The Food Medic - S7 E10: No period? why it matters and how to get it back with Danielle Logue

Episode Date: March 9, 2022

You might think you’re at your peak fitness - you’re exercising regularly, maybe even competing or running marathons, you’re strict on your nutrition and perhaps you’ve even lost weight but you’re periods have gone? This is a lot more common than you might think. In fact one study of regular exercising women, found that half had menstrual disturbances and over a third had no period at all. If this sounds like you - the road to recovery can be long and daunting but hopefully this episode will help. In this episode Dr Hazel is joined by Danielle Logue who is currently working as a performance nutritionist within Sport Ireland Institute, delivering nutritional services to high performing athletes. In 2019, she completed my PhD in University College Dublin in collaboration with Sport Ireland Institute. The area of research was Relative Energy Deficiency in Sport and its relationship with injury, illness, health and performance.This episode covers:- RED-S : what is it and who is affected? - Health effects of not having a menstrual cycle- How to get your period back- RED-S in males - Matching your nutrition to your training demands- Specific nutritional requirements for female athletes- Common signs of under-fuelling - What to eat when recovering from an injury- Advice for nutrition undergrads who want to do postgraduate research. If you loved this episode make sure to give it a review, rating (hopefully 5 stars) and share it with your friends and family. Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

What's better than a well-marbled ribeye sizzling on the barbecue? A well-marbled ribeye sizzling on the barbecue that was carefully selected by an Instacart shopper and delivered to your door. A well-marbled ribeye you ordered without even leaving the kiddie pool. Whatever groceries your summer calls for, Instacart has you covered. Download the Instacart app and enjoy $0 delivery fees on your first three orders. Service fees, exclusions, and terms apply. Instacart. Grocer $0 delivery fees on your first three orders. Service fees, exclusions and terms apply. Instacart, groceries that over-deliver. You might think you're at your peak fitness. You're exercising regularly,

maybe you're even competing or running marathons. You're strict on your nutrition and perhaps you've even lost weight, but your periods have gone. This is a lot more common than you might think. In fact, one study of regular exercising women found that half had menstrual cycle disturbances and over a third had no period at all. Anecdotally, one of the most common reasons women contact me directly is because they've lost their period. And while there are many reasons why someone might experience this, one of the most common things in active females is a mismatch between energy intake and energy output. This is down to overtraining, underfueling, training in a fasted state, weight loss, or having a low body weight, or restricting key macronutrients such as carbs. Well, you might be thinking, it's just my period, I'm not thinking about children yet or at all, but there are many health and performance effects

of not having a regular cycle. So if this is happening to you, then I'm advising you to seek medical help first. It's also really important that we rule out other causes for why this is happening. Assuming all of that's happening and you're on the road to recovery, I know it can be quite a daunting thing to take on alone but hopefully this episode will help and it might even prevent you going down that path in the first place. So to help with this I'm joined by Danielle Loke who is currently working as a performance nutritionist within Sport Ireland Institute, delivering nutritional services to high performing athletes. In 2019, she completed her PhD in the University College Dublin in collaboration with Sport Ireland

Institute. The area of her research was relative energy deficiency in sport and its relationship with injury, illness, health and performance. Gentle reminder that the information provided in this episode should not be taken as medical advice and does not replace that provided by your usual healthcare practitioner but we still hope it will help your recovery. I would love to start out by asking you to tell us a bit more about you and who you are, what you do and what you're passionate about. So I'm currently working as a performance nutritionist in Sport Ireland Institute and my main role there would be supporting the health of athletes in a range of sports

and ensuring that they're well fuelled and ready to train or perform. But I suppose prior to that I completed my undergrad a long time ago now in human nutrition in Ulster University. So that was a four-year program. But it really wasn't until final year where I actually got some exposure to sports nutrition, which is where I've always had a keen interest in that space. But I suppose after my undergrad, I tried to get some work, sent my CV to my old lecturer in UU,

basically tried anything to get some exposure in the area of sport. But it is a real competitive field. And I kind of knew that I would need to go back and do further study. So the January of that year, then I applied in to do the dietetics in Cardiff. And in April then of that year, I applied in to do the dietetics in Cardiff and in April then of that year I might like I was working at home at the time and a call came to my phone like eight o'clock in the morning it was the head of the institute looking me to come down to Belfast and talk through a sports nutrition PhD opportunity and a funding application so of course off I went and

