The Female(?) Athlete Triad - Part III/III: Road to Recovery! Step #2 = Accept There is No Magic Macronutrient Ratio

No need to raid another tomb, Lara, the quest for the one and only ideal macronutrient composition that will yield optimal results for the rest of your life ends here (img courtesy of Paramount)!

I am not planning to bore you with a longish summary of the previous installment(s) of this series, here. Still, I don't want to head on to the 2nd step of the "Road to Recovery", which is going to deal with the quest for the "optimal" macronutrient ratio, without a brief reminder of the central role of nutrient availability in both the etiology, as well as the recovery from the athlete triad - or, as Dr. Zanker from the Carnegie Research Institute at the Leeds Metropolitan University in the United Kingdom puts it, the simple fact that the "exercise associated reproductive dysfunction in women is attributable to deficits of readily available energy" (Zanker. 2006)

In a couple of more general remarks some of you have recently (not without good reason, by the way) criticized my excessive and in parts random use of mark-ups like bold print or underlining. In the introductory paragraph to today's post the word "readily" is however so important that the underlining is obligatory.

Your hypothalamus does not like to wait, therefore "readily" is the keyword, here!

It is after all the lack of appropriate readily available energy, primarily in the form of circulating glucose, liver glycogen, and adipose tissue triacylglycerol that precedes the low plasma insulin concentration and reductions in total body fat content and corresponding disturbance of leptin secretion, ghrelin, cortisol, thyroid and of course luteinizing hormone (see data in figure 1; the absolute levels from the healthy group may also serve as a reference to compare your own labwork to; mind the units!).

Figure 1: Hormonal and glucose metabolism (* indicates 24h values) of women with functional hypothalamic amenorrhea (not necessarily exercise induced) expressed relative to values in eumenorrheic control; values above the bars indicate the total values of the respective markers in healthy controls and may provide you with some orientation, when you are looking at your own bloodwork (data based on Loughlin. 1998)

In order to avoid / counter the reproductive and associated problems and break out of the vicious circle of the athlete's triad, Zanker proposes the following three steps (based on Zanker. 2006; yet with a couple of additions from my side): 

• Avoid abrupt and rapid weight loss and maintain an “adequate” body fat content, which may be individually specific, but coincides with regular reproductive function.
• Consume adequate amounts of energy to fuel your increased metabolic demands; never go below your resting energy expenditure, regardless of whether you  want to or even have to lose weight.
• Make sure you get an adequate amount of carbohydrates either on a continuous (low GI carbs with every meal) or in a cyclic manner as part of a low(er)* carbohydrate diet with a baseline intake of 90-120g/day and additional carbs after every workout.
  *compared to the RDA of ~60% carbs

"Carbohydrates? But aren't those just making you fat?" With this very question that's now probably on the mind of one or two (or three ;-) of you, we did eventually arrive at the topic of this episode of the Athlete's Triad Series:

Is there a ideal macronutrient ratio that will prevent the onset
and help you get rid of the athlete's triad?

To be honest, I don't know the answer to this question... and although I had almost typed the word "yet" win the place where you now see the "..." , I must admit that I am not even sure if there actually is a definitive answer to this question. What I do have to offer, though, is a couple of things to keep in mind, when it comes to the macronutrient make-up of your diet.

1. There is no such thing as a "bad" nutrient. There are about as many good arguments to vilify the overconsumption of protein, as there are arguments against the usual scapegoats, carbohydrates and fats.
2. Glucose and saturated fats can be essential, too. Just because your body can produce carbs and saturated fats on its own, this does not mean that you do not have to, let alone should not eat them.
3. The optimal macronutrient ratio will change over time - just like and in response to the way your physique, conditioning, lifestyle, training and general stress levels  will be changing. This implies that diet X, which may have worked magically for you, when you got rid of slabs of body fat is now that you are finally in the "normal range", let alone already so lean that your body's alarm bells are constantly ringing, hampering your progress.

And even if the previous comments on the importance of readily available energy and glycogen repletion would suggest that carbohydrates should make up the lion's share of the diet of any athlete trying to recover from the triad (or not to fall victim to it), an extreme high carbohydrate alone is neither guaranteed to solve the problem nor is it a sustainable way of eating you could stick to once you've "carbed" yourself out of the dark hole you have been digging over the past months.

