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August 3, 2020

The Impact of Triathlon Training on Women’s Health

Triathlon training can positively affect health and fitness. But women should be aware of warning signs and symptoms that can occur when your energy expenditure exceeds your nutritional intake. Expert nutritionist Dr. Krista Austin outlines how REDs (Relative Energy Deficiency in sport) can impact reproductive, psychological, and bone health. Together with podcast host, Andrew Harley and professional triathlete, Elizabeth James, Dr. Austin provides recommendations for assessing your health and what to do if you recognize some of these symptoms in your own training.

TriDot Podcast .045 The Impact of Triathlon Training on Women’s Health This is the TriDot podcast. TriDot uses your training data and genetic profile, combined with predictive analytics and artificial intelligence to optimize your training, giving you better results in less time with fewer injuries. Our podcast is here to educate, inspire, and entertain. We’ll talk all things triathlon with expert coaches and special guests. Join the conversation and let’s improve together. Andrew: Hey, folks, welcome to the show! It just makes sense that there are different nutrition needs and training implications between male and female athletes.  And we want to talk about them! This week we’ll be focusing on the nutritional needs of the female athletes in the group, and on our next episode we’ll circle back and cover the guys.  So really excited for these back to back nutrition talks, and we really hope we all learn a lot about our needs along the way. Our key guide for this talk is our resident nutritional expert Dr. Krista Austin. Krista is an exercise physiologist and nutritionist who consulted with the U.S. Olympic Committee and the English Institute of Sport. She has a PhD in exercise physiology & sports nutrition, a Master's degree in exercise physiology, and is a Certified Strength & Conditioning Specialist. Krista, thanks for coming on to guide us on this important topic! Dr. Krista Austin: Hey, Andrew & Elizabeth! I’m very glad that we’re going to talk about this and put out some critical information that will work for many individuals, not only the female athlete, but anyone who coaches female athletes, including possibly their male coach. Andrew: Absolutely. That’s a great distinguishment, too, because this episode has far reaching implications for the coaches as well. So, great point there. Also joining us is Pro Triathlete and Coach Elizabeth James. Elizabeth came to the sport from a soccer background and quickly rose through the triathlon ranks using TriDot--from a beginner to top age-grouper to a professional triathlete.  She is a Kona & Boston Marathon Qualifier who has coached triathletes with TriDot since 2014. Elizabeth thanks for coming on! Elizabeth: Thank you. I am thrilled to be here today and part of today’s discussion. I’m so glad that Dr. Austin is here to provide some very important considerations for women in training and I know that this episode is going to be a fantastic resource! Andrew: And who am I?  I am your host, Andrew the average triathlete. Voice of the people and captain of the middle of the pack.  Today we’ll get going with our warm up question before moving onto our Main Set conversation about the specific health and nutrition needs of women. Then we’ll cool down by hearing from a TriDot athlete who took control of her own health through many of the principles we will be talking about here today. Great show lined up. Let’s get to it. Time to warm up! Let’s get moving. Andrew: Whether it's single discipline or a triathlon, every good race provides its participants with a goodie bag full of fun swag. Athletes are used to receiving some combination of shirts, hats, backpacks, bars, gels, product samples, sometimes even gear discount codes, and more.  Dr. Austin, Elizabeth, from all the events you have raced what is the weirdest item you’ve ever received in a Race Swag Bag? Elizabeth, I’ll start with you. Elizabeth: Um…a mouse pad. Yeah, I got a mouse pad in a race swag bag. Andrew: What was on it? Elizabeth: I think it was a doctor’s office or something. But does anyone even use those anymore? Is that a relevant thing? Andrew: Some people…probably? I don’t. I use a mouse, but I don’t use a mouse pad under it. Elizabeth: Yeah, I don’t either. It just seemed a very weird thing for a race. Andrew: They just had them laying around and were asked to sponsor a race and said, sure, here’s some mouse pads. Dr. Austin, do you use a mouse pad? Dr. Krista Austin: No, I don’t use a mouse pad. I forgo that. Andrew: Dr. Austin, what is the weirdest thing you have ever received in a race day swag bag? Dr. Krista Austin: An eraser, like the old school erasers. Andrew: You guys are both tracking with office supplies. Dr. Krista Austin: I got a flashlight once, too, but I kind of understood the purpose of the flashlight given when the race started. Elizabeth: See, that would actually be useful. Andrew: That would be useful around the house. You can always use a flashlight. Now our phones have them, but it’s a useful thing to have by the bed or in the garage or what not. But an eraser is just…how often are you writing in pencil to really need an eraser? I don’t know. For me, the one I’m going to throw out—I did a local small town Texas race that had beef seasoning. I guess it makes sense when you think of the venue, just a small Texas town, a couple hours away outside any of the major cities, but it wasn’t even like they gave you anything to use the beef seasoning with, it was just like you have your race packet, your swim cap, really