Are You Eating Enough For Your Activity Level, Part II

If you read running websites or magazines, view social media accounts of various athletes, and perhaps overhear conversations in your run community, in the past few years you may have noticed an increased attention to a topic called RED-S (pronounced reds), or relative energy deficiency in sport, which can also be called low energy availability. 

Low energy availability is most accurately calculated by removing the energy cost of your daily exercise from your total dietary caloric (energy) intake, and then having what is left not being enough energy (calories) to support the body’s normal physiological function, such as bone metabolism, endocrine/hormones, reproductive system, etc. Low energy availability is associated with downregulation and impairment of key physiological processes due to the lack of adequate energy support. 

That’s the scientific definition. I simply call it “Not eating enough for your activity level.” Even simpler, that translates to not eating enough.

Not Eating Enough

For a couple decades, one piece of the larger puzzle of relative energy deficiency was known in the sporting community. That piece is the Female Athlete Triad, in which female athletes present with a pattern of low energy availability with or without an eating disorder, in relationship with amenorrhea (lack of menstrual cycle), or irregular menstrual cycle, and low bone density leading to osteopenia and osteoporosis. What we now know is that the Female Athlete Triad is just one section of a larger picture of pathophysiology that can present in athletes with long-term low energy availability. And it is not just a female athlete concern. 

When active individuals are not eating enough for their on-the-move lifestyles – the body, because it is wise, makes decisions about where it is going to prioritize its precious calories. So if you’re going to go for a long run in the forest for several hours, followed by an evening hike or weight session, and then follow with something similar tomorrow and the next day, and throw in a weekend of back-to-back long runs,  AND you’re routinely not eating enough to meet your caloric needs, the body is going to choose where to spend those nutrients—because when this precious energy is used for one function, it is not available for another one. 

Essentially, you are putting your system into survival mode.

And it plays out along these lines as your body says,  “Well, if you’re going to make me go do these workouts, I’ll put my energy here, though maybe with a little less pep, energy, and high-intensity ability, but I’ve got to compromise somewhere, so I’ll make a trade-off  over here with bone metabolism, or over here with female reproductive hormones or thyroid health, or immune function, or over here with the GI system and the ability to break down nutrients in food (because digestive enzymes are made of proteins which may be lacking in the diet), or muscle and tissue repair or”…. and the list goes on.

On Our Radar

So why is this topic suddenly on more people’s radar? One, we have more research and knowledge on the expanded umbrella of RED-S and the widespread physiological consequences of being at a long-term energy deficit. But also because it’s fairly common for active individuals to not realize they’ve adopted many of the beliefs of the diet industry into their eating habits over the years. Or they may simply be eating to hunger levels, and still not be eating enough.

And, just eating to hunger can sometimes be misleading for us as highly active folks. For instance, many athletes have a suppressed appetite after long or intense workouts or races. In those cases, it’s ideal to replace nutrients after exercise—but when digestion is compromised, the body won’t metabolize the food as it should—hence the potential for working with a nutrition professional to help get the digestive system back to balance. Alternatively, we might need to learn to recognize the symptoms of hunger that often go beyond an empty stomach.

Within-Day Energy Balance

The other side of that low energy availability coin can also mean within-day energy balance. Meaning we don’t stack the majority of our calories into one meal or couple of hours of the day. Eating to fullness, or 80 percent of fullness, is recommended, but if you ever notice you get to the point of overeating after exercise by having excessively large meals that seem to top you up beyond fullness, it is often because of low energy intake throughout the day fueling a need for more food spread throughout the hours. This can often occur after a long run. In this case, you can train your body to tolerate more fuel during a run, and then you’ll likely both recover better, but also will have stressed your body less with the huge energy deficits and then subsequent deposits. 

 With a more even or adequate energy intake before and during a long workout, you can avoid that ravenous feeling of needing to eat quickly and impulsively.

