TriDot Podcast .242

Bone Health for Triathletes

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Intro: This is the TriDot podcast. TriDot uses yourtraining data and genetic profile, combined with predictive analytics andartificial intelligence to optimize your training, giving you better results inless time with fewer injuries. Our podcast is here to educate, inspire, andentertain. We’ll talk all things triathlon with expert coaches and specialguests. Join the conversation and let’s improve together.

Vanessa Ronksley: Hello friends, and welcometo the TriDot podcast! I have been looking forward to this podcast topic for avery long time. Today we are going to be talking about bone health forendurance athletes, and we have with us two outstanding guests. I am pleased tointroduce you to Dr. Gillian Wooldridge. Gillian is a primary care sportsmedicine physician working with Houston Methodist. She is a team physician forRice University, and is on teaching faculty in the Texas A&M EngineeringMedicine Program. Doctor Wooldridge also serves on the Rodeo Sports MedicineCommittee, and she is a consultant for the Houston Ballet. Her expertise liesin osteoporosis and bone health, and she is part of the International Societyfor Clinical Densitometry, and member of the teaching faculty for theOsteoporosis Essentials Course. Gillian, welcome to the TriDot podcast!

Gillian Woodridge: Thanks so much! Happy to be here, and happy tohelp share some information on bone health for your listeners.

Vanessa:We are also welcoming back Dr. Krista Austin. Dr. Austin is an exercisephysiologist and nutritionist, who consulted with the U.S. Olympic Committeeand the English Institute of Sport. She has a PhD in Exercise Physiology andSports Nutrition, a Master's degree in Exercise Physiology, and is a CertifiedStrength and Conditioning Specialist. It's nice to be on the show with youagain, Krista!

Krista Austin: Yeah, I'm looking forward to having a great conversation on a reallyimportant topic.

Vanessa:Me too. I'm Vanessa, your Average Triathlete with Elite-Level Enthusiasm. We'regoing to start off as usual with the warmup question, move into the main set,and then we'll cool down with our Coach Cooldown Tip. It's going to be a greatset today everybody, let's get to it!

Warm up theme: Time to warm up! Let’s get moving.

Vanessa:  For our warmup question, I want to know yourmost comical, memorable, or embarrassing injury story. Gillian, let's startwith you.

Gillian:Sure. So I have something that happened relatively recently. Back in January, Iwas skiing for the second time ever in my life in Vail, Colorado. I was tiredand should have taken a break, but I didn't, I was wanting to push through. AndI had the least dramatic fall in skiing history ever. It would never have madeany sort of news story, but I managed to tear my ACL. And that's not even themost dramatic part of it. So it was unfortunate I had this little fall, felt apop, I knew exactly what I had done. But I was on this very steep part at thevery, very top of Vail Mountain, which if you're not familiar, it's a giganticmountain. And a very kind gentleman stopped and asked me if I was okay. I saidno, I was not. He asked me if I could get down the slope, I said, “No, Icannot.” Then he asked if I would like to have ski patrol come get me and Isaid “Yes, I would.” So they had to strap me into that little coffin thingywhere you're wrapped up. And it was the very top of the mountain, so I was likesnowmobiled and dragged down, and it took like 20 minutes because we're at thevery top of the mountain. And I'm wearing bright pink because I always wantedto be able to be spotted easily by rescuers. So yeah, it was a little bitembarrassing.

Vanessa:Yeah, and you know what is the craziest thing about those little toboggans orsleds that they use, is that they go so fast down the hill! Was it like thefastest sled ride of your life?

Gillian:It very much felt that way, and they hadn't had snow in about ten days, so itwas a little rough. At one part I had to lift my head up because it was bumpinginto the back, and I really didn't want a concussion on top of my torn ACL. Itwas an interesting scene.

Vanessa:Yeah, that's crazy. Well, I'm sorry to hear that you're in recovery mode rightnow. Krista, what about you? Do you have any crazy injury stories for us?

Krista:You know, I haven't had many injuries, so for me I would tell you the storyabout my right shoulder. I had been preparing to actually follow, through ArmyRanger School, the first group of women that would be going through. And I’dbeen doing a lot of training just with a ruck on my back, running with it onyour back, because that's part of what they do. And then I found out that Iwasn't going, so I decided to treat myself to a massage. And after the massage,I came back to my parents’ house, and noticed that the dog's favorite toy wasover the fence in the neighbors’ yard. I was very used to going and getting thedog's toy from the neighbors’ yard. So there was a fence, and I popped over itlike I usually do, but unfortunately this time it wasn't clear. There was apile of Spanish tiles on the other side of the wall, and it caused me to gospilling into a brick wall when I hopped over that tore my right labrum andbroke the bone that helps hold the humeral head in. So I had to actually pullmyself back over the fence and drive to the ER, and they said I was very stoic.But that's probably about as exciting as I get. It's not total embarrassment,but I did have to go back to work that way with a whole bunch of recon Marines,and in the Marine Corps, any sign of weakness they kind of take advantage of.So I had my fun I guess with injuries, but nothing ever too serious, so I guessI'm pretty fortunate in that regard. But there's my fun, embarrassing story. Idon't know how embarrassing it truly is.