nothing else, just all of a sudden here’s this…it wasn’t even like a company’s beef seasoning. Elizabeth: Are you sure that was in everybody’s bag or did you just get a random… Andrew: Hopefully it was actually beef seasoning and not “beef seasoning.” Hey guys, we’re going to throw this out on social media because I know from the TriDot podcast audience is going to be some great answers to this question. Race directors are always looking for sponsors and fun things to put in the bags, so we’re going to throw this out on our Facebook group “I am TriDot” and we want to hear from you: what is the weirdest thing you’ve ever received in a race day swag bag? On to the main set. Going in 3…2…1… Andrew: Our main set today is brought to you by our good friends at UCAN. Here at TriDot we are huge believers in using UCAN to fuel our training and racing. In the crowded field of nutrition companies, what separates UCAN from the pack is the science behind their super starch, the key ingredient in UCAN products. While most energy powders are filled with sugar or stimulants that cause a spike or crash, UCAN energy powders powered by super starch deliver a steady release of complex carbs to give you stable blood sugar and provide long-lasting energy. UCAN also offers tasty and refreshing hydration mixes and energy bars for when you are on the go. When I was new to UCAN my first purchase was their perfectly named tri starter pack. It’s the best way to discover what super starch power UCAN products are best for you. So head to their website, generationucan.com and use the code TriDot to save 15% on your entire order. So I grew up with two sisters and a brother. And when you have sisters, along the way growing up in life you hear things, and you kind of get comfortable learning a thing or two along the way that just wasn’t at the time meant for you.  So today, I’m happy to host, and I'm going to hear some things, and learn some things as I toss up questions and let Dr. Austin and Elizabeth share their knowledge with us all. Elizabeth: Let me just quickly interject to say this, Andrew, and I know Dr. Austin had mentioned it as well when we were going started, I am glad you are hosting. It is my hope that it’s more than just women who listen to this episode. It is going to be women specific, certainly, but for the male coaches that work with female athletes, this information is for you too! Andrew: Yeah, that’s a great point. I hadn’t thought of that. Lots of benefit all around. And even knowing the episode we’re going to put out next week where Dr. Austin and I do a talk about men’s health, some of the things we cover today are also going to be part of that conversation because there are some principles that go both ways. So, yeah, we’re excited to have these talks. Dr. Austin let's get into it with this: Even for nutrition professionals like yourself, women’s health has become a greater focus just over the last 30 years. Why has this just now become a major focus for the industry recently? Dr. Krista Austin: I think what has really happened, Andrew, is that back in the day we didn’t know a whole lot. It was just thought that if women did sports, and this was more so just based off of rumor and myth, was that they couldn’t stay healthy. They would get stress fractures, they would lose their period, they would hurt their reproductive health. But as times have progressed and women have gained a little bit more rights, what happened over time is that we started increasing our participation in sport and especially endurance sport. Women like Joan Benoit Samuelson broke into the marathon and really turned heads showing that she could go out and do this and do it in a healthy manner. So from points like that we’ve seen a huge increase in participation. As a result, people said we better start figuring this out because women may go out and harm their health. Secondly, as a result of that, a good bit of research was launched into whether or not it was just “safe” (and I put that in quotation marks) for women to train as hard as they wanted to, because they didn’t know. They didn’t know if they could train hard and actually lose weight. So I remember studies from years ago where they took two groups of women and they said we’re going to keep one weight stable and teach them to train. You’re talking about ramping up to like 40 or 50 miles of running. And we’re going to take this other group and let them lose about a pound a week and we’re going to see what happens to something like luteinizing hormone. Luteinizing hormone is responsible for sending the signals to our unique sex organs to actually help ensure that we’re going to make our sex steroids. So for women that’s predominantly estrogen and progesterone. They wanted to know what was going to happen to that hormone because they thought if women disrupt it, they shouldn’t be out there participating in sport. So studies like that really went and launched a good bit of research to say can women safely participate in sport? The third reason is becoming a really major focus is because the influence that sport has brought to body image over the years. If you take a look at a lot of endurance sports, women are asked to compete in uniforms that can be pretty revealing. They can really drive women toward trying to optimize how they look in their suit, more so in distance running, probably, than in triathlon, but, regardless, they’re very tight clad and they put a very heavy emphasis on how the female looks. Especially the lighter, the leaner, this must be better. They said well this could have a huge potential to harm women if they become too obsessed with their body image and results in disordered eating. The