete though that's not on or that's not like meant to get a regular menstrual cycle or a period. They're on some form of hormonal birth control or they might be going through pregnancy postpartum. Those other considerations we talked about. How are you meant to screen them?

Because we have this really good indicator but we lose it when we don't have the ability to assess. Yeah. And I'm proud of those female athletes who say that because another problem is that the education around hormonal contraceptives isn't great. And so some females still get a bleed during their like, if they're on some form of, like, oral contraceptive and they have the active pill days and the non active pill days. During those non active days, they might experience a bleed.

It's it's a withdrawal bleed, it's not a period. But clinicians, like, even those in like OB GYN settings will still call it a period. And I'm like, no, please stop calling it that like it confuses them and I get a lot of questions about it because if you don't do a little bit of digging, like, there are some well meaning clinicians that might just ask that question and they say, oh, no. I'm not. And the athlete doesn't caveat it with I'm on some form of hormonal birth control.

So I'd say word of caution to the clinicians and the athletes is to make sure that you do make that distinction. Like, are you able to get a regular menstrual cycle and are you on some form of hormonal birth control? Like, those are two separate camps.

Jimmy: Mhmm.

Melissa: And then the challenge here becomes, which is part of what I'm like looking to to work on from a research perspective, is how do we really screen these athletes because we don't have a good answer. We need to look at the whole clinical picture. So, we lose one of the most important indicators but it's not the only indicator that we have. So, you can still look at bone mineral density. You can still look at lipid profile.

So, LDL and total cholesterol can be really important in the RED's clinical picture. You can look at injury history for the athletes who might be not at menarche yet, who are still like under the age of 20, you can look at their growth and development charts. And so I would just it's similar to male male athletes. Right? Like, we can't screen for menstrual function in males.

We do look at testosterone or morning erections in terms of, like, sex drive for for males. But, like, that's not a one for one for females on hormonal birth control. So the answer is honestly, like, to be determined and hopefully, we have, like, a better way. But I think the most important thing is to recognize for female athletes who do decide to be on some form of hormonal birth control that we do lose that. And it's just important to not weigh those two options similarly and then hopefully we have a better approach in the future because right now we just don't have an adjunct to the menstrual cycle in the in the period.

Yeah. It doesn't tell us. And sometimes what might also happen is a female athlete on hormonal birth control gets a withdrawal bleed and they lose their withdrawal bleed, also not the same thing. It's not that, like, we can't use that as an indicator. It's a great, like, learning opportunity for that athlete.

Like, if you are working with an athlete and you do ask them that question, you you might just use that as an opportunity to be like, okay. So actually when you are on a hormonal birth control, you can't get your natural menstrual cycle. So we actually can't use this as an indicator because they might not know, right? In my field, we all we often give them like a not applicable option, right? So, those who have that knowledge and information will just tell us like, this question doesn't apply to me because I can't even use it as a gauge.

But oftentimes, we are having to have that conversation because they might check off, yes, I'm having a normal menstrual cycle but I'm also on birth control or no, I don't and no, I'm not. So, you kind of have to use both of those answers to come up with a plan of attack. Yeah.

Jimmy: Got it. No. That's great. Very helpful. It's something I've I've personally struggled with as a clinician knowing how to interpret that and what to do with it.

So thank you. Alright. Number the next one. You build your bones in your teens and early twenties.

Melissa: Yep. So, I mean, you you probably well know this as a physical therapist that our bone health is built in our teens and early twenties. Earlier twenties for females, little bit later twenties for males, but peak bone mass accrual is happening rapidly during adolescence. And so if we meet our peak bone mass in our twenties, we might be hovering around there for a couple of years and then as we're aging, every single one of us is just fighting off losses. So our bone is dynamic, we're building tissue, we're breaking it down.

In adolescence, we're building more than we're breaking down. Then for a period of time, they might be matched. So we're not actually losing bone mass, but we're not gaining more. And then as we age, we start to lose more than we're gaining. And that's a natural process of aging.

Like, that's not something that we need to be concerned about. That just happens. But where the concern comes is if we aren't meeting our peak and then we're losing as we age, you might not be unfortunately, we do see like 18 year old female athletes who have osteoporosis because they might not have been fueling enough and then that's gonna put them in even more danger like further down the road. But if you do have somebody who let's say they're not osteoporotic but they didn't reach their peak, then they're starting from a lower peak and then inevitably they're gonna lose and they might end up in a place where they're osteoporotic when they're 70 when otherwise they wouldn't have been if they were fueling enough and training at like appropriately and increasing their load in the appropriate amounts at the appropriate times. And so, it's really hard.

This is this is the one that I struggle with because I think about myself in my early teens and twenties. Guess, sure, whatever. Like, I don't care. Like, I care about what's happening to me right now and I I'm not gonna I'm not even thinking about myself when I'm 70 right now. So I think in terms of what to do with this information, it can be really challenging to create an action plan or convince an athlete to really really care about this one.

But I think as clinicians and people who work with athletes, it's important for you to know this so that you can help protect it and also continue that conversation with athletes. Like, they might not care but but we do. Like Yeah. We care about having healthy adults and like if you're at risk for osteoporosis and then you're at risk for osteoporotic related fractures and then that decreases your, like, life expectancy so much more than you would think it should. And so there's real long term consequences to this.

And I don't mean that to sound like scary or intimidating, but the things that we're doing now really matter. And I think that we don't wanna take that lightly. Like we wanna make sure that we're healthy now, but also that we're setting ourselves up for not only a long lifespan, but a long health span that we're healthy for all of those years as well.