Vanessa:My injury story most definitely falls into the embarrassing category. I'mredheaded, I am left-handed, and apparently those two things are not a goodcombination for staying on your feet. So one thing, I've only shared this storywith friends up to this point. And when I told Andrew about this experience awhile ago, he immediately said, “This story must end up on the podcastsomeday.” So the day has come everybody! I hope you enjoy it. I'm getting alittle bit vulnerable here. But I was an awkward 14-year-old. I was practicingthe piano, I was home alone, and my dog was like the most precious thing to meat this point in my life. His name was Waldo, and he came up behind me as I wasplaying on the piano. And I adored him so much that I stopped playing, and Ileaned back off of the piano bench to pet him, and then what happened was Iended up falling off the piano bench backwards in a very enthusiastic way, ofcourse that's part of my nature. And somehow the piano bench landed on top ofme, and it was one of those benches that opens so you can store your booksinside. So it landed on top of me, and when it opened, it opened so hard rightonto my nose. I don't know how I defied the laws of physics in this situation,but it opened onto my nose. I got up, I was crying, my nose was bleeding. Iended up with a fully broken nose and very black eyes, and a very bruised egoas a result. So that's my embarrassing story.

Well,let's throw this out to the wild! Make sure you're a part of the I AM TriDot Facebook community, and I'm actually going to be posting this very question. I'm lookingforward to reading the comments and hearing about your most comical,embarrassing, or memorable injury story. So make sure you're part of that groupso we can share the love.

Main set theme: On to the main set. Going in 3…2…1…

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Asendurance athletes, we are often preoccupied with our training schedules, howwe're going to balance it all with family, social life, work, fueling ourselvesbefore, during, and after sessions, and the list just goes on. There is a lotto think about, but have you ever thought of this pretty important thing thatsupports us the whole way through? Something that we probably don't payattention to unless something goes wrong? What I'm talking about is ourskeleton. It is the reason we can actually move our bodies for the fun trainingthat we get to do, and unless we have broken it in some way, we most likelyneglect it. So today, let's shine the spotlight on our unsung hero, and findways to keep it healthy and working for us instead of hindering our progressand our race dreams and goals. So Dr. Woodridge, I would love to know whatsparked your interest in working in this particular field of sports medicine.

Gillian:So for sports med kind of as a whole, my journey probably starts like a lot ofmy sports medicine colleagues, where I was an athlete. I did all sorts of ballsports that I was not very good at, but really my primary sport wascheerleading. I cheered in high school and college. And I had noticed, being anathlete, I was the human version of a lemon, like a car that keeps breakingdown? That was me, with just various overuse injuries. So I was practicallyliving in the training room, just trying to be able to keep tumbling andstunting. And eventually I just started wondering, “Why am I doing this, whatdoes this exercise do? This modality, what's going on here?” So my plan was Iwas going to be an endocrinologist and I was going to cure diabetes, that wasmy goal. But then I really discovered sports medicine, and learned howphysicians work in that space, and I ended up changing my major to kinesiology,probably the best decision I've ever made. I love what I do. My background isfamily medicine, which was my residency training, and then I did a sportsmedicine fellowship afterwards. What's great about sports medicine, it’s a bigumbrella and encompasses a lot of topics, so there's always an opportunity tohave a niche within that. And as I'd been in practice for a few years out oftraining, there was an interest in our orthopedic department about enhancingour one health initiatives – to reduce fracture rates, improve care forosteoporosis patients, especially those who had undergone fracture. And as afamily doc, I of course knew about osteoporosis, but I would hardly haveconsidered myself an expert. So I identified some great mentors and really dovein feet-first, learned a lot, and then now I have become kind of the go-to bonehealth person for our university. And I get a lot of referrals, not only foryour traditional osteoporotic patients who have had the hip or wrist fracture,but I end up seeing a lot of our ballet dancers, distance runners, as well asweekend warriors, triathletes and marathoners in the community who get referredto me after they've had stress fractures, to identify any major issues and seewhat we can do to prevent future injury.

Vanessa:That is quite the path! It's always so fascinating to hear how people start outon a particular path, and then as they follow the things that they'repassionate about, their journey evolves into something completely differentthan what they imagined. It's wonderful how you ended up where you are. Dr.Wooldridge, can you give us a quick rundown of the full picture of bone healthand how it evolves over the course of our lives?

Gillian:Sure.  It has to do with where we are inour growth cycles. So from babyhood, from infancy onward until you're hittingyour late teens and early 20s, you're in growth mode. When I explain to mypatients, we have this balance of bone breakdown and bone building. When youare an infant until you hit skeletal maturity, probably in your early tomid-20s technically, you are just in growth mode. Very little bone breakdown,lots of bone growing. Once you hit skeletal maturity, you have this nicebalance of bone breakdown and bone building. And then for women when they hitmenopause, or in men and a little bit later, average age maybe about 70, whatwill happen is you get that shift where there's more bone breakdown than thereis bone building. And what happens is you end up getting kind of thinner bonethat is more vulnerable to fracture. We call that spectrum – there's osteopeniaor low bone mass, and then it gets to a certain point where it's actuallyosteoporosis. But the way that this impacts our athletes is that our bone isalways in flux. I think people can sometimes make the mistake of thinking thatbone is a static organ, but it’s really in a constant state of turnover. Damageis being removed and new bone is laid down. And if you are allowing yourself tohave adequate nutrition, adequate rest, and a variety of exercise, that balanceis favorable. But if we're not getting enough nutrition, if we are not allowingenough rest, or perhaps if we're doing the same exercise over and over, wedon't allow for healing of the damaged tissue, and then that can accumulate andlead to stress injury.

Vanessa:Right. Okay, that was a great overview, thank you for that. What are some ofthe common injury concerns that triathletes and endurance athletes mightactually be prone to?

Gillian:Of course bone stress injuries, or stress reactions, or stress fractures, whichwill obviously be a big part of our talk today. But I see various issues,especially sometimes chronic shoulder pain like shoulder impingement ortendonitis, during mostly the swimming portions when they’ll notice that ofcourse. You can of course sometimes see a little bit of wear and tear withtime, as people continue to participate in sports throughout the course oftheir life, you start acquiring a little arthritis. And that has nothing to dowith the sport, it has to do with genetics, but sometimes it will start tobother you a little bit more. I feel like I see a lot of more overuse stuff. Imean, the only time I've really seen any acute injuries – concussions, fractures,that kind of thing – they typically have to do with a fall off the bike, whichunfortunately does happen. But I would say our biggest concerns are going to beour overuse injuries, and bone stress injuries are included in that.