last thing that has come out here recently is a greater understanding of what today is known as REDS. That stands for Relative Energy Deficiency Syndrome. Back when I was in school, they had the first statement on what emerged prior to this, which was to talk about something known as the female athlete triad. Back then it consisted of what they knew, which was the absence of menstrual cycles. It was disordered eating. It was the loss of bone. So low bone density. But over the years they’ve come to understand more and more so it can be even more than just that, there are different shades of RED in that people can have a very low level of REDS, have perfectly fine bone density, perfectly fine resting metabolic rate, but at the end of the day it can go out and compromise their endocrine system and eventually result in disruptions to it. So because of our increased knowledge in these areas we’re seeing a greater and greater focus on what is happening to women. We’ll talk about this in our next episode, but also men’s health. What is sport doing to us that we need to help mitigate? Elizabeth: So while sport is such a great way for women to grow in many facets of their life, what are some primary concerns for health that a female athlete should be aware of? Dr. Krista Austin: So one of the greatest concerns that we have for women participating in sport is the impact on reproductive health. One of the reasons we have such a concern for that is that you can do sport for your entire life, but if you do sport in a manner that harms your reproductive health it may impact other aspects of life, including a woman’s ability to have children, their ability to maintain good bone density. At the end of the day the fact that it has the ability to impact so much outside of just your ability to run and bike and swim very well, it’s become primary concerns that we focus in on the reproductive health of women, whether it’s amenorrhea, which is the complete absence of menstrual cycles, or possibly even oligomenorrhea which means we’re not having regular menstrual cycles and having too few of them to constitute a check in the box that says our health is okay. The other thing is the impact on psychological health, especially body image. I have gone over this with coaches over the years who train even elite athletes and they’re very cognizant of the fact that their young elite athletes will look to those stars that we’ve seen rise over the years and they say hey, Krista, when I come do nutrition with you, I want to look like those women there. And the coaches have become very smart to stop their female athletes and say yes, but you’re 22, 23 years old. The picture you see there of this great endurance athlete, they’re 32, 33 years old and it took time to get there. And because there’s so much media these days, there’s such an emphasis from Hollywood, I think you could really attribute it to a good bit. Even to the clothes that we maybe go shopping for that women’s bodies are supposed to look a certain way. Sport has become a tool for many women to help them get their bodies where they want to go. So there can be a very significant psychological impact and it’s one of the greatest things that we actually have to harness in young women is how they psychologically view the sport that they’re participating in, their body, and how they respect their body as a result. Andrew: So what is it exactly about training for the sport triathlon and all these endurance sports that can lead to us compromising our health? Dr. Krista Austin: So first and foremost is the lack of what we call energy availability. And just know that energy availability does not mean just oh, I don’t have enough calories. It also means do we have sufficient carbohydrate intake to keep our endocrine system, our hormonal system working properly and maintain also our psychological health? Secondly, is the potential for overtraining. I’ve seen this a lot in sport where the athlete has no idea how hard they’re actually going. They’re very committed and will do whatever is asked of them, but eventually that really hard training stimulus can result in disruptions to endocrine or what we call your hormonal health. As a result, end up compromising even the youngest of athletes and their ability to continue on in sport. And the third, really, is pressure from peers and competition. If you take a group of young women and put them together they will start to pick apart what makes other women maybe a little bit better than the rest of them. And because of that, there will become a peer pressure to lose weight, to maybe lean up, to look a certain way in their clothes, and then they also become competitive. They want to win that meet. And when they want to win that meet, they sit there and they say, “I’ve got to look like x and in doing so I’m going to not only fit into my group and be more a part of my group as a result, but I’m going to go out and win.” And that was something that back in the day we actually used to refer to it, when it was really severe, anorexia athletica. When the actual outcome that was desired was not just thinness, but rather was a performance outcome. So there’s a number of things that can lead to compromising health and if we base everything on the way our bodies look, our weight, our composition, and how well we do in sport as a result of that, it ties all together and can lead to an otherwise compromised health that’s even very psychological in nature. Elizabeth: I want to kind of go back for a second to the first point you were making there about the lack of energy availability. If an athlete is experiencing that lack of energy availability, could you go in a little bit more