Readily available energy? Does that mean I have to eat sugar all day?

Figure 2: Cortisol (left) and testosterone (right) levels in healthy men after 10 days on high protein vs. high carbohydrate diets (based on Anderson. 1987). Tegelman et al. report similar results from Swedish elite male Ice Hockey players after a reduction of fat and an increase in carbs (Tegelman. 2007)

On the one hand, we've known for over two decades that a high carbohydrate diet based on bread, vegetables, fruit, juices, pastry, and candy having a protein / carb / fat ratio of 10% / 70% / 20% will result in lower cortisol and higher testosterone levels (in men) than a high protein diet with a protein / carb / fat ratio of 44% / 35% / 21% that's based on lots of meat, fish, poultry, egg whites, and a liquid dietary supplement protein supplement (Anderson. 1987; see figure 2). On the other hand, a closer analysis of the data I compiled based on the tabular overview of pertinent studies on amenorrheic from the review by Manore (see figure 3 in the last installment) suggests that real.world advantage of carbohydrates depends on the deepness of the whole you already dug (the deeper the more advantageous) and your willingness / ability to cover or even surpass your daily energy requirements (the more you eat on a daily basis and in at least three square meals spread equally across the day, the less you will depend on the readily available energy from carbs).

Against that background, the high carbohydrate intake (62% of total energy from carbohydrates; nutrient ratio in grams 16% protein, 71% carbs, 14% fats) was probably necessary for the women in the eumenorrheic group with an energy intake of slightly less than 30g/kg body weight (figure 3, R5).

Figure 3: Macronutrient compositions (in kcal!) of amenorrheic and eumenorrheic women from 15 different studies (based on an overview in Manore. 2002)

For the eumenorrheic female athletes who were at, or way above the average mean energy intake of 35g/kg body weight, the "high" carbohydrate intake of 265g/day probably wasn't detrimental. On the other hand, it appears questionable, whether an increase in protein intake from 1.2g protein per kg of body weight to 1.5-2.0g/kg and a corresponding protein to carbohydrate ratio of 25% / 62% would not have been more facilitative to their goals (specifically if those include strength training). The same goes for both, the replacement of yet another part of the carbohydrate ration with an isocaloric amount of fats and the overall role of fats in the etiology of and the recovery from the athlete's triad.

The fat-phobia still loomed large, when the majority of studies was conducted

Part of the problem of reconciling theoretical considerations, such as the "availability advantage" of carbohydrates and the scarce and almost exclusively observational data based on which I compiled the overview in figure 3 of this, as well as the last installment of this series, is that eating patterns of both the eumenorrheic, as well as the amennorheic athletes was geared towards the dietary paradigm of the day. With "the day" being the late 1980s and 1990s, i.e. those years in which the fat-phobia literally climaxed, it should be obvious that the baseline diet was low in fat and high in carbs.

Against that background it should also be clear that anyone trying to "cut calories" would reduce the amount of fats, the "bad energy dense heart killers" and keep the intake of carbohydrates constant (=high). This is probably also, the reason that the ostensible disproportionate lack of fats in the diets of the amenorrheic women vanished, once I weighted the data with the number of participants.

Figure 4: Total dietary intake of protein, carbohydrates and fats (in g; left) and differences between women with and without regular menses (right); data expressed either as simple group averages or weighed for the number of study participants (same sources as figure 3)

The picture that emerges after this adjustment has been done (figure 4, right, light bars) is clear and stands in line with my initial remarks on the primary of readily available energy in the form of circulating glucose, liver glycogen, and adipose tissue triacylglycerol, of which at least the former are way more readily derived from carbohydrates than fats.

And even the triacylglycers do, as the name implies, require a certain amount of glucose for the glycerol backbone (could be produced in the liver from amino acids and/or fats, though) and a minimal amount insulin to be stored in the fat cells (can be secreted in response to high amounts of protein and fat, as well, though).

So no fats? Just carbs and some protein?

Yet though carbohydrates have the availability bonus and proteins are necessary to maintain, better even build muscle mass, you would be ill-advised to steer clear of all dietary fats and, even more so the many good foods that contain them. Not so much because of the "essential" polyunsaturated fatty acid, though. According to a study by Tomten and Høstmark the dietary intake of PUFAs in 20 female runners with regular (n=10) and irregular (n=10) menses (LH levels of 7.6 vs. 2.9 IU/l!) was not statistically different. The intake saturated fats (-28%) and even more the intake of MUFAs (-38%), on the other hand was (Tomten. 2009) and the corresponding total fat-intake of 1.1g/kg body weight was obviously not sufficient to maintain optimal hormonal levels in the presence of a training volume of 7.5h per week.