the rest kind of says itself but I actually went to Cardiff for the year because I didn't know whether I was going to get the PhD funding or not and within I think it was within the first month I got the email to say that the funding had been granted so it was a tough decision to make whether to keep on the keep on going with the dietetics or sway towards the PhD but I think that I was never going to get an opportunity like that again so the PhD funding then was through the Irish Research Council and how that works is that you have an academic partner who in my case was UCD and then you have your industry-based partner who was Sport Ireland so it was really it was a fantastic four years you know you get to conduct

your research you get to see it come to life in practice, and then you also gain practical experience through working and travelling with athletes as well. So, and then I suppose you get employment out of it now too. So it's been a one-win. Yeah, what a story. But like you said, it was a difficult decision for you to make. But where you've ended up,

I'm sure you're really happy with your kind of choice and you'll never know which was the right one or the wrong one and there is no real right or wrong decision there so your PhD was in REDS or REDS is that correct? Yeah that's correct yeah. Yeah and so for people who are listening who may be unfamiliar with this term can you tell us a bit more about it and who's at risk? Yeah, so RED-S stands for Relative Energy Deficiency in Sport. It's a relatively new term used to describe the impact of low energy availability on physiological and psychological health and athlete performance as well. And it can affect both male and female athletes of all levels

and all ages so we're talking here from our international representatives right through to our recreationally active individuals or gym goers or crossfitters or weekend warriors. So really just a bit of background on that then in the early 90s the female athlete coalition introduced the term the female athlete triad and that was introduced to highlight the impact of low energy availability on menstrual function and bone health but then in 2014 the international olympic committee introduced the term reds so not to replace the triad as, as it's really built within the REDS health model, but it's to highlight that males can also be impacted by low energy availability and that the impact on health can go far beyond menstrual function and bone health. So for each of the

health and performance outcomes outlined within the REDS models, they need to be further investigated, but there has been great strides made in that area over the last eight to nine years. So for example, the development of a low energy availability screening tool for females has allowed us to screen and gain a greater insight into the prevalence. And hopefully we'll see the same type of screening tool developed for males within the next year or two as well, which would be great great just to give us a handle on the extent of the problem and an easy means of doing that as well using something like a screening tool. Yeah absolutely you know many of the signs and symptoms can be disguised as other things but one of the most common clinical signs in women is amenorrhea or they lose their periods so for

people listening who this you know may have happened to them, why is this happening? Yeah, well, I suppose really the answer to that really lies in the understanding of how the body handles energy. And in order to do that, we really need to think about energy availability. So what that is, it's a term used to describe the energy you need, number one, to fuel your exercise or training and then number two to fuel your bodily function so energy availability is made up of two components energy to fuel training and energy to fuel health so ideally you want your energy intake to cover the cost of both your training and your health however if you reduce what you eat

if you increase the amount of training or a mixture of both the result is that there may not be enough energy specifically available to support all bodily functions so some of these functions that we have in our body are critical obviously for keeping us alive such as your heart pumping dot around your body your thermoregulation while others are one for better or nice to have, but not essential for keeping us alive. So your reproductive function. And that's what happens in the state of low energy availability. These functions can be turned down or turned off in an emergency. And that's what you would classify as a low energy availability state. Yeah. And so, you know, for some women,

they may be thinking, well, it's just my period I'm not planning on having children anytime soon so I don't need to worry about it but what are some of the health effects of not having that regular menstrual cycle? So yeah with that then your reproduction is shut down, oestrogen levels drop and as we know that's the key hormone in the regulation of our periods but it also plays a huge role in bone health as well so estrogen is a key regulator of bone metabolism and prevents bone breakdown so by not getting a period there's a lack of estrogen circulating in the body meaning that bones are more quickly broken down and they're not being rebuilt and this puts you at increased risk of fracture in the short term.

And then in the long term, health implications of that, then we're looking at things like osteoporosis or brittle bone disease. I know, Hazel, for me and you, those ring alarm bells and the health implications of that is severe. You couldn't get any more severe. But for a younger athlete who doesn't think about 30 or 40 years down the line you know it's it's really hard to drive that message home so for us as practitioners it's really important to orientate that message around performance outcomes so for example not having a period greater risk of injury occurring which means missing days of training and

potentially not actually being able to train or perform and we actually did some research with our athletes in the institute there over the last year and a lot of them have come back and said that that message around fueling for linking it back to performance really encourages them to take the message on board and that's what we want is athlete behavior change but also on that actually another point would be the education of coaches as well the importance of actually having a period as there is loads of misconceptions within various sporting groups so you know like not having a period is normal and that's what the athlete should strive for so I think we really need to get better at delivering that message and how important it is to have a menstrual cycle in sport yeah that's that's really interesting