and talk about what that specifically does, kind of from a standpoint of compromising health? Dr. Krista Austin: Yeah, so a lack of energy availability essentially can go in and disrupt a female’s ability to make their sex steroids. For the most part that means estrogen, progesterone. Women can make testosterone, that’s just not their predominant sex steroid. But, essentially, when we starve our body or reduce the energy that’s available to it, the muscle gets signals and those signals that it starts to send actually tells the organs of our body that we’re stressing it to a point where we don’t have enough to do what it is we need to get done. Typically that’s because the muscle cells in and of themselves are not replete enough with carbohydrate, either 1) because you’re either not taking in enough calories or 2) because the calories you are taking in don’t have enough carbohydrate. As a result, it sends a signal to an organ that is responsible for what I call our energy hormone and that is our thyroid. The thyroid responds by saying I’m going to have to try and conserve, I have to try and protect this person. So I’m going to send a little bit of a distress signal to the pituitary to produce a hormone called prolactin. Prolactin will go and inhibit that hormone we heard about, luteinizing hormone. I’ve talked about that earlier. Luteinizing hormone will stop sending the signal to our sex organs to produce the sex steroids that we need. So it’s an entire cascade in which in order to try and protect our body, the thyroid says I’m in a state of stress, let me kind of put out the word that we need to conserve here. And one of the ways it goes out and conserve is by shutting down some of the things we’re able to do, which is to produce sex steroids. A lot of what we know in this area actually comes from studies of Ranger School. I don’t know if you guys have ever heard of the Army’s Ranger School, but it’s where they send them through days of energy deprivation. I mean, numerous days. What they documented about 50 years ago was that because of that energy depletion, and they were given some good MREs. They had what we would call adequate energy intake, but that adequate energy intake was so much less than their expenditure they go into a state in which they’re lacking energy availability. What they showed was that the thyroid responded by putting out a distress signal, which is the increase in a hormone called thyroid stimulating hormone. As a result, the men that were going to Ranger School ended up with low testosterone. So that was actually our first significant insight into how a lack of energy availability, even if we’re taking in what we deem as adequate nutrition intake to sustain life, might do to actually our endocrine system. As a result of that, we’re going to have an inability to lay down bone. What we’ll learn later is that that inability to lay down bone may result in decreased bone density, and, as a result, even injury. In addition, the cascade of hormones that happened can go in and impair sleep. So if you ever get the chance to talk to a Ranger and talk to what they experience as they go to that school, their sleep becomes very impaired. It starts to actually even impact your mental health because your blood glucose values stay a good bit lower. You’re not able to recover as well. Even cognition is impaired due to energy deficiency, or a lack of energy availability. And so a lot of the knowledge that we have in this area actually comes from the military. That’s where we probably got our greatest insights early on, but it really refers to the fact that you don’t have enough calories and/or you don’t have enough carbohydrate to facilitate metabolism like you need to. Elizabeth: One of the things that you were talking about there is that disruption in the ability to make those female sex hormones. What impact is there with using birth control? Dr. Krista Austin: So, often times what will happen is that women kind of fall into 3 categories in sport, I would say. There are women who are on birth control because they need it to help ensure they do not get pregnant and typically those are the women that when we are assessing their energy status, it makes things a little bit more difficult because their sex steroids are stable because they’re on that birth control. There’s a reason to be on it, right? It’s to help prevent pregnancy. The second side to that is if you develop REDS or develop amenorrhea or oligomenorrhea, what you may find is doctors will turn around and say, “You know what, we may want to address this by giving you birth control.” In all reality, what we need to understand is that that is a band-aid. In fact, it’s a band-aid to try and help protect the female, but, in turn, it may actually backfire on us because if we don’t make our own sex steroids, we need to know that because it’s a signal that there’s something actually wrong because we’re not having an actual menstrual cycle. And then there are those women out there that they say, “You know what, I may use birth control because I just don’t want to have to deal with my menstrual cycle,” and they’re using it to help control symptoms of it. That’s why when where they are on birth control, we have to say okay, how much is this potentially impacting their potential to lay down bone, the picture that we have of REDS, and is it the right thing that we should be doing by a female? So it is an area that we need to always take into account when we’re evaluating the female athlete. Why are we utilizing it and making sure that we don’t ever utilize it as a band-aid for REDS or for overall, you know, eating disorders that result in amenorrhea. Andrew: So for