Jimmy: Yeah, and I think it's such a challenging time too, like in your teens, you're in high school, cafeteria food, social issues, body image issues. But yeah, super important. I'm thinking of a 16 year old girl I work with now and she basically skips lunch every day because she doesn't like the cafeteria food, it's not healthy. And she's trying to train for some pretty high level stuff and trying to help her without scaring her like you said, or fear mongering or something like that, but just to help educate her as like, this is a very important time for your bone health and probably even parents because I think maybe a lot of parents aren't aware that this is that this is a thing.

Melissa: Yeah, you bring up a wonderful point about parents because some of this information is also meant to go to them like there's they're in charge a lot of the times of the eating that happens in and around the household. They're guardrails for that athlete. And so a lot of the times, these are important things for the athlete to know, but really for parents as well to educate them because they might not have an understanding and

Jimmy: Yeah, recently came across a book, I think it's called A Young Runner's Guide to Nutrition and I thought it was really great. I shared it with this client that I'm talking about and her parent just to help them become more aware about the role that nutrition plays this. So that's a resource I'd encourage people to check out too. Awesome. All right, two more to go and one of them is a fun one, but we'll save that for last.

So the next one, it's not as simple as energy in versus energy out. What are you trying to tell us here?

Melissa: I think most people are pretty familiar at this point with the energy balance equation, which simply states energy in versus energy out and then

Jimmy: Why are they wrong?

Melissa: Why is it not? So well, first and like, the the energy availability equation, if people are unfamiliar, is energy intake minus exercise energy expenditure. So just the energy you're burning from training divided by fat free mass. So you're more metabolically active tissue. And so that's gonna leave you your energy availability which we can actual thresholds but they're debated in the literature so it's not necessarily a one for one.

But if you're below a certain threshold, you meet the criteria for low energy availability. That means you basically don't have enough energy left after you take out your training, which an athlete is going to do anyways, to support the rest of your physiological functions. That's why you start to see a lot of health consequences as a result because your body shuts other things down. It says, well, I don't need to reproduce this month. So I'm gonna shut that process down altogether.

I'm actually not gonna give as much energy to building bone because I don't have any to spare. I'm gonna suppress my resting metabolic rate because I'm gonna make everything cost the least amount of energy as possible because I'm not getting enough energy in. So when you think about it from the energy availability standpoint, it's not just energy in versus energy out. Then it becomes a layer deeper when you think about energy in versus energy out. People think, oh, if I just eat a little bit less than I need, I'm gonna lose weight.

But our bodies are smart. They're trying to keep us alive. Most people have a happy settling point with their weight and they want their body wants to be within a certain range. And so it has compens like, it has mechanisms that are gonna kick in to try to keep it where it wants to be. And so if you are trying to eat way less, like you're trying to burn way more than you're taking in, your body is not going to be happy with that and ultimately, you're going to need to be more evenly matched.

And so I think that when when you get even deeper into the weeds of like what actually happens when you start eating less than you're burning, it gets way more complicated. And it's not just like, oh, yeah, all of a sudden, you're easy peasy gonna lose one pound per 500 calorie deficit that you have.

Jimmy: Interesting. Yeah. I feel like there's a book about this that I may have started to read, Good Calories, Bad Calories. Have you heard of this book? Mm-mm.

This was a long time ago. So forget I mentioned it then. Let's move on.

Melissa: But you do do bring up an actual another interesting point, which is where does your energy come from? It comes from your macronutrients. What's the composition of those? So if you ate all of your total energy needs in only protein, that's not the same energy in. So it's

Jimmy: Yeah. Yeah.

Melissa: It goes back to like people oversimplifying things that I'm not saying it's completely inaccurate or it doesn't matter at all, but it's just not as simple as as people make it out to be sometimes.

Jimmy: That makes sense. Alright. Last one. It's reds not red s. Explain.

Melissa: Yes. This one's simple and it's also, like you said, quite fun because I use this as a litmus test for people who are talking to the right people and having the right conversations. Relative energy deficiency in sport is capital r, capital e, capital d, lowercase s. Now, it did used to be all capitals, r e d dash s. It was always intended to be pronounced reds, but the way that that looked, people just called it REDS.

People still do from time to time and the REDS is a is a position statement from the International Olympic Committee and the lead author always intended for it to be pronounced REDs. And so if you're in this world and you're going to like listen to the authors of the position statement, if you're talking in the research circles where this work is happening, you would know that. And so I do think that it's important and I like to kind of it's not necessarily the best barometer, but if there's one thing that I can piece of advice that I can leave listeners with, it's if you hear somebody say that, you might wanna think twice about the rest of what they're saying because they might just be regurgitating information that they've read somewhere and not necessarily as up to date with the advancements in this space from research standpoint.

Jimmy: We're talking about, we call it REDs. Yes. Nice. All right. Well, that sums up our 10 points on REDs and that everyone should know.

So for I really appreciate your time. For all the listeners that wanna learn more about you and where can they find you?

Melissa: Yeah. So primarily on Fed Collaborative, I try to post regularly all things female athlete health and performance, REDs, despite what I said about the menstrual cycle, it's still important, so I post and share about that, and hormonal birth control, and all of the life stages that female athletes experience during their sporting careers. Yeah. It's fedcollaborative.

Jimmy: Yeah. So there's an underscore in there. We'll put a link in the show notes, but yes, go check her out. It's amazing, great content. Again, thank you so much for your time and for coming on here.

Really appreciate it.

Melissa: Of course. Thanks for having me.

Jimmy: That's it for today on the Physio Insights podcast presented by Runeasi. Would you like to share an interesting case, insight, or have a thought about the podcast? Comment below, and don't forget to follow us for more episodes.