about how to encourage athletes to pursue getting their periods back and taking the measures necessary and kind of turning it towards a more performance angle is if that's what you have to do to get them to take it seriously then that's what you need to do yeah absolutely because of course like it's not just bone health and heart health and performance but also even like your mood is affected and it's just so many different things it's like an entire system effect um but yeah of course maybe some women will only take it seriously when they get it to a certain age or they do have a fracture and I think that that is a really difficult message to hammer home you know even when we're talking to people who are recreational gym goers totally and so

assuming someone has the diagnosis of red s or amenorrhea functional hypothalamic amenorrhea in this context how does someone go about getting their periods back now for me this is a question that's constantly asked and the kind of audience who would follow the food medic page would be a very active female audience and for me having this question asked so often tells me that this problem is a lot more prevalent than maybe we understand yeah 100% I totally agree with you there and I think a lot of it boils down to the etiology of REDS or functional hypothalamic amenorrhea you know so in order for us to put the best treatment plan in place and to work collaboratively with an MDT, we need to know that that stem from disordered eating, eating disordered behaviors. Is it completely unintentional?

Is it a mismanagement of energy? So that will really determine what treatment plan will be most effective for that individual. So it is extremely individualized but from a nutritional standpoint then there was that or ct published this year refuel and they looked at the effectiveness of increasing energy intake for 12 months on menstrual function i think it was 78 or 76 exercising woman with menstrual disturbances and the main things that they found were that a modest increase in calories, so we're talking roughly 350 calories per day, with no change to their exercise energy expenditure, actually brought back their period. And for those women who recovered with the increase

in calories daily, the majority recovered their menses by six months again these findings they highlight that a modest increase is doable and that is achievable but what they don't actually look into is you know the psychological side of things as well there's a lot of factors when we think about reds it's not just tell someone to eat this they need to be consistent with this and their period will come back because they have other behaviors around that, you know, are they a perfectionist? Are they quite anxious? You know, is there any mood disturbances, like you had said, so it'd be really interesting to know the quality of recovery beyond those hormonal changes, and to investigate it from a psychological factor perspective, you know, the change of mindset throughout that process.

And I suppose along with those findings, then know the increase in energy intake this will differ dependent on the athlete so it might be 350 for one and the recovery again may be different depending on the etiology but another thing that is really important is improving your within day energy balance so avoiding long periods of time without actually taking in any fuel and is really important is improving your within day energy balance so avoiding long periods of time without actually taking in any fuel and is really important so things like intermittent fasting that are quite on trend you know if you if you don't have a period that's not going to help the recovery process from that so it's important to be mindful of those quack diets as well out there yeah that's a really important point and kind of training fasted as

well yeah is another kind of risky thing that was really helpful and then you know we've been focusing on females for most of this conversation but Red S also includes males so what are some of the clinical signs that we see in men? Okay so we also mentioned the importance of estrogen in terms of female reproductive and bone health. But I suppose it's important to mention when it comes to men, testosterone is believed to play the key role in erectile function and libido. And research in exercising men has demonstrated that exposure to chronic endurance training may exhibit alterations in their reproductive hormonal profile as well. So for example, low testosterone and low lignizing hormone levels. And males displaying such alterations are thought to exhibit what has been defined as exercise

hypogonadal male condition. And this has been described as the equivalent of functional hypothalamic amenorrhea in females. So some of the signs for males then to look out for things like low libido, fractures or reoccurring injuries, low mood, feeling lethargic, again decrease in athletic performance or problems concentrating. So again not a million miles away from the female signs and symptoms, but this is a very understudied population. But although saying that low energy availability may or may not be as big of a problem within the male cohort. So further research is needed to gain a better understanding of the extent of that problem and to ensure that males are receiving the exact same support as females in terms of their health and performance as well. Yeah. And so why do you think that low energy availability is less common in males? Do you

think it's because women are more often actively trying to restrict their calories? I don't know if it's a fact that maybe males are a little bit more robust you know women are we're not small men we are made up very differently again we have that piece around menstruation and which men don't have that fluctuation hormones every month and again there is a higher prevalence of eating disorders and disorder eating behaviors within females versus males but that's not saying that there's other issues there within the male context we think of things like muscle dysmorphia and orthorexia which is becoming more and more common among platforms like instagram and things like that you know it's so many people with tops off and abs and leanness and stuff like that so it's very hard not to get sucked in by that and then that can create a