the candidates at Ranger School, their low energy availability was induced by not having appropriate food intake. Is this usually how low energy availability occurs? Or can it be induced by some sort of eating disorder or other ways? Dr. Krista Austin: So there’s a few different ways that low energy availability can occur. To be honest with you, for those of us that eat on these normal 12-hour circadian rhythm patterns, every morning when we all wake up, technically we’re in a state of low energy availability because we haven’t eaten for anywhere between probably 10 to 12 hours. Andrew: That explains why I want food right away. Dr. Krista Austin: Yes, that’s right. That is why you want food right away. So that’s where eating breakfast in the morning is often very critical for an athlete so that we start to fill in the energy needs for our day. But at the end of the day, if someone has low energy availability, it might not be something that’s intentional. I know this is very true of a lot of the athletes I’ve worked with over the years, especially young athletes. Even some that have become elites and they’ve just never been educated on nutrition. They just happen to have a lack of knowledge as to what they need with regards to calories and macronutrients. So usually one of the first things I’ll do with an athlete is to take a look at that area and say what is their knowledge base. Do they know they may be potentially compromising themselves by even reducing caloric intake by 250 to 500 calories in a day? That is very non-intentional. The second way that is pretty unintentional, in my opinion, and some might disagree with me, is excessive exercising and training, which is usually a function of an addiction to exercise and we do have to be very cognizant of it. But at the end of the day, because they’re training so much, they don’t spend as much time…you know, the time isn’t there to go and eat like they need to eat. And then on top of it, the training itself inhibits their appetite. And they’re not meaning to not eat, but because of that training they don’t. So those are two ways that inadvertently we may have low energy availability. The other way is the actual intentional restriction of food intake. This is where an athlete is choosing whether it’s to help facilitate weight loss or because they have an eating disorder, to restrict because they’re trying to meet some other goal and objective. So what we have to remember is that for many athletes…and I would say this is typically the case…if they do have low energy availability, it’s not always because they mean to. It might be because we need to educate them and work with them to understand their fueling needs. Andrew: So you also mentioned over-training. And I latched on to that because I know plenty of athletes in the endurance sports community have been guilty of that in the past or know that they’re even guilty of that right now. Honestly, this is something that TriDot training is designed to help us avoid. How does overtaining differ from low energy availability? Dr. Krista Austin: So over-training, when it’s truly over-training means you have an excessive training load especially in relation to your recovery and that everything that’s being induced in terms of hormonal disruption is a function of the training itself. At the end of the day, the athlete’s actually matching energy intake to energy output. They’re fueling their body, they’re meeting all their calorie needs, but the level at which they’re training is actually starting to become harmful. So that’s where we would say that’s not low energy availability, but rather is a different mechanism that is going in and disrupting women’s health. I’ve definitely had that happen to a number of women over the years. Elizabeth: So what specifically does that over-training do from a female health perspective? Dr. Krista Austin: So when you’re over-training, one of the biggest things that we document in females is that there’s a chronic taxation of their adrenals. The adrenals are responsible for producing cortisol. So in these athletes we’ll see very elevated levels of cortisol. It will be there all throughout the day. We’ll do a 24-hour cortisol pattern and what you’ll see is that in the mornings, typically athletes have a spike, but if they go and recover appropriately that cortisol comes down and kind of flatlines on them. Conversely, in the athlete that is over-training, that cortisol is chronically elevated and doesn’t take the dip it’s supposed to, especially if the training itself is disrupting sleep. So if they’re not sleeping well, they’ll continue to see the elevation in cortisol. As a result of the result of the elevation in cortisol, you’re going to get an elevation in other stress hormones. This comes back to that stress hormone prolactin as being induced in a different manner. It will go in and actually inhibit luteinizing hormone, and, again, prevent us from maybe making all the sex steroids that we should be making to have a menstrual cycle as a female. The other thing is that the chronic taxation of cortisol is oftentimes linked to increased bone injury. So in people who are over-training we commonly will see an increased prevalence in stress reactions and/or stress fractures. The reason is they are spending so much time taxing their bones and muscles themselves, they don’t have enough capability to actually go in and repair. The other factor that we’ll see in the over-training syndrome is a compromise in their immune system. They can be eating as best as possible, getting all their micronutrients in, but at the end of the day (and I’ve said this before)  you can’t out-eat the over-training syndrome. So they’ll