Vanessa:Yeah. Krista, do you have anything to add in that front?

Krista:No, not really. Usually it's the same type of injuries, and you're just part ofthat overall care team that helps them return. So a lot of the work that I didwhen I was younger was looking at the interaction between biomechanics and thepotential for the overuse injury, especially in elite athletes. And then alsojust screening for RED-S and helping athletes understand how we can usenutrition to help prevent recurring stress reactions or stress fractures. Likewhat's the actual cause of it, is it nutritional, is it biomechanical? That'susually where someone like myself steps into the picture, once they've seen themedical physician, to help try and prevent it from showing back up again.

Vanessa:Right. Yeah, that makes complete sense. Dr. Wooldridge, can you tell us whatbone density is, and what methods are available to assess bone health in thefirst place?

Gillian:Sure. Bone density is basically how much bone you have per either centimetersquared or centimeter cubed, if you're looking at aerial versus volumetric.It's just about how much bone tissue is there. As we age, as I mentioned, oncewe're kind of entering menopause or getting a little bit older, our bonedensity will tend to start to wane a little bit, and that's because as we getthat imbalance of bone breakdown and bone building, that's precisely whathappens. The ways that we have of measuring bone density, our gold standard isgoing to be through a machine called a DEXA, which is dual X-rayabsorptiometry. DEXA primarily looks at the lumbar spine, so the lower back, aswell as the hips. You can also get a forearm DEXA, which is valuable in certainpopulations, or in our spinal cord injury patients we look at the distal femur.But for most people we’re looking at the hips and the spine, those are thesites that have been validated.

Thereare some other ways of doing it as well. Sometimes at some of these healthscreenings or health fairs, you may see people doing ultrasound on the heel,which is pretty good for ruling OUT osteoporosis. If it's really normal, youknow that it's going to be fine, but sometimes you have this big gray areawhere someone could actually be osteoporotic, but the ultrasound is not reallysuggestive. There has been an increased interest in the use of CT scans. We geta lot of patients that have CT abdomen and pelvis, and you can actuallyestimate their bone density at the lumbar spine using that. Or there's specialkinds of CT technology that we can actually look at the bone density of thehips and spine using a special software add-on. So definitely a lot ofdifferent ways, but probably the most validated is your standard DEXA.

Vanessa:For the DEXA scan, are there any risks involved in having one of these scans interms of the radiation that might be present for that scan?

Gillian:Minimal risk, but obviously we don't want to do DEXAs on pregnant women,because there's a fetus overlying that part of the spine when they get largeenough, so you're not really getting their spine anyway. But really what's kindof cool about it is there is so little radiation that is involved with it. Infact, the DEXA technologists don't even have to wear lead aprons the way thatX-ray techs do, and the room that the DEXA machine is in does not even have tobe lead-lined, because as soon as you're about three feet away from themachine, the radiation exposure is like background radiation, like you're noteven around the machine. So incredibly minute amounts of radiation, it'sroughly the same amount of radiation that you would be exposed to just with aday of living on planet Earth. Very, very, little radiation exposurewhatsoever.

Vanessa:We do swimming, we do biking, we do running, and I'm wondering if these threesports affect our bodies in different ways. Do they stress our bonesdifferently, or is it all a similar type of load? Gillian, let's go to you.

Gillian:They do stress the bodies in different ways. We'll start with running. Thinkingabout just the mechanical impact of landing, that's where a lot of our stressinjuries tend to occur. Especially for athletes who are a little bit more likequad- and calf- dominant runners, where they tend to be kind of a bouncy runneror a loud runner. They'll usually get more increased ground reaction forceswhen they land, so that's getting absorbed by your skeleton, and that's where alot of your stress injuries can occur. When we think about swimming, probablymore than anything it gets your shoulders, especially if you have any shoulderinstability, or maybe any upper-back or scapular muscle weakness orunderdevelopment, it can cause a little bit of stress there. Then with cycling,I find some of the biggest issues are from patients being in that bent-forwardposition for a prolonged time, sometimes their backs can start to bother them alittle bit. Sometimes they'll get nerve irritation in the perineal nerve and thepudendal nerve from the compression of the bike seat. Sometimes some hip pain,if they've got any underlying hip impingement. That's typically what I see inthe clinic.

Vanessa:And do any of these sports help to preserve more of the bone health that wemight see? So if we have some kind of loss in bone density as we age, are anyof these sports going to help us to maintain the level that we have?

Gillian:So the TLDR version of that answer is probably “not really”, but it doesn'tmean that these are bad sports. So probably the most effective bone-preservingexercises are going to be weight training and plyometric training. Whenever youare applying a load across the joint or the bone through the muscle with weighttraining, it actually helps preserve bone density. Then when you are engagingin moderate to high-impact exercise, especially multidirectional exercise, thatis probably some of the most osteogenic or bone-building kind of exercise thatyou can engage in. Think about your box jumps, jumping rope, that kind of thingcan actually be great, especially because you're waking up your bones’mechanoreceptors. Your bone has these little receptors in it that senseshearing forces, and they sense directionality as well as impact. And becauseour bodies are really good at surviving – I mean, we've survived as a speciesfor 20,000 years by prioritizing where we put our energy, and our bodies liketo see new activity, because it's going to pay attention to that. So withdistance running for example, after about 20 loading cycles, you lose about 80%of your mechanosensitivity. So basically what happens is, as you're going onyour long run, your bone cells get to the point where they think, “You knowwhat? I've seen this before. All we're doing is running in a straight line on aflat surface. I'm not going to waste my energy or resources to repair damagefrom this.” That's actually how we can get stress fractures or stressreactions. Meanwhile, if you incorporate plyometrics into your training –you're doing some box jumps, you're doing some agility-type training, becauseit's in multiple directions, your brain’s like, “Wait a minute, whoa, this isnew. We actually have to pay attention to this and dedicate resources torecover from this activity.” Now that does not mean swimming is bad for yourbones. It does not mean cycling is bad for your bones. It does not mean runningis bad for your bones. But it does mean that only doing any one of thosespecific exercises is probably not going to help you in the long run when itcomes to your bone health.