cascade of problems so I suppose that they might have similar types of problems but in a different context if that makes sense so you know striving for muscularity and leanness as opposed to with well females are the same but maybe um to a less lesser degree yeah it's kind of different messaging coming at them so then to kind of avoid all of that when it comes to fueling training and fueling the work that we're doing how best can people adjust their diet to match their training demands like I know that you are giving your athletes very prescriptive you know dietary recommendations but thinking about just kind of general gym goers what kind of things should they keep in mind? Yeah and with that you know prescription is really important but also visually being able to see that

is really important as well so sometimes that would work with particularly a younger group of athletes versus maybe an athlete that's further on in their career so i suppose when it comes to fueling training carbs are king so depending on the intensity and the duration of your session carbs will increase or decrease so using something like your athlete plate recommendations and adjusting carbs based on how tough that session was and then on top of that we need to think about variety in color to support immune health but the athlete plate recommendations are a really good go-to tool to help guide you around your meal times and training but also one thing and just when we're on

that is the protein i think a lot of people fixate on the importance of protein and yes it is really important but what's more important is the distribution throughout the day so getting A lot of people fixate on the importance of protein. And yes, it is really important. But what's more important is the distribution throughout the day. So getting equal hits across each meal is far more important than consuming your 100, 150 grams, you know. So it's, you know, thinking smart, getting their timings right. And that will make all the difference as well. And particularly with low energy availability, we're talking about feeding the muscle at regular intervals yeah it's really important it's

interesting about that kind of what you mentioned there with protein because I think oftentimes there's this assumption that you just need to kind of focus it all around pre and post workout window and then not really worry about it at any other point in the day but really it's those kind of regular intervals of having just protein spread throughout the day. Yeah. And so are there any specific nutritional considerations that females need to take into consideration when it comes to fueling their sport or exercise? So unfortunately the research into optimizing nutrition for health and performance specific to the female physiology is lacking but there's a few things that females should consider when it comes to fuel in sports so the first one would be adequate energy availability to ensure that there's enough energy in the tank

for training and for health so some ways to manage that then is eating every three to four hours eating around training eating to match that training volume so really advanced planning and preparation are key in order to prevent underfeeding another tip to get those additional calories in will be to add toppings to cereals fillings and mix-ins in your sandwiches or your wraps, or make simple swaps, you know, such as fresh fruit to dried fruit, your bread to your bagel, and always go for the full-fat yogurt, dressings, or things like that. I suppose the next thing then to consider would be some of the common micronutrient deficiencies in females that have been reported, so iron, vitamin D, and calcium, and again, increasing the consumption of a wide variety of foods so your

dairy foods are foods fortified with these nutrients as well and potential supplementation may be important but again we need to keep in mind that these requirements may change during different phases of the menstrual cycle as a result of hormonal fluctuations but for me definitely the bone health friendly micronutrients your vitamin d and calcium and ensuring there's enough energy in the system yeah and then so for people recovering from injuries are there key nutritional strategies that you would implement with your athletes for example i suppose the main thing there you would focus on your energy intake so calories are necessary for the healing process and consuming too few will likely slow that healing process

and that's a common mistake athletes make they restrict their energy intake when an injury happens and you know it's not an opportunity to get lean or focus on body composition recovery is an energy demanding process and dependent on the severity or the stage of recovery for that individual the energy demands increase above that of your maintenance calories so maintaining body weight or even putting on some body fat is part of the recovery and for me that's nearly a good sign it shows that you're supporting your needs so now don't go mad and eat everything in front of you whenever you're injured you know there has to be a focus on whole

foods and variety in that as well so many athletes are often used to you know grabbing gels having sports drinks shakes but this is a really good opportunity for them to get into the kitchen to explore different recipes and to use whole foods so really focusing on foundations there you know including protein having that spread out through each meal and that's to stimulate your muscle protein synthesis and so aiming for equal amounts across the day including your fiber-rich whole grains fruit and veg dairy and your healthy fats as well and also the same as the females including your bone friendly nutrients vitamin d and calcium so your dairy food group salmon broccoli kale