go in and start to get sick. They might get upper respiratory infections. They might just be that person that sidelines on a regular basis, saying I just don’t feel good. It’s because the immune system is in fact compromised. Lastly, it can have a significant impact on mental health for a variety of reasons. One, elevations in cortisol are not going to make us feel good. So if you don’t feel good, you’re impacting your mental health. Secondly, for over-training we also don’t always get the performance outcomes that we want. So when we start to see our performance decline, sometimes an athlete’s natural reaction is to actually just try and train harder. So there can be significant circles that we run around in when we are over-training that ends up resulting in impaired hormonal function and hurting us long term. Andrew: For an athlete who might be over-training, what are maybe the first signs that would kind of be the “tells” that they have a problem with over-training? Dr. Krista Austin: The first sign is typically their recovery. It usually comes in a format of being unable to stack workouts that they used to be able to stack. They’ll also feel that their muscles are just very drained and that they don’t really have anything in them. I’ll say, “How do your muscles feel overall? Do they feel full and replete? Or do they feel like they’re overly taxed?” Typically those are the first signs they’ll see along with sleep disruption. With that cascade they’ll start to see the disruption in their health, the immune response, they’ll start to get sick more frequently. Then ultimately the ability to train with others or even go out and perform like they’re used to usually comes to a screeching halt. In women, oftentimes we’ll also see that they become oligomenorrheic or even amenorrheic during this process. As a result they end up then with stress fractures or stress reactions. Elizabeth: So how would you best recommend assessing health as a female athlete? What should we be doing? Dr. Krista Austin: The first thing I actually ask women to do is to take a look at two key components. That is their bone density. The second is a very honest assessment of energy intake and expenditure. Sometimes that’s really hard to let people know what it is we’re eating versus our actual training, but it’s a really good thing for them to do is to try and go in and dial in, even if it means wearing the heart rate strap for a whole week, taking pictures of all of our food or recording all of our food in an app, and saying, “Is there any potential here that I have signs of REDS?” That’s the first thing that I ask any athlete regardless of whether they’re male or female to take a good look at. The third thing is their menstrual cycle. You’ll be amazed at how many women do not track their menstrual cycle. They say, “You know what, I know I have it throughout the year, but if you were to ask me does it happen every 25 to 45 days…” in that time frame they might turn around and go, “You know, I don’t know.” Some females have said to me, “You know, Krista, I don’t even stop and think about it. Sometimes I just keep going. I would’ve never thought before I met you to put the brakes on or say something when my menstrual cycle didn’t happen within the usual window that it traditionally does.” So those are the things that I always first start with with female health. Now, if we start taking a look at all that and we find, you know what…maybe we’re not as healthy as we should be…and, in fact, a loss of the menstrual cycle is usually the biggest key. We will go in and take a look at their biochemical profile. We’ll look at patterns of cortisol. We’ll look at thyroid function. And, of course, we’ll look at their sex steroids. Do they have the ability to produce the sex steroids that they need to? If not, it’s one of the greater indicators that we need a greater intervention than may originally be thought. It can be a very objective marker. Then every once in awhile, when it is possible to get a good resting metabolic rate test—it’s not always easy to obtain—we’ll get that and we’ll say, “Do they have what we expect them to? Or, by chance, is it lowered? Is it impaired?” That can be a very significant sign of not only low energy availability, but something that is impacting the actual endocrine system, their hormonal system. Then with every athlete, I really do encourage them to monitor training load. I encourage them to monitor both the mechanical, which is the impact of what they’re doing on their actual bodies from the load, the power side. And then also the cardiovascular side. The reason I ask them to track both is because the mechanical is going to be more related to bone injury or overall injury itself, whereas the cardiovascular load is very related to their endocrine system, their hormonal system. When I have women show up who are having issues with their menstrual cycle, I’ll say let’s take a look at that cardiovascular load. Let’s see if you’re taxing your body far too much, even if the mechanical side isn’t that disrupted. It may be there. In fact, when we look at the cardiovascular side, we see that they are in fact over-training. So those are the things that I try to always ask the female athlete if they are open to actually taking a look at. It also gives us a good indicator that if they are healthy, they are eumenorrheic, they don’t have any injuries at that point in time, that if we do go in and track some of these factors, we can possibly catch something very early on that may harm them down the road. Andrew: Does having an abnormal menstrual cycle or even a negative result in any of the tests you just discussed for bone density, biochemical