Vanessa:Now Krista, I have a question for you specifically because of your backgroundin strength training. How much of this plyometric activity do we have to do toretain the mechanosensitivity of the bones, so that we're constantly utilizingthem and allowing them to retain that bone structure and density?

Krista:One of the things that Gillian highlighted was the need to apply a novel or newload to that bone. That's a lot of what she's talking about. So even if you gointo the weight room and you do plyometrics and strength training, if you'renever truly kind of shocking those receptors with something new and novel, orgiving it proper rest and recovery cycles, it's not going to know that you'reactually doing anything for it. So what we try to do is to develop, at leasttwo to three times a week, a novel plyometric strength-based program fortriathletes that actually kind of shocks those receptors. So sometimes it's notas much about volume, but it's about introducing something new that causes themto wake up in the face of it. So at least two to three times a week, going intothe weight room and incorporating the heavy resistance training and theplyometrics, will get you the results you need. The biggest mistake people makeis going back and doing the same thing over and over again. You want new and novel,same with applying a training load. When you train for triathlon, you need itto be new and novel. If you keep doing the same thing over and over again,you're not going to get the results. So even then, you can start to cause thosemechanoreceptors to respond, but if you're not changing up the way you train,you're not going to get the response out of them. That's the biggest key togetting them to respond. And that's hard, because the better you get, the morekind of monotonous endurance training can become, and the less likely they areto be awake. So the key is to make sure that the variety in training is there,and the chronic load is there as well. And obviously, just being smart about itso that you don't overstress those receptors, because then you can have anegative reaction as well.

Vanessa:That makes total sense. So if you're saying we need to be doing theseactivities two to three times a week, is it fair to say that if we were to addin five minutes of a different type of plyometric activity to each of ourstrength workouts, would that be sufficient? Or is it something we have tospend more time on when we're in the gym?

Krista:I would suggest a progressive warmup that wakes up those receptors, and thenincreases in intensity over probably about a 15-minute period of time. That'stypically what most strength coaches would allow for the warmup. Because youdon't want to just start doing it, because you're going to land inappropriatelyand run the risk of ligament injuries. So typically what most strength andconditioning coaches do is warm you up gently for a few minutes, move you intodifferent planes of motion through a dynamic warm up like an agility ladder.Then they start to have you do a little bounding on either a grass surface orsome type of a softer surface, we don't want to use a hard one. Then they mightmove you into something more advanced, like a small box jump. Or if you're alittle bit older, we take a jump rope, and we do have you mix it up. That'swhere we might use duration a little bit more, to wake those receptors up, thanyou would with a younger athlete that is maybe a little bit safer to do the moreadvanced plyometrics. So it's all about how you load those receptors and wakethem back up. Now what we hope is that when you're young, you actually buildsome really good bone density, so that as you do get older and can'tnecessarily do the more advanced plyometrics or workouts, that you have bonedensity to rely on, and you can use nutrition to help maintain it as bestpossible. That's really the goal over the course of a lifetime.

Gillian:I know this is obviously focusing with our triathletes, but one thing I want toadd, especially for the parents who may be listening who maybe have kids thatare in sports, is that you will never accrue as much bone in a concentratedamount of time as you do between about the ages of 10 to 14 or 15. It reallydoes represent a once-in-a-lifetime opportunity to build a strong, healthyskeleton for the rest of your life. So getting kids up and active, having goodnutrition, and doing a variety of sports really serves them well, not only inthe short-term but the long-term.

Vanessa:Yeah, I think that's really important to highlight. A lot of us athletes andtriathletes have kids, so it's important for us to know that information. Nowsomething both of you had mentioned earlier is that recovery is a reallyimportant aspect about training, which sometimes we neglect because we're sobusy. In terms of the injuries and conditions that we've talked about, is theresomething that you recommend to athletes to promote optimal recovery for thetypes of injuries that we might sustain as an endurance athlete? Gillian, whatdo you think about this one?

Gillian:A couple of things that I recommend. Getting sleep is very important. A lack ofsleep will cause your body to produce more cortisol, and cortisol actuallystimulates osteoclasts, which are bone breakdown cells. So it can actually havea negative impact on your bone health if your body is under a constant state ofstress from sleep deprivation. Then of course nutrition is so important. Youcan't build a house without bricks or without other materials, so you need tohave adequate nutrition. You need to have adequate rest. You need to haveadequate sleep in order to be successful.

Vanessa:In terms of recovery, Dr. Austin, you have an extensive background innutrition. Is there anything that we can do for recovery in terms of ournutrition?

