Is get­ting too lean risk­ing your fer­til­ity?

Women's Health Australia - - CONTENTS - By Gemma Askham

Bump up your baby chances with the re­port ev­ery fit woman should read


While mus­cle-bound, sweat-drenched In­sta­gram sto­ries (and dis­cus­sions over brunch plates prac­ti­cally burst­ing with pro­tein) seem to con­firm that the strong-not-skinny mes­sage is alive and well, out­side the well­ness bub­ble, the sta­tis­tics show a dif­fer­ent story. In the most re­cent

WH Global Naked Sur­vey, a stag­ger­ing 90 per cent of read­ers sur­veyed said they wanted to re­duce their lev­els of body fat, while Roy Mor­gan Re­search shows 72 per cent of Aussie women aged 18–24 want to lose weight even though only 36 per cent have a BMI in the over­weight cat­e­gory. What this points to? A de­sire to get re­ally lean. But as this body goal re­mains hugely pop­u­lar, what isn’t im­me­di­ately clear is the dam­age super-low-fat goals will make to your fu­ture gains – and it’s all down to a sim­ple yet lit­tle-known con­cept called ‘en­ergy avail­abil­ity’.


We’re talk­ing about fer­til­ity specif­i­cally, and that monthly re­minder that ev­ery­thing in the ovary arena is work­ing. In­sta­gram sen­sa­tions Sally O’neil (@th­e­fit­food­ieblog) and Sarah Steven­son (@sarah­s_­day) have spo­ken about pre­vi­ously los­ing their pe­ri­ods in the face of over­train­ing and un­der-eat­ing, with O’neil ac­knowl­edg­ing her abs-quest wasn’t worth the health sacri­fice. Francesca Baker, 30, took up run­ning at uni to coun­ter­bal­ance boozy nights but wound up hooked on daily gym ses­sions and re­stric­tive di­ets. “I stopped tak­ing the pill around the same time, so I told my­self the abrupt stop in my pe­ri­ods was down to that, in­stead of what was becoming an out-of­con­trol de­sire to be ‘healthy’.”

It wasn’t healthy. Francesca was suf­fer­ing from rel­a­tive en­ergy de­fi­ciency in sports (RED-S, pro­nounced ‘reds’). “RED-S is a dis­par­ity be­tween food in­take

(the en­ergy you’re con­sum­ing) and the nutri­tion re­quired to cover the en­ergy de­mands of ba­sic house­keep­ing tasks in the body and ex­er­cise,” says sports en­docri­nol­o­gist Dr Nicky Keay. Like hav­ing a smart­phone on 9 per cent bat­tery, fail to top up its juice and it re­verts to an en­ergy-sav­ing mode where au­to­matic func­tions – in women’s case, pe­ri­ods – switch off.

Un­sur­pris­ingly, hu­mans aren’t quite as ho­mo­ge­neous as iphone mod­els, so the level at which th­ese pro­cesses slow or halt is dif­fer­ent for ev­ery­one. A reg­i­men or body fat per­cent­age that one woman can keep up with­out say­ing good­bye to reg­u­lar pe­ri­ods could af­fect the re­pro­duc­tive cy­cle of an­other.

“When you’re fo­cused on low­er­ing body fat, whether through an ex­treme ex­er­cise reg­i­men and/ or re­strict­ing kilo­joules, the body per­ceives you to be in a stressed state and de­cides this is not the time to re­pro­duce,” says Dr Meg­gie Smith, re­pro­duc­tive en­docrinol­ogy expert at the Univer­sity of South­ern Cal­i­for­nia. “Sig­nals from the brain to the ovaries, known as the hy­potha­la­mic-pi­tu­itary-ovar­ian axis, shut down. The lutein­is­ing hor­mone [which trig­gers ovu­la­tion] isn’t pro­duced and the ovary nei­ther re­leases an egg or makes oe­stro­gen and pro­ges­terone.”

While be­ing over­weight or obese dis­rupts your re­pro­duc­tive sys­tem by pro­duc­ing too much oe­stro­gen, veer to­wards the other ex­treme and “you es­sen­tially en­ter a post­menopausal state”, warns Smith.


Given that RED-S could se­verely dis­rupt your fer­til­ity, it’s fair to won­der why this hasn’t been grab­bing head­lines. Un­til re­cently, the phe­nom­e­non was known as the fe­male ath­lete triad – or sim­ply ‘the triad’ (we can’t imag­ine why the acro­nym FAT didn’t take off). The triad linked en­ergy de­fi­ciency to men­strual dis­tur­bances and loss of bone min­eral den­sity to ex­plain once-puz­zling pe­riod loss data, such as why 69 per cent of fe­male univer­sity-aged dancers* and 65 per cent of fe­male long-dis­tance run­ners* didn’t have reg­u­lar cy­cles. But in 2014, the In­ter­na­tional Olympic Com­mit­tee re­named it, real­is­ing that the triad wasn’t ac­tu­ally a three­some af­ter all.