profile, resting metabolic rate…does this always mean you have REDS or over-training syndrome? Dr. Krista Austin: No, it does not. And that’s really important, Andrew, because sometimes we do have athletes that have an actual endocrine issue. There is something with one of their organs that is causing them to exhibit some of the signs of REDS or the over-training syndrome. So it’s very important that when we go through these assessments that we are cognizant that people may in fact have an endocrine disorder that needs to be addressed. And, in fact, some of the athletes that I’ve worked with this over the years…a lot of it has to do with how hard they train and not knowing quite how hard they train or the real lack of energy intake over time, they will end up with an actual endocrine disorder. One of those might be a disorder of the thyroid. You’re talking about overt hypothyroidism that may occur or even what they call subclinical hypothyroidism just because there was something that was out of balance and they had no idea that it was. At the end of the day, it can impact fertility and so because all these things have the potential to really impact an athlete long-term, we want to make sure we’re cognizant of them. Do they have REDS and over-training syndrome or do they possibly have an actual endocrine issue that we need to be cognizant of? Elizabeth: This has just been already wonderful so far and I think for all of our female athletes listening in… [overlapping] Andrew: I’ve learned a lot. Elizabeth: …listening in, there’s a lot of concerns here that have already been addressed, but what steps should an athlete take if they’ve identified with one of these concerns that we’ve talked about so far? Dr. Krista Austin: Well, first and foremost, if you feel like it is an actual medical issue, then you want to speak with your medical physician, okay? Or your non-physician healthcare provider that’s responsible for your female health. The other thing you can do is raise the flag to your coach and say, “Is there any potential I need to work with a sports nutritionist or a physiologist to better understand whether or not I have REDS or the over-training syndrome?” Let us work with your medical provider to do that full assessment. I do that really frequently where young women or coaches don’t know what’s going on with their athlete and they say what do I do? I’ll say, “Well, you know what…we’ve got a few tell-tale signs. Often for women the first one is in fact amenorrhea.” When we see that I say, “You know what, let’s go make an appointment with your doctor, but while we’re at it let’s start with that initial assessment of bone density and energy intake and output and actually take that to your physician. Let’s take a look at training load and how well you’re managing that and let’s see if this is something that’s more training related or if it’s something that is in fact more medical.” That’s usually a real treat for physicians, by the way, to have someone show up and all of a sudden they’ve got to learn the concepts of training load and how we do our assessments of energy expenditure and intake in sport because it usually gives them a whole other dimension to their practice and to their interaction with their patient. They usually…it’s really a treat for them to learn those things. I know I’ve put a load management systems in front of physicians before and they’ve said, “Are you serious? This is kind of cool.” So know that it is something that is very necessary to often integrate with your medical proprietor and that if we catch it at the right times we’re going to get through everything just fine. Elizabeth: So I know we’ve identified a lot of…kind of scary things, so maybe we can offer some reassurance to the women training, too. Can women still be training hard, having a high training load without experiencing some of these issues and concerns that we’ve raised here today? Dr. Krista Austin: Absolutely. Yes, that is a good point, Elizabeth. Oftentimes you hear this and think how is that going to happen to me? I can’t tell you how many women I’ve worked with over the years that have been 100% healthy. They’ve figured out what it means to have the fuel to do it, to go out there and take on the training. They’ve found the right coach for them that knows how to listen to them and understands when they are maybe a little bit more tired and have figured out how to balance that training load and they’ve competed for years and years and years. Oftentimes, 20 plus years even. And some of the athletes I’ve worked with at the elite level and finally retired and maybe then that’s when they have their children. Or I have ones that compete at that level and they have a few kids along the way because they are healthy females and they have made sure that that balance in training load and energy intake are there. They’ve made sure that that profile on them is 100% positive and that they aren’t ever crossing that line and making sure that they don’t compromise their health. Andrew: So, Dr. Austin, let’s maybe end with this today. It sounds like, then, that even just adopting a healthy mindset with a relationship to food and body image can really go a long way. So as our resident nutrition expert, what have you done just on a personal level to form a healthy mindset and make sure that you’re getting the energy intake you need and resisting that disordered eating that female athletes can fall into? Dr. Krista Austin: I think first and foremost for me, Andrew, is who I’ve had surround me from the time I was in high school all the way even through my post-collegiate years. I was fortunate to have teammates where we had a good culture and even a coach