A Self-Assessment to Help Navigate Your Energy Needs

If this topic has kindled your curiosity about meeting your own energy needs, my suggestion is to start with a self-assessment rather than calculating calories and meticulously tracking meals—those can be highly inaccurate and lead to neurotic food obsession. Ask yourself these questions:

– Am I frequently sick more than a couple times per year?
– Do I struggle with fatigue frequently?
– Have I stopped improving in my performance – either have plateaued or gone backwards despite training?
– Have I had a lot of injuries?
– How’s my overall health? Basic bloodwork results hold a plethora of data on how the body is ‘performing’ internally.
– How is my menstrual cycle and/or sex drive? Women have a little advantage here in that any menstrual symptoms or irregularities* are symptoms telling you to heed warning because there’s a larger health imbalance.
– Do I have a lot of gut upset / discomfort, or food intolerances?
– Am I routinely irritable, depressed, anxious, or have decreased concentration?
– Am I sleeping well?
– and if you have teammates or friends/family that you work out with regularly: Do I eat less than my teammates but have a higher body fat? This is subjective of course because every body is different, but higher body fat and eating less is also a tell-tale sign, since lower metabolic rate occurs with lower energy availability, meaning you might be eating less but weighing more or having more “cushion” than previously.
– and one more because it can become prevalent with long-term low energy availability: Am I thinking about food ALL THE TIME? We know from eating disorder and starvation studies that chronically deprived individuals become obsessed with food, far beyond just being interested in food.

Where to go from here?

Above all, food and exercise should make you feel good. The goal is to be aware and in tune with yourself and your body’s ability to show you signs that something may not feel right or as great as it should.

And you may benefit from professional guidance. If you’re confused or concerned about your needs, or would like a professional opinion, I invite you to reach out to me for more personalized support.

*Women on hormonal birth control will not have the same ability to use their menstrual cycle to gauge abnormalities, since it is designed to eliminate ovulation and the normal hormonal fluctuation that occurs. If symptoms or irregularities occur without birth control, that is a vital sign that your body has an imbalance somewhere.
The  information shared in this article does not intend to treat, diagnose, cure, or prevent any disease.

 

Mini-Meals to Keep You Going

Ideally we spread our meals out throughout the day and leave time in between them for full digestion to occur, so we’re not throwing more food in when the last meal hasn’t fully digested. This causes more problems over time in other ways. In an ideal routine, aim for eating at intervals of four to six hours after a full meal, and two to four hours after a light meal instead of snacking continuously all day. The above article is featured over on the Territory Run Co. run journal, along with three snack recipes for those in-between times, featuring iron and vitamin C-rich Wonder Woman Bars, William’s Oatmeal Raisin Bites, and Sweet Potato Spanish Tortilla. Get the recipes here.

References:

2018 UPDATE: Relative Energy Deficiency in Sport (RED-S)
Fahrenholtz, IL., Sjodin, A., Benardot, D., Tornberg, AB., Skouby, S.,…and Melin, AK. (2018). Within-day energy deficiency and reproductive function in female endurance athletes.
Jeukendrup, A. (2013). The New Carbohydrate Intake Recommendations. Nutritional Coaching Strategy to Modulate Training Efficiency. Nestlé Nutrition Institute Workshop Series,63-71. doi:10.1159/000345820 
Jeukendrup, A. E. (2017). Training the Gut for Athletes. Sports Medicine (Auckland, N.z.), 47(Suppl 1), 101–110. http://doi.org/10.1007/s40279-017-0690-6
McKay, A.K.A., Pyne, D.B., Burke, L.M. and Peeling, P. (2020). Iron Metabolism: Interactions with Energy and Carbohydrate Availability. Nutrients, 12: 3692. https://doi.org/10.3390/nu12123692.
Torstveit, MK., Fahrenholtz, IL., stenqvist, TB., Svlta, O., Melin, A. (2018). Within-day energy deficiency and metabolic perturbation in male endurance athletes.