What about vegetarianism? I know a few of you won't like this, but unless you are at least ovo-lacto vegetarian, i.e. a person who eats dairy and eggs, you are going to have a hard time fueling your athletic endeavors appropriately. After all, vegetarianism is associated with hormonal and menstrual abnormalities even in the non-athletic population, when they are dieting (Pirke. 1986). If you combine a mild energy deficit, as it is often seen in vegetarian, let alone vegan athletes, simply because it's harder for them to cover their energy and specifically protein and fat requirements without guzzling omega-6 oils and soy shakes all day (both not advisable, by the way), it is actually not surprising that Benson et al. mention vegetarianism right along low calorie intakes, nutritional inadequacies and low body fat stores as one of the main contributers to the (female) athlete triad (Benson. 1996).

Now you can certainly argue that all this comes down to the energy density and the correspondingly lower overall energy intake and could have been compensated for, if the women with menstrual irregularities had simply eaten more carbohydrates. In view of the fact that they didn't do so, I can hardly refute this argument. On the other hand, we have seen in the previous installment that an overexpression of GH and ghrelin is in as much part of the problem as too little insulin and a pathologically high insulin sensitivity. And some more fat in the diet (alongside carbs / not as the sole energy source!) couId in fact come handy to get that back in check.

Moreover, having a carb to fat ratio of ~2:1 (in energy equivalents) and a baseline fat intake in the range  of 80-100g (total) as the female runners with regular menses in the Tomton sudy had, has the beauty of never having to throw away the egg yolks, being able to get your share of fatty fish, full fat dairy, Kerrygold butter, virgin coconut and olive oil and beef or better calf liver as well as nuts once in a while. This in turn will allow you not just to stay sane and flexible with your diet, but also to satisfy your need for all those vital micronutrients you won't find in any of E-number laden fat-reduced garbage from the "low fat" shelves at the supermarket.

You see, in the end it all comes back eating simply more of the usual suspects, many people would probably file under "a paleo diet with lots of (safe) starches & fruit to fuel the energetic demands of a hard working athlete", these days.

If we think of the hypothetical daily energy requirement of 2000kcal/day which is often used as a reference for the nutrition information on those products of which you are going to buy less in the future (most real foods don't have nutritional information printed on them, you know ;-), the corresponding "numbers" could be anywhere on a continuum

• from 110g protein / 190g carbs / 100g fats, for someone without an endurance component in his workouts*, 
• to 100g protein / 240g carbs / 80g fats for someone who has a major endurance component and / or follows a high volume lifting routine*
  *pre- and post workout nutrition are not included, here!

This approach would ensure that you get enough protein, appropriate amounts of readily available energy, mainly in the form of safe starches and fruit, quasi unlimited amounts of vegetables and so much fat that you don't have to resort to the devastating "chicken breast, rice and broccoli diet", which will only worsen your situation.


References:

• Anderson KE, Rosner W, Khan MS, New MI, Pang SY, Wissel PS, Kappas A. Diet-hormone interactions: protein/carbohydrate ratio alters reciprocally the plasma levels of testosterone and cortisol and their respective binding globulins in man. Life Sci. 1987 May 4;40(18):1761-8.
• Benson JE, Engelbert-Fenton KA, Eisenman PA. Nutritional aspects of amenorrhea in the female athlete triad. Int J Sport Nutr. 1996 Jun;6(2):134-45.
• Laughlin GA, Dominguez CE, Yen SS. Nutritional and endocrine-metabolic aberrations in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab. 1998 Jan;83(1):25-32.
• Manore MM. Dietary recommendations and athletic menstrual dysfunction. Sports Med. 2002;32(14):887-901.
• Pirke KM, Schweiger U, Laessle R, Dickhaut B, Schweiger M, Waechtler M. Dieting influences the menstrual cycle: vegetarian versus nonvegetarian diet. Fertil Steril. 1986 Dec;46(6):1083-8.
• Tegelman R, Aberg T, Pousette A, Carlström K. Effects of a diet regimen on pituitary and steroid hormones in male ice hockey players. Int J Sports Med. 1992 Jul;13(5):424-30.
• Tomten SE, Høstmark AT. Serum vitamin E concentration and osmotic fragility in female long-distance runners. J Sports Sci. 2009 Jan 1;27(1):69-76.
• Zanker CL. Regulation of reproductive function in athletic women: an investigation of the roles of energy availability and body composition. Br J Sports Med. 2006 Jun;40(6):489-90; discussion 490.