Krista:Recovery starts before training begins. There is some good research out therewith regards to how carbohydrate and calcium prior to training helps maintainactual bone metabolism, mainly because it can keep serum calcium levels higher,that's their understanding. They get a reduction in what's called parathyroidhormone when they do this. So with athletes who maybe have a propensity towardsstress fractures or reactions, or maybe have lower bone density, I do try touse nutrient timing to help support the bone as they go through training. Thenalso a lot of times with athletes, the cortisol response is really importantbecause those osteoclasts do respond to cortisol. So we get up in the morning,and our cortisol is in a normative range. Then all of a sudden, if we have notfueled our bodies, especially with maybe a 10 to 12 hour break between dinnerand breakfast, we can actually elevate cortisol to a point if we don't havecarbohydrates prior to, it becomes very negative and detrimental throughout theday. So we try to use nutrient timing to help keep cortisol under control tohelp take care of the bone, to prevent injury, and to help facilitate recoveryearly on. So like with one of my collegiate athletes, I took a good look at hernutrient timing. What was she having prior to her morning runs, and thenimmediately post? What we saw was that she actually had a deficit incarbohydrate very early on in the day, yet she was training in the morning. Sowe actually took her carbohydrates and we moved them to the very front. We alsosaw that her calcium intake was okay, but it wasn't great, so we put about agram of carbohydrate prior to the run, and then also a gram after the run tohelp make sure her bones were being taken care of. Same thing with calcium.Because it's a little hard to run on a stomach filled with some yogurt or whathave you, we do take a calcium chew called Caltrate prior to running to helpelevate the calcium level. Then post, we want to start that refueling processwith protein and carbohydrate with something like a Greek yogurt. There's somegood 20 gram protein Greek yogurts out there right now, so I encourage them tohave that before they then go to the cafeteria and really start the energyrepletion process. We want to try and get as many calories as possible in thosewindows, so their body is not chronically wearing down. The other thing I tryto teach them is that when you elevate cortisol, you actually impair theability of your thyroid to function, and the thyroid is very important withregards to vitamin D metabolism. So if we don't take care of cortisol, it hasthis kind of domino effect within the entire endocrine system that really hurtsbone density and bone health if you don't control it. So we try to use nutrienttiming to help control that endocrine response as best possible, and supportbone health. So if you're trying to make sure that you're recovering well, youneed to do that continuously throughout the day to keep cortisol under control,to make sure that you are taking in the calcium and vitamin D that you need tohelp supplement what you're getting from the sun.

Vanessa:Krista, I've been noticing, just looking at the labels in some of the workoutsupplements that I have in my cupboard, there are some of them that actuallycontain a large amount of calcium and magnesium, and they are coined as “duringworkout” supplements. Is that why there's so much calcium? I'm curious as towhy there was calcium and magnesium in there, and I'm just thinking this mighthave to do with it.

Krista:There's a couple reasons they may do that. One is that they know that athletes’diets can be deficient in calcium, so the calcium might be trying to help thebone. It's also a very popular filler in those products when they're developingthem, so they might just go ahead and use it regardless without intent. Theother thing is they know that athletes struggle to get enough magnesium in thediet if they aren't really dialed in. But you have to be cognizant thatsupplement companies sometimes just do it for a branding or marketingperspective.

Vanessa:I just want to circle back to one other thing that you had mentioned earlierabout nutrient timing. Does this nutrient timing and the quantity of thenutrients that are required differ between males and females?

Krista:It does in the sense that energy expenditure is oftentimes different enoughthat they need to have more as males than they do as females. The guyssometimes have a bigger job to do, and they're also a little bit heavier. Butyou're talking about 200 to 300 calories at any one point in time, usually not500 to 1,000. I would just say go by the recommendations of grams per kilogramof body weight for carbohydrates, and know that every two to three hours youneed about 20 to 25 grams of good quality protein to help maintain muscleprotein synthesis. And they show that if athletes actually follow theseguidelines, they'll end up being leaner. They have healthier profiles when wetake a look at blood chemistry and bone density. Those are ones that are doingreally well. So oftentimes it's just about following the guidelines, and we doit per kilogram of body weight to make sure that it matches the overall size ofthe individual.

Vanessa:Gillian, did you have something that you wanted to add in there?

Gillian:Yeah, just about calcium. I'm a big believer in food as medicine, so you'llvery rarely hear me really endorse a lot of supplements unless somebody isreally struggling getting it from the diet. So when it comes to calcium, wejoke that calcium is a Goldilocks nutrient – you can have too much, too little,and just right. So I definitely caution people on going overboard with calcium,only because it can have a detrimental effect. You can absolutely have too muchof a good thing, so always be mindful of that. And again, we know that thedietary source is always going to be preferred because of the way that youabsorb it is more natural for your body, and it's easier for your body torecover from. Of course supplements absolutely have a role if there isdifficulty in doing that. For instance, you don't want something that's heavyon the stomach right before an endurance training bout, that's incrediblyuncomfortable. Or if there's certain patients who have undergone bariatricsurgeries for weight loss, or some things that they need lifelongsupplementation of certain nutrients. But again, I'm a big believer that foodis medicine.

Vanessa:Yeah, I fully agree with you on that one, I'm sure Dr. Austin does as well. NowI'm really curious, I've always wondered this – because we know that calcium isabsorbed better as a food source than as a supplement, does that have anythingto do with the type of calcium that is present in the supplement? Is that lesslikely to be absorbed within the body?