Iron + The Athlete: Considerations for Intake and Absorption

I took my first formal nutrition class back in 2014. At the time, I already had a ton of nutrition knowledge, both from on-the-job training and from personal study, but I was beginning to realize I wanted to shift my career from public health into individual nutrition.

As a female and athlete (with digestive issues), I had always struggled with iron, despite eating a fairly high iron diet. At first, I also ate some red meat, and in my nutrition class, we had to complete a three-day food log and perform a nutritional analysis. I was easily meeting the recommended dietary allowance (RDA) for iron. When I asked my instructor about it, a locally practicing registered dietician, she told me, “If you’re consuming the RDA in iron,  you should not have low iron status.”  

That conversation turned out to be a good jumping off point for wanting to know a whole lot more about nutrition, and nutrient and lifestyle interactions.

If you’re an athlete (male or female), and you’ve ever wondered about what all the hype is on iron, or why you have low iron, or what exercise has to do with iron regulation and absorption, this article is for you.

The Role of Iron and How Iron Deficiency Impacts Athletic Performance

First let’s review what iron does in the body. When we speak about iron, we’re often speaking about it in the context of iron-deficiency anemia. There are many reasons for anemia, not just low iron stores, but iron-deficiency anemia is the most common. Anemia at its most literal means “without blood.” And that’s where we start to talk about iron (though again there are other nutrient depletions that can also cause anemia). 

Iron is an essential part of oxygen transport and energy production at a cellular level, and is important for cognitive and immune function (1,2). Hence the reason you feel fatigued when your body is without iron. Note that low energy is also a feature of many nutrient deficiencies since many nutrients are involved in cellular energy production.

For endurance athletes, iron is dually important because it is used for multiple metabolic pathways, including 1) it is used for oxygen transport to the exercising muscle and 2) the production of ATP (energy) is highly reliant on iron.  

Common symptoms of compromised iron status include fatigue, lethargy, negative mood, and poor performance during endurance exercise. 

A Hormone Called Hepcidin and its Impact on Iron Absorption  

Hepcidin is an inflammatory and iron-regulatory hormone that increases for 3 to 6 hours after exercise. This is likely a result of the exercise-induced inflammatory response, and associated increases in an inflammatory cytokine, interleukin-6 (IL-6). Increases in hepcidin result in a decrease in iron absorption as well as decreases in recycling iron from the gut.  

So there’s likely a window of time following exercise where the body has altered iron metabolism. 

Who is at risk for iron deficiency? The mechanisms that influence iron absorption in athletes

Traditionally, we think of compromised iron status as something that females suffer from. This is because women in their menstruating years generally lose iron through blood loss each month; whereas men should not be losing blood. However, active women are estimated to be twice as likely to present with Iron Deficiency Non-Anemia (stage 2 of iron deficiency) than sedentary, non-active women. Among athletes, we see much higher iron deficiency rates than in the general population with estimates of greater than 50% of female athletes and up to 30% of male athletes having compromised iron stores (1).

Both testosterone and estrogen can influence iron metabolism because they suppress hepcidin (more on this hormone above). When women are exercising at a high training load, this may result in an altered hormonal profile, with gonadotropin-releasing hormone (GnRH), which is a sex-hormone precursor, being suppressed. Consequently, luteinising hormone (LH), follicle stimulating hormone (FSH), and then estrogen will be suppressed. So lower estrogen leads to higher hepcidin (or at least less suppression of hepcidin), and thus more difficulty in absorbing iron. 

Likewise, the same result can happen in males with a high training load, with gonadotropin-releasing hormone being suppressed, and consequently suppressed testosterone, and less suppression of hepcidin. In turn, chronically low testosterone in males may be linked to higher hepcidin levels, potentially impairing iron regulation. 

Another variable is relative energy deficiency- what I call not eating enough for one’s activity level. Overall low energy availability (LEA) and energy intake may relate to either an overall deficit in dietary iron intake, and/or a dysfunction in iron absorption from the foods that are consumed. 

Further, we’re also finding that the makeup of one’s microbiome also affects iron absorption, with iron-deficient individuals lacking lactobacilli species–a key species often cited with good health. Many other bacteria also require iron for growth (3).

Otherwise, vegetarian and vegan / plant-based diets can also impact iron absorption and stores since non-heme plant sources of iron are more difficult to absorb. A big one though, is the general state of your digestion. You have to have good digestive function to assimilate the nutrient.

Finally, some good news: the inflammatory response following exercise can be reduced after long exercise bouts of two hours or longer by consuming carbohydrates during exercise. Eating during exercise decreases the depletion of glycogen stores in the muscle (2), and ingesting carbohydrate during exercise has also been shown to improve the recovery response from long/high intensity efforts.

The Stages of Iron Deficiency:

Stage 1: Iron Deficiency: Iron stores in the bone marrow, liver, and spleen are depleted, indicated by ferritin values less than 35ug/L, Hemoglobin values > 115 g/L, (11.5) and transferrin saturation >16%

Stage 2: Iron-Deficient Non-Anemia: Red blood cell production decreases as the iron supply to the bone marrow is reduced, indicated by ferritin values less than 20ug/L, Hemoglobin >115 g/L (11.5), and transferrin saturation < 16%

Stage 3: Iron Deficiency Anemia: Hemoglobin production falls, resulting in anemia, indicated by ferritin values less than 12 ug/L, Hemoglobin <115 g/L, transferrin saturation less than 16%. 

From current research, it appears that depleted iron stores (in stage 1) have minimal or no impact on physical performance, but this is likely particular to you as an individual–some athletes will notice the impact sooner.

What You Are Eating in Your Diet and Iron Status

The timing, amount and source of iron from your diet, in combination with the overall composition of the diet are all important factors to consider when looking at iron status. The most easily absorbed source of iron is heme iron (from meat).

The presence of Vitamin C can enhance non-heme iron absorption, but vitamin C is destroyed by heat (and light), so cooking a vitamin C-rich food into a dish will likely not help much. A couple squeezes of citrus juice at the end of cooking when the food is on your plate can be an effective method to get around this.

Otherwise, polyphenols, phytates, oxalates, calcium, zinc, copper, and vitamin E, which are all part of many nutritious, plant-rich diets and in particular are in whole grains, legumes, leafy greens, and tea and coffee, can decrease the amount of non-heme iron that is absorbed in a meal. Suddenly, your (or my) quinoa salad bowl with nuts, seeds, lentils, spinach and other dark leafy greens, and tahini or almond sauce is not a recipe for a hearty, iron-absorptive meal. Note, these are foods that are frequently on the high-in-iron list! And there are ways to prepare them to make their iron more absorbable, such as soaking, sprouting, fermenting, etc.

Want to Know More?

Within my nutrition practice, I specialize in endurance athletes and digestive imbalances. If you’ve struggled with chronically low iron, or recently have experienced it, I encourage you to reach out to me for more personalized support about how to boost iron around your exercise load.

References:

1). Sim, M., Garvican-Lewis, L.A., Cox, G.R., Govus, A., McKay, A.K.A.,…and Peeling, P. (2019). Iron considerations for the athlete: a narrative review. European Journal of Applied Physiology, 119: 1463-1478. https://doi.org/10.1007/s00421-019-04157-y

2). McKay, A.K.A., Pyne, D.B., Burke, L.M. and Peeling, P. (2020). Iron Metabolism: Interactions with Energy and Carbohydrate Availability. Nutrients, 12: 3692. https://doi.org/10.3390/nu12123692

3. Frame, L. (2021, October 7th). Mixed Diet and the Microbiome- Challenges with Complexity. Linus Pauling Institute Diet and Optimum Health Conference, Corvallis, OR, United States. 

Barriers to Healing: Ownership or Attachment to our Struggles

I’ve been reminded lately of barriers we put in place that prevent us from healing chronic health challenges, or negative habits.

That barrier is how we attach ourselves to and start to own our struggles.

Here are a few example statements that illustrate this:
– My typical GI struggles.
– I’ve always hated vegetables.
– I’ve always struggled with digestion. So have my parents.
– I’ve had that ever since I was kid. I’ve always had it.
– I never recover well during a (marathon) training cycle, and never get my nutrition and health to go right enough to be prepared for the race.
– My anemia pattern.

Another example is identifying with our diagnosis or diet pattern as if it were a job title. This is often easily visible on social media. You might witness or use something like IBS Warrior or Ulcerative Colitis Warrior, or Celiac next to a name in a bio, as an example.

I’ll use my past self as another example. For a long time, I felt like whatever medical mystery that presented as something autoimmune meant I’d be in daily chronic pain forever. This began at age 27. I was in constant fear and anxiety about the pain, and I felt like I couldn’t get outside that experience, even temporarily. Fast forward seven years and my body and mind feel remarkably different. The cloud of bleakness hanging over me, the fear of pain, the internal anguish that I couldn’t understand is no longer part of my everyday.

Yes, when it comes to healing something that has been chronic, finding the right nutrition plan and lifestyle practices are incredibly important. But healing is also energetic. You have to believe it’s possible. And you have to change your mindset and the energy you put around the process.

You have to believe your body is meant to heal.

And we start to believe what we say about ourselves. By saying we always struggle with something, that means deep down that we probably believe we will always struggle with it.

This simple, though definitely not easy, nugget of first changing what we say (out loud and internally) is what catalyzes healing. We start to believe lasting healing is possible. We seek out and then are put into connection with individuals who further light the healing pathway from whatever we’re currently experiencing – an autoimmune condition, IBS, chronic fatigue, a lifetime of emotional and disordered eating and body hate, weight woes, medical diagnoses that are largely written off, etc.

And sometimes our catalyst for healing is just an example from another person.

For instance, we all operate within a community, whether that’s in person in our daily lives, or people we follow online who influence us. Often, we identify with individuals who have journeyed through similar experiences and challenges as us.

What often distinguishes individuals who are incredibly good at healing themselves for the long term, and those that have chronic set-backs, lies in what the first group don’t spend their time doing.

These “experts at healing” don’t hang out in forums or self-help groups with individuals discussing the woes of their symptoms or how bad it is. They get out of their negative head space as soon as they notice they’ve fallen into it. They change their language in how they talk about their health. Instead of statements like “I always struggle with….” or “My faulty digestion….”, they view a health challenge as a temporary setback. My digestion is currently less than ideal — That’s a less permanent way to state that.

Or I haven’t yet arrived at the end of a training cycle feeling like I’ve nailed my nutrition and recovery strategies, but I believe it’s possible and I’m committed to exploring what has prevented me in the past.

Or My doctor believes I have lupus that I’ve put into semi-remission enough to be below the threshold for clinical diagnosis. I am not a victim. And I’m committed to my nutrition and lifestyle practices to continue my journey towards complete healing. This statement was my personal example.

In my case, I refused to mentally identify with or use the word lupus. For one, I didn’t have an actual diagnosis. But for me, that choice was energetic. This is similar to (before then) never using the words celiac, IBS, or dysbiosis about myself–though they were all either likely or true. These words we attach ourselves to are incredibly powerful. And here I am a handful of years later, and I haven’t thought about the words “autoimmune” or “lupus,” “IBS,” or “dysbiosis” as it relates to myself in quite a while.

Think about how you can shift the statements you make about your health. Catch yourself when you say what “you’ve always” said about your situation. Restate it in a less attached, or less in ownership, way.

Let the way you speak be a catalyst for how you think about your health.

*Note on the book pictured above: I don’t remember the plot. But I do remember it was part of my finding joy and rewiring how I thought about my health process.