they're all good source of calcium and adding plenty of variety into the diet too absolutely and um kind of thinking back to fueling the work that we're doing I know that we're kind of jumping back here but for someone who is just kind of eyeballing everything they're doing well they're not really running into any issues how do you know if you're under fueling okay so some of the comments saying I think we've we've touched on quite a few of them so around menstrual disturbance in females low libido in males the injury piece your low mood but we also have to think about that individual as well so for example is there a history of dieting or frequent weight cycling are they a perfectionist are they that type of mindset that's quite obsessive do they

have a high training volume so particularly when training ramps up it could be a time that an individual is also at school or college or they may have started a new job or you know life is stressy and busy that nutrition kind of just gets through to the wayside and that's where the under fueling piece can creep in and also then various sports have sport specific demands you know such as weight making sports but I suppose instead of watching for signs and symptoms of under fueling try and recommend athletes to be more proactive and aware of the things that they should be doing to prevent that so I often ask them you know are you eating frequently so four to six smaller but nutritionally dense meals? Have you optimized your pre and your post recovery foods? What about your sleep? Your hydration? Are you focused on proper acute and your daily hydration practices?

So really, if they're answering no to a lot of these questions, it's really time for them to get their house in order. Because it's not the training plan. It's really that they're under recovering. So just little reminders, a few questions to get them thinking about the things they should be doing outside of their training environment. Yeah. And I think it's important to say what you've sort of alluded to there, that when it comes to under-fueling, it's not always intentional. It can be unintentional, especially if you're increasing your training and you're just not increasing your calories to match that. Yes, definitely. And it happens more times than enough.

You know, and that's potentially the types of individuals that we would see more so than the ones that have the clinical eating disorders. It's that mismatch. And, you know, I think putting the title of REDS on it sounds quite, oh, my God, I've got Reds. This is this is awful. But it's actually if we can just get your house in order, get you even more to support that training. You know, things will try to balance themselves out, you know, not making it out to be something that is mega dramatic to you. Absolutely. Well, I think we kind of rounded up the conversation of Red S but the other question that I would love to ask you and you touched on this in the beginning is getting into research from your undergrad degree and you've had an interesting pathway and I know a lot of nutrition undergrads

listen to this podcast so what advice would you give them if they are interested in pursuing a PhD I would highly recommend networking and if there is a particular research area that you're interested in try and get up to speed with the current research in that space but also reach out if you are in university or if you've just recently left and reach out to your old lecturers and get them to help you veer in the right direction because they may be aware of collaborations with other practitioners, other industry-based partners that are also looking to conduct some research. And for us as students, or you know yourself, Hazel,

it's not easy to establish those connections unless you have the appropriate people to put you in contact with those outside of the university setting and like feel free Hazel you can put up my email address or if any of them wants to reach out you know if they are interested in conducting research or want to hear a bit more about the Irish Research Council programme in terms of the practicalities of that or even applying in for funding you know feel free to drop me a line that's fine no problem amazing and I guess that also shows you know Instagram and Twitter and places like that they can

they can have their downsides but they can also have their upsides when it comes to connecting with other professionals totally yes and so just to finish off the podcast we end with three questions every time the first one is pretty straightforward. What is the number one takeaway you want people to take from this podcast? The key message, what you do outside of your training, i.e. your fueling, sleep, is everybody as important as the training itself. So food is not the enemy and try really to use it to your advantage. Amazing.

And if you could go back and give your 18-year self one piece of advice what would it be oh god i well when i was a teen now so i'd say i was a real stress head so i'd probably tell myself to chill the beans a bit no but like seriously that's easy for me to say that now um but there really was probably no need to stress to the degree that I stress about exams and look if you want something bad enough there's always another way it might be a bit longer it might you might require a bit more work but you'll get there in the end so yeah totally agree with that one and then finally what is one book you recommend everyone reads there's plenty of nursery rhymes lying around here but I actually have Stacey Simms book at Roar I've literally just started last week

and I'd say I'm about what about 20 pages in but it's actually quite informative and it's around female physiology and how food and fitness filters around that. So yeah, it's been good so far. Yeah, amazing. Well, that was great. Thank you so much for joining us. If people want to hear more from you, are you best to get in touch with on Instagram or other platforms? Yeah, well, Instagram or Twitter,

or you can put up my email. I have no problem at all with that. But thank you very much for having me on as well. It's been lovely. No worries. I hope that podcast was helpful. I can't stress enough how important it is that we don't ignore red flags like losing our period.

It's never normal nor healthy for that to happen, regardless of what anyone says. If you did enjoy this episode, you know the drill. Please rate, review and share the podcast with someone you think will enjoy it too. That's all from me. I'll see you again next time.