that really emphasized that it was about how strong you were, how powerful you were, how well you were performing, and he didn’t really put the emphasis on body weight for me. I think that was huge. It taught me very early on in life that it wasn’t about what I weighed or it wasn’t about the amount of body fat I had, but it was about the factors that were related to performance. Really that has protected me over the years. I think because of that, when I did come into situations much later on in life where someone would criticize the way that I looked I was able to sit there and say, “You know what? I know I have the endurance, the strength, the power to do this regardless of where I’m at with my body at this point.” I think that’s been huge. It’s never really been something that has compromised me. I really thank all the elite athletes and the coaches I’ve met over the years for showing me what that looks like. I think I was really fortunate. If you’re a female listening, find that really great role model that teaches you that, that shows you that. If you’re a coach listening, know that that’s what you want to focus around. You want to focus on the performance factors and not necessarily a number on the scale. Great set everyone! Let’s cool down. Andrew: One of the really cool things about plugging into the TriDot community is getting to learn from the stories of other athletes in the group. We have so many incredible people in the TriDot family and each one brings their own valuable experiences to this crew. With today’s focus on women’s health and nutrition, I asked TriDot ambassador Jenna Gorham to share her story of reviving her own health through many of the principles we talked about today. Jenna: Hi. My name is Jenna Gorham from Sammamish, Washington. Several years ago I thought I was taking good care of myself. Shortly after starting with TriDot three years ago and working with my coach, Ryan Tibball, I was having significant energy deficiency, which Ryan recognized was based on my diet and lack of sufficient sleep. He encouraged me to increase my carbohydrate intake, which was too low for my activity level. He introduced me to UCAN nutrition for fueling my workouts and for racing, which made an immediate improvement in how I felt during and after workouts. Ryan encouraged me to eat a more well-rounded diet with healthy fats. Having spent two years prior to this eating Paleo for performance and losing about 9% of my current healthy weight, I needed this guidance to get back on track. At the recommendation of my family, who were concerned for me since my weight was lower than it should be, I spoke with the nutritionist at my athletic club who encouraged me to bring back complex carbohydrates into my diet, which did make a big difference in how I felt. I even saw the health of my fingernails improve. Slowly I started having more energy in the afternoons and didn’t need to take naps as often. I began to get more sleep and made it a priority. Ryan also had me work on mobility to help with some of the soreness I was struggling with at that time. This past fall/winter I was advised by my naturopathic doctor to start an elimination diet to work through some digestive issues I was having and to see if it would help with the sinus reactions I was having to open water swimming. I worked with a nutritionist from the medical group to guide me through fueling for my activities with the short-term diet change. I did some reading to learn more about my dietary needs as an active female athlete in the book ROAR by Dr. Stacy Simms. I was excited about what I was learning so I brought the book to a nutrition session and found out my nutritionist also had the book. She used some of the protein intake guidelines for a peri-menopausal woman, such as myself, to determine how much and how often I needed to take protein, including the right type of protein for my digestive needs to support my training. Since reading ROAR I have a better understanding of the menstrual cycle and how estrogen and progesterone fluctuations within a woman’s cycle affect how my body may react during training. Recently I have noticed increases in my strength and power in my training as a result from incorporating the protein guidance given by my nutritionist, taken from the book. I have continued to work with my coach, Ryan, who has had me working on mobility daily. I don’t find myself with much muscle soreness anymore. If you’re having similar symptoms or challenges with energy levels and muscle adaptations like I have had, I would encourage you to do some reading and research. Talk with a professional like a nutritionist and/or coach. Take care of yourself. Andrew: That’s it for today, folks. I want to thank Dr. Krista Austin and TriDot coach, Elizabeth James, for talking about the specific nutrition needs of female triathletes. A big thanks, as well, to Jenna Gorham for sharing her story. And a shout-out to UCAN for partnering with us on today’s episode. Head to generationucan.com to see what super-starch power products are best for you. Have any triathlon questions or topics you want to hear us talk about? Head to https://TriDot.com/podcasts to let us know what you’re thinking. We’ll have a new show coming your way soon. Until then, happy training! Thanks for joining us. Make sure to subscribe and share the TriDot podcast with your triathlon crew. For more great tri content and community, connect with us on Facebook, YouTube, and Instagram. Ready to optimize your training? Head to https://TriDot.com/podcasts and start your free trial today! TriDot – the obvious and automatic choice for triathlon training.   
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