Gillian:It kind of depends. Calcium primarily comes in three different variations insupplement forms. The most common ones are going to be calcium carbonate,calcium citrate, and tricalcium phosphate. Calcium citrate is generally bestabsorbed, because calcium is best absorbed and there's a little bit of acidaround. So if you're going to do a calcium citrate supplement, it's generallypretty well absorbed because that citrate in there is going to help it bebetter absorbed by the system. So you don't have to take it with food, it canbe taken on an empty stomach. The downside of that is calcium citrate is a muchlarger molecule, so usually it's two tablets to get the amount of calcium itsays on the bottle, and it additionally tends to be a little bit moreexpensive. Calcium carbonate is less expensive typically, it's a little bit ofa smaller molecule so it's only like one tablet to give what it says on thebottle. But because carbonate is more of a base, it's not as well absorbed, soit really needs to be taken with a meal if calcium carbonate is going to be thepreferred. I find that one also tends to cause more GI distress, causes someconstipation and stomach upset. But taken with food, it's best absorbed.Tricalcium phosphate is typically what is found in your gummy calciumformulations, so if you ever get somebody that does like the gummies – that oneI don't really have much of a problem with. I just caution people with kidneydisease, they're already a little bit high in phosphorus, so if they're goingto be on a calcium supplement, I try not to recommend a lot of tricalciumphosphate. But if someone tends to run a little bit lower on their phosphoruslevels, then maybe it's beneficial.

Krista:If you're going to take a supplement, make sure you've had a nutrient analysisdone prior to going down that road. Very few athletes have a need for anythingmore than about 50% of the RDA to be added in by a dietary supplement. So ifyou're already rich in the micronutrient and you're not having any medicalissues that may be related to it, then you need to go ahead and just place thesupplement aside. Conversely, sometimes athletes get to eat a lot of greatfood, but the quality is not always a hundred percent of what they might need.Or we have a circumstance where people are prone to injury, so we increase thedemand, or they just aren't great at getting it into the diet.

Vanessa:I think we need to backtrack just a little bit, because we talked aboutsupplementation before we actually talked about nutrition itself. And Krista,you've done so much work in the nutrition field, can you tell us what sourcesof food we're going to be able to get these nutrients from that are soimportant for bone health? What do we need to be eating regularly to make surethat we're hitting these targets? Especially if we're requiring, as you said,150% of the RDA for – I'm not even sure if it's just calcium, or if there'sother nutrients that we need to have for bone health. How can you help us toget what we need? Krista, tell us.

Krista:Well, this may sound like a generic answer, but it's a highly diversified diet,pulling from all the major food groups. Because bone is not just a function ofcalcium, it's a function of a lot of other micronutrients, from vitamin K, tocholine, to biotin, protein, manganese – you name it, it's helping with boneformation, as is energy density. So the biggest thing we can do for athletes isto help them actually pull from all the food groups, to create reallynutritious meals throughout the day that represent everything. Make surethey're not just leaving something out accidentally. Or if they have a specificnutrition approach, that we're helping them meet those needs with the type offoods that they require. Some of the most challenging might be a vegan diet, orpeople who do not want to take in calcium products. That's where we probablyhave to work a little bit harder to make sure that we have all of thosenutrients in there, and you may see a little bit more of a need forsupplementation if calorie density is not high enough. So if they're a veganand doing triathlon, and we want to really try to work to maintain their bones,sometimes calorie intakes at around 2,000 for a vegan presents a little bit ofa challenge to work with on a day-to-day basis. That's where food charting ornutrition plans really have to be worked on more intensively, so that we get asmuch as possible from food.

Nowhere's where I'm going to kind of throw a loop in for you on this, Vanessa, andthat is the role of vitamin D. This is what's really interesting to me, whenpeople come in and they think they're going to get the majority of theirvitamin D from food. Can we get vitamin D from food? Yes, we can a little bit.But at the end of the day, when doctors tell you to go outside and get somesunshine, some UVB light, they're doing so because most of our vitamin D comesfrom our eyes. That's where we absorb it the best. We also absorb it in ourskin. And the challenging thing about athletes is that they go, “Oh my gosh,I'm getting too much sun. I don't want cancer.” So they go and they lather upwith their sunblock, put their sunglasses on, and then go down the road andthey're like, “Why is my vitamin D low? I just don't know why.” Well, maybewe’ve got to warm up for at least 15 to 30 minutes and get some sunshine in,and then put our sunblock on, then put the shades on. Because vitamin D isactually stored in our adipose tissue, and when we exercise we inducelipolysis, where we release energy from fat stores. And what they have shown isthat with endurance exercise, if you have someone who's not doing it and thenyou train them to a certain level, they'll actually increase their serumvitamin D, because they might have been taking it in, but they weren'treleasing it. So when you look at vitamin D stores, you actually have to bepretty careful in my opinion, because not only is it environment, but it's alsoepigenetic factors that we have to take a look at, to see what might bemanipulating the value that we see in front of us. And that's where our foodmatters, and our supplementation matters if we really need it. That's when westart to move down that road in saying how much we need to get from food, howmuch can we get from food, and also how high we get those vitamin D stores.Endocrinologists talk a good bit about what are those stores, when and how dowe need to supplement, and it's something that is a chronic state of debate.Even if our bodies are using far more than what the RDA is giving us from food,if we are in a state of sufficiency, is anything more than the RDA needed? Sojust be cognizant that not everything comes from food itself. We do want you toget out there and get some sunshine without your sunglasses on.

Gillian:Vitamin D is the one time you'll hear me say that it's probably better to getit from a pill, just because I've seen some gnarly cases of skin cancer. Overthe course of a lifetime, that sun damage accumulates. I have some good friendswho are dermatologists. So that's the one time I will probably recommendsomeone get it from a pill, because I think it's sometimes a little bit easierto manipulate. Especially in the South, in Texas, during those high sunshineparts of the day, it's so exquisitely hot that it's miserable to be outside, sothen I worry about risks of other things. So that's the one time I will usuallyrecommend getting it from a pill, but vitamin D absolutely can come fromsynthesis from sun exposure. They’ve actually done some research on Hawaiiansurfers that spend all day without any sunscreen, and I think their vitamin Dlevels end up naturally topping out around 70 nanograms per deciliter, that'swhere they’ve kind of reached their maximum and their bodies are like, “That'senough.” But I usually aim for a level of about 40 to 60 nanograms perdeciliter, that’s usually my goal for my bone health.

Vanessa:I think we're going to shift completely and do a total 180 in terms of wherewe're going with this, because this is the question I've been dying to hear youanswer. I really want to know about hormone levels and how they influence bonehealth. And especially is there a difference between females and males and theeffects of these hormone levels on that population? So Gillian, please talk tous about hormone levels and bone health.

Gillian:Sure. So the most important hormone for both men and women for bone health isestrogen. Women are at increased risk of stress injuries compared to men. A lotof that honestly is probably from bone size. Men just tend to have largerbones, so they’re going to be more resistant to injuries. But for both men andwomen, it's actually estrogen. A lot of people might say, “Well that's crazy,because men have testosterone.” Well, it gets aromatized or converted toestrogen, and that's actually what protects the skeleton. So all men shouldhave some degree of estrogen that is present, and that's actually what helpsthem preserve their bones. So whether it's a male or female, when an athlete isin a nutrient-balanced state where they are exercising, but they are gettingsufficient rest and sufficient nutrients to support their activity level,they're in a nice state of homeostasis. They're getting the hormones that theyneed to support their skeleton. However, when there's an imbalance there – itcould be they're not getting the rest that they need, they're exercising toomuch, or they're not fueling enough for their exercise –their bodies, as Imentioned earlier, are meant to survive. What that means is your body willprioritize your brain and your heart above everything else. It will doeverything it can, including dissolve your skeleton and eat away at your ownmuscle, in order to produce energy for your brain and your heart to continuegoing. So whenever you are in starvation mode or preservation mode, your bodydoes not care about producing happy hormones. Your dopamine, your serotonin,your norepinephrine, it's not going to prioritize using different substrates inyour body to actually produce those. They will also not bother with producingsex hormones like your estrogen and testosterone. So when you end up in thatenergy-deficient state, your body is just not going to waste the energy. That'swhy, especially for our female endurance athletes, we'll notice their periodsstart to get wider or go away altogether. That is a big, big red flag. Thereused to be a school of thought of, “Oh, that means you're training hardenough.” But we know that that is a big flashing neon sign that we have aproblem, if your periods are going away. Because if your body is not producingenough estrogen to maintain a menstrual cycle, it is certainly not producingenough estrogen to maintain your skeleton, and you are at substantiallyincreased risk for having poor bone density and developing not only bone stressinjuries, but other injuries.

Theway this translates over into the male population is, if you are so lean andhave such little body fat that your testosterone is not being aromatized intoestrogen, it may also have a negative impact on your bone health. You can alsoget drops in testosterone, you can experience things like decreased libido orerectile dysfunction that just don't improve your quality of life. So beingsufficient in energy consumption, and balancing that with your energyutilization to maintain your sex hormones, is such an important part of yourbone health.

Vanessa:Yeah, I think that's really important, thank you for bringing that up. So youtalked about the red flags in terms of hormone levels and how they affect thebody. Are there any other red flags that might indicate an athlete isdeveloping a bone-related issue?

Gillian:Obviously pain, right? One of the biggest things is you get that pain withactivity that gets better when you rest, probably about 30 minutes or so tofeel better. Or maybe you don't feel as bad early in the day, like shin pain orsomething, but as you're going on you're getting that deep, aching pain thatworsens with activity and gets better when you sit down. That's something youneed to pay attention to. Having a hard time recovering from other injury Ithink is also a big issue, if you're getting those chronic overuse injuriesthat are just lingering around. Again, this can be multifactorial. It can befrom doing the same activity over and over, or it can be from just not gettingwhat you need in order to recover from that well. Having excessive fatigue,just feeling kind of worn out all the time, those are probably our little neonsigns that say there's an issue here. And we always want to intervene on thatsooner rather than later, because then we don't have as deep of a hole to getourselves out of. So I always lean towards intervening as soon as possible.Because even if we do have a male or a female athlete with something likeRED-S, sometimes all it takes is about 250 or so calories a day to get yourperiods back, that's a Snickers bar. So sometimes it's actually not that hardto get it back. But the deeper you've dug yourself into that hole, the harderit's going to be to get out of. So identifying your treatment team and yoursupport system during this time of training is important, so you can havesomebody intervene sooner rather than later.

Vanessa:And that is a perfect segue into my last question that I have for today. How doyou suggest that someone finds a good practitioner who can help them get backon track towards optimal bone health? I think that this is a huge barrier for alot of people, is knowing that they have an issue, but then not knowing who toactually seek out to help them overcome this issue. What kind of recommendationdo you have for that?

Gillian:From a medical care physician standpoint, two of the sports organizations thatI'm a member of are the American Medical Society for Sports Medicine and theAmerican Osteopathic Academy of Sports Medicine. Both of those websitesactually have a “find a doc” link through their website where you can actuallylook by zip code, by city, and you can find where we have members there, wherewe have board-certified sports medicine specialists. The sports med world isjust like any other medical specialty, where maybe not every single person isgoing to do this, but we certainly all have training in it, and you can atleast get resources to be directed to someone who can help you. So for theUnited States we've got that. We definitely have sports medicine colleagues inCanada, although I confess that I don't know as much about the Canadian SportsMedicine Society’s website and what it has to offer. But that's at leastsomething, from a pure physician standpoint, of finding somebody who can helpget you the support you need.

Vanessa:Yeah, and for those who are in the Houston area, how can they get connectedwith you?

Gillian:Sure! In order to reach me, I just tell people calling our office is theeasiest way to get an appointment with me. Our phone number is 713-441-9000.And I do a lot of this. I have a lot of patients with disordered eating andfull on eating disorders that I manage, as well as some of the RED-S stuff.Whether it's intentional or unintentional restricting, I tend to do a lot ofthis. Then I also have some patients that just seek me out for dietary andexercise counseling in general. And if it's something that I think they need alot more fine-tuned advice from what I can offer, I’m really lucky to be in acity the size of Houston where I’ve got some wonderful sports dieticians andsports psychologists that I know. And some of our hospital systems in the citycan actually do really intense analysis. They're actually going through anddoing the full metabolic analysis like resting metabolic rate, basal metabolicrate, and VO2 max testing for those higher-level, elite folks who really wantto optimize. I'm lucky to be in a very resource-rich area.

Cool down theme: Great set everyone! Let’s cool down.

Vanessa Ronksley: It's Coach Cooldown Tip time, and I'm Vanessa,your Average Triathlete with Elite-Level Enthusiasm! We are all in for a treattoday with our next guest. TriDot Coach Ben Sommerville is in the house. Ben isa member of the Precision Coaching Team over in the UK, and has quite thetriathlon résumé. He is a former Elite Junior Triathlete, has represented GreatBritain as an age-grouper at Worlds and European Championships. He has eightNational Championship medals and is a two-time National Champion. Coach Benaccomplished all of this over ten years, and has since progressed to coachingas a way of giving back to the community by helping others improve theirphysical and mental health and wellbeing through triathlon. He specializes inintermediate to elite-level triathletes who have an interest in sprint andOlympic-distance races. Not only is he a rock star triathlete and coach, herounds out his knowledge base working full-time for a sports collagen recoverynutrition supplement brand, where he supports people to optimize their recoveryto drive better performance. Welcome to the show, Coach Ben!

Ben Sommerville: Thank you so much for having me! It is anabsolute pleasure.

Vanessa:Alrighty. Now I hear that you are a wee bit superstitious, and that you willalways put your right sock on before the left. So where on Earth did thissuperstition come from?

Ben:Oh, I was hoping no one would find out about that one, but the secret has letslip. I would like to say it's got a really interesting and fascinatingbackground, but I think at the root of it is quite literally because I'mright-handed. I write with my right hand, I do most things with my right hand,and I think it's a force of habit. But in the process of becoming a moreaccomplished triathlete, I think in those little minute processes, the act ofusing the right hand, the left hand to put my socks on at 4:00 in the morningbefore I go to a race start – it's those little things in my mind that make allthe difference. And it starts with a good pair of socks – the more outrageous,the more stripes, the more dots, the brightest colors. I love a good funky pairof socks, and it all starts with the right one, and then to the left.

Vanessa:I love that. I also have a very fond love for crazy socks. But it doesn't justend at the socks, it carries on throughout the entire outfit. The crazier thebetter. That's great. So I have a feeling that this superstition that you havemay lend into your tip that you have for us. So what can you tell us todayabout your tip for your athletes?

Ben:So my main primary tip, the most important thing – that I won't take credit formyself, it’s something that I merely pass on to the people I come into contactwith, and it's less of a tip and more of a coaching point, – but it is thatsuccess is not a chance event. This comes from a wonderful colleague of mine,Professor Greg White based here in the UK, an Olympian and sports scientist andan ultra-endurance specialist. So all credit to him, not to me, for thisamazing saying. It's all about those little things that make the biggestdifference. It's about all the things you can optimize in your lifestyle, inthe environment around you, the right equipment, the right coaching, just theright nutrition, the right quality of sleep, the right training. All of thosethings equal proper preparation and planning. It drives your passion, it drivesyour enthusiasm, and your discipline, and that's where success comes from.Success just doesn't happen because you say one day, “I'm a triathlete and I'mgoing to achieve my triathlon goal.” It's a culmination of all the small thingsyou do every single day, every single week. Doing the right training right,with all the right support around you and the right enthusiasm, people who areequally invested in your progress and your journey as you are. That's whysuccess is not a chance event.

Vanessa:I love that you said that. And one of the things that you had mentioned is thatit's all of these little things that you do that will culminate to success. Butnot only do you do those little things on a daily basis, but it's theconsistency of doing those things every day for a long period of time that isgoing to breed that success.

Ben:Absolutely. And if you look at the primary determinants of enduranceperformance and endurance progression, the nature of the training comes secondto just consistency. Doing something consistently, doing it consistently right,consistently well, drives better performance than the variety or the actualminutia of the training that you're doing. The plan is important, but if youcan just do something consistently that works for you – keeps you motivated,fits into your life, adds to your life rather than subtracts from the rest ofyour life – do that consistently, then you'll achieve your goals. Then you'llachieve your success, whatever that means to you. Because obviously,everybody's definition of success will be completely different.

Vanessa:I love that very much. Everybody's definition of success will be completelydifferent. That is so spot-on, because some people are in this sport to improvetheir lifestyle, or to be a role model for their children, or maybe it's to beon the podium. I love that having that success is a unique circumstance forevery single person.

Ben:Absolutely. And part of the process is identifying what that will mean to you.And in working with a good coach, working in a club environment even thoughwe're in a very individual sport, if you find those right people to inspireyou, you'll find what success means to you. As daunting as it may seem on theoutside, you'll find it very quickly, and you'll find it very, very engaging.Just speaking from experience, this sport changed my life, and I see it changethe lives of countless other people when they just recognize the benefit it canhave for both their physical and mental health.

Outro:Thanks for joining us. Make sure to subscribe and share the TriDot podcast withyour triathlon crew. For more great tri content and community, connect with uson Facebook, YouTube, and Instagram. Ready to optimize your training? Head totridot.com and start your free trial today! TriDot – the obvious and automaticchoice for triathlon training.

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