En­ergy de­fi­ciency was also found to slow meta­bolic rate, im­pair im­mu­nity, in­crease fa­tigue and af­fect car­dio­vas­cu­lar and even gut health. Plus, in July last year, the British Jour­nal Of Sports

Medicine pub­lished re­search that ex­plored RED-S in un­der­nour­ished

male ath­letes, while Keay be­lieves the press­ing is­sue for women is de­cod­ing its ef­fect on non-ath­letes – you know, the rest of us.

“Elite ath­letes have the ex­per­tise of a coach or team doc­tor. A ded­i­cated am­a­teur with no such sup­port is there­fore more at risk of RED-S if they’re tak­ing mea­sures to sig­nif­i­cantly de­crease body fat through ex­er­cise and di­et­ing,” she ex­plains. “I see this in dancers: as­pir­ing stu­dents are of­ten at risk un­til they join a com­pany, where there is a sup­port net­work.”

Keay’s in­ter­est isn’t just pro­fes­sional, though. As a child gym­nast, she’d train four times a week, along­side bal­let classes that left her in­cred­i­bly lean. As a re­sult, it wasn’t un­til af­ter her sec­ond son was born – con­ceived with the help of an ovu­la­tion-in­duc­ing tablet and in­jec­tion – that she got her first pe­riod. She was 32. “I was for­tu­nate to work in a hos­pi­tal where I could seek con­cep­tion ad­vice. If I hadn’t

had this med­i­cal knowl­edge, who knows what would have hap­pened. That’s why it’s im­por­tant women are aware of RED-S.”


“In my ex­pe­ri­ence, those most sus­cep­ti­ble to fall­ing into dif­fi­culty are women in their 20s,” says reg­is­tered di­eti­tian and sports nu­tri­tion­ist Laura Clark. “They hit the gym six or seven times a week – some­times twice a day. In­tense train­ing is one thing, but if the nutri­tion isn’t there to sup­port that en­ergy ex­pen­di­ture and body func­tion, body fat drops sig­nif­i­cantly and you will run into real dif­fi­cul­ties.”

On the dilemma of too much ex­er­cise ver­sus too lit­tle food, Smith says that kilo­joule re­stric­tion is far more dan­ger­ous than high­in­ten­sity ex­er­cise. The study

Neu­roen­docrinol­ogy of Nu­tri­tional

In­fer­til­ity found that just one month of a sig­nif­i­cant drop in en­ergy in­take could mess with men­strual func­tion.

But as long as you have a BMI in the healthy range, you’re golden, right? Well, the ex­perts can’t seem to agree on how use­ful tra­di­tional mea­sure­ments are. The late bi­ol­o­gist Rose Frisch found that eval­u­at­ing weight alone could be mis­lead­ing – as mus­cles are heavy (80 per cent wa­ter com­pared to 5–10 per cent wa­ter in fatty tis­sue), many ath­letes ap­peared in the “nor­mal” weight range de­spite hav­ing no pe­ri­ods. Even with body composition scales, Clark points out that you’ll get dif­fer­ent re­sults de­pend­ing on where you are dur­ing your men­strual cy­cle, as that af­fects how much wa­ter your cells hold.

Frisch sug­gested women needed at least 17 per cent body fat to fall preg­nant – nick­nam­ing it “sex fat”, as it pro­vides en­ergy for re­pro­duc­tion. This is in line with Royal Col­lege of Nurs­ing find­ings in 2015, stat­ing the healthy body fat per­cent­age for women aged 20–39 is be­tween 21 and 33 per cent.

It’s why en­ergy avail­abil­ity – the dif­fer­ence be­tween en­ergy in­take and ex­pen­di­ture from ex­er­cise – is the new buzz­word. “The en­ergy re­quire­ment is 188kj per kilo­gram of lean body mass for en­docrine func­tion,” says Keay. “It’s also about the qual­ity of your diet. I had a dancer who got to that level by eat­ing bis­cuits and sweets, but she still had no pe­ri­ods as she wasn’t cov­er­ing the ma­jor food groups.”


How to spot whether you’re at risk of RED-S? “Even if your weight is steady, if your pe­ri­ods have stopped or