Women Have a Much Harder Time Losing Body Fat Than Men, But Both Benefit From Doubling Their Protein Intake!

Image 1: Looks good, tastes good, is good - and contrary to zinc, ingesting 2x the RDA will help you lose body fat, instead of setting you up for insulin resistance.

Enough of useless (ALA, zinc) and useful (glutamin) supplements for at least 24h! Let's get back to what really counts: Training? No, not today,.. the other thing! The one, which is actually to be supplemented - your diet! Believe it or not - even after all those years, I am finding time and again that the food you put into your mouth has much more pronounced effects on the ways you look feel and perform than any of the countless useless and useful supplements. Accordingly and in response to the futile notion of "calories in vs. calories out" and the bomb-calorimeter representation of the human metabolism as a simple furnace, the past couple of years have seen an increasing public and (as of late) scientific interest in the effects varying macronutrient compositions will have on your ability to shed weight and, more importantly, to keep it off in the long run.

Submitted on December 30, 2011 and published in the latest issue of the Journal of Nutrition & Metabolism (9:55) the results of a "randomized clinical weight loss trial" comparing more or less isocaloric (-500kcal/day) weight loss regimen in 130 (58 male, 72 female) overweight middle-aged (40-56) subjects (BMI  =  32.5  ±  0.5 kg/m²) provide further insights into the real-world effects of  prescribed minimal protein intake levels on the outcomes of a 4 months weight loss and 8 months weight maintenance intervention (Evans. 2013).

RDA = 0.8g/bw vs. 2x RDA = 1.6g/bw protein - Round 1: Education & Adherence

In many of the previous posts on this issue (e.g. "High Carb vs. High Fat for Obese Type II Diabetics and What Really Happens, When Science Meets Real Life"), adherence or even an appropriate awareness of what "high protein" actually means turned out to be one of the main culprits as far as the significance of respective data is concerned (Krebs. 2013). In this respect, the subjects in the study by Evans et al. who were supported by a pretty extensive educational and support program that included

• the provision of electronic food scales and instruction on how to weigh and record food servings at all meals (logs were monitored for compliance on a weekly base!)
• a specific diet program with detailed instructions from a research dietitian including the menus, food substitutions and portion sizes
• an obligatory weekly 1 h meeting at the weight management research facility, where they received dietary counseling, had the ability to pose questions and instructions referring to the minimum of 30 min of walking 5 d/wk

constitute a positive exception from the average "study participant" who receives a handout with instructions and a clammy handshake for his/her willingness to step on the scale twice within a given time-frame.

Figure 1: Energy intake (total) from different macronutrients (left) and relative reduction compared to basesline in the 4-month weight loss and the subsequent 12 months "maintenance" period (based on Evans. 2013)

Based on the activity logs, the average amount of exercise was less than 100min/wk and not different between the two treatment groups. As far as the drop outs are concerned, there was yet a trend for lower drop out rates of the male participants in the protein compared to the carbohydrate group (9/28 vs. 18/30). 

Figure 2: Adherence to the prescribed macronutrient ratios was similarly "good" for men and women in both the high carbohydrate and high protein arm of the study (based on Evans. 2013)

The overall adherence to the prescribed nutrient ratios, i.e. 15% protein, 55% carbohydrates and 30% fat in the high carbohydrate and 30% protein, 40% carbohydrates and 30% fat in the high protein group was similarly good (the deviations were smaller than one standard deviation) among both men and women; and still, the net results of the study appear somewhat disappointing - at least if you make the all too common mistake of judging the outcome of an already intrinsically mislabeled "weight loss" intervention solely by the figures on your scale, which were, for the subjects in the study at hand, identical for both groups (PRO:-10.7  ±  6.8 %, CARB:-10.1  ±  6.2 %, expressed relative to body weight at baseline).

Feminists beware! Life is not fair...

A closer analysis of the data does yet reveal that despite an overall greater reduction in calorie intake in the high protein group (-31% vs. -22% in the weight loss phase and -27% vs. -16% in the maintenance phase) and slightly but statistically non-significantly greater body fat loss in the male participants on the high carbohydrate diet at the end of the maintenance phase, the "net" effect on the lean to fat mass ratio in men and women speaks in favor of increased protein intakes during phases of reduced energy intake.

Figure 1: It is obvious that compared to baseline the loss in body fat (expressed relative to baseline, left) was significantly more pronounced in the male compared to the female participants; the favorable effects of the high(er) protein diet on the lean to fat mass ratio (4% and 6% greater improvements) is yet of even greater importance for the ladies.

There is yet no denying that middle-aged women are - irrespective of their diets - having a substantially harder time losing body fat than men of the same age. In view of the fact that this is at least partly mediated by their significantly lower lean body mass to fat mass ratio (1.3 in women vs. 2.2 in men), the aforementioned protein sparing effects of "high" protein diets are of even greater importance for female dieters than for their male peers (cf. figure 3, right) - unfortunately, even the latter rarely rarely spare a thought about that, when their short-sighted and often likewise overweight Dr. tells them "you got to lose weight, if you want to see your grand children graduate, buddy!"

... and if you want sexual equality you got to lift weight and eat your meat ;-)

Against that background the results of the recently published exercise-only trial by Washburn et al. come to mind (cf. "Strength Training Ain't For Women -  Really!?" and Washburn. 2013). In the study at hand, The absence of at least a minimalist strength training regimen, as it was employed in the Washburn study, could in fact be one of the major reasons for the small overall effect size Evans et al. observed in their "walk in the park if you will" study. Eventually, the preservation of an already low amount of lean tissue mass is one thing, increasing the latter and thusly building the metabolic advantage of greater lean muscle mass, based on which the male study participants shed roughly 15% more body fat within the 12 month than their female peers is yet another one, of which I can hardly repeat often enough that it will not turn Angels into Divas over night (see image 2). And while you can easily regain 2 pounds of fat you lost, you will have to acknowledge that the lean mass you have either never built or lost over years of mainstream dieting, won't come back easily (cf. Beavers. 2011).

Image 2 (unkown Facebook source): Strength training and a high protein diet don't turn Angel's into Divas over night - what a pity ;-)

Bottom line: Regardless of whether you are a woman or a man, an angel or a diva, Homer Simpson, Peter Griffin, or Stanley Smith (cf. "Stocktaking, Goal Setting, -Tracking & -Resetting to Achieve a Healthy Weight & Shed Excess Body Fat"), greasy steaks, eggs, fish, dairy and a gym membership will not just have a much more pronounced impact on the outcome of your next diet, than all the diet products and books your money can buy, as an elementary part of your new lifestyle they will also lay the foundation of your future health - and what's even better: You will have more than enough extra years to spend all the money you would otherwise have spent on all those gimmicks, false promises, useless supplements and defacing cosmetic surgeries! Now you tell me eating a high(er) protein diet and spending time in the gym instead of the office was uneconomical ;-)

References:

1. Beavers KM, Lyles MF, Davis CC, Wang X, Beavers DP, Nicklas BJ. Is lost lean mass from intentional weight loss recovered during weight regain in postmenopausal women? Am J Clin Nutr. 2011 Sep;94(3):767-74. Epub 2011 Jul 27.
2. Evans EM, Mojtahedi MC, Thorpe MP, Valentine RJ, Kris-Etherton PM, Layman DK. Effects of protein intake and gender on body composition changes: a randomized clinical weight loss trial. Nutr Metab (Lond). 2013 Jun 12;9(1):55.
3. Krebs JD, Elley CR, Parry-Strong A, Lunt H, Drury PL, Bell DA, Robinson E, Moyes SA, Mann JI. The Diabetes Excess Weight Loss (DEWL) Trial: a randomised controlled trial of high-protein versus high-carbohydrate diets over 2 years in type 2 diabetes. Diabetologia. 2013 Apr;55(4):905-14. 
4. Washburn RA, Kirk EP, Smith BK, Honas JJ, Lecheminant JD, Bailey BW, Donnelly JE. One set resistance training: effect on body composition in overweight young adults. J Sports Med Phys Fitness. 2013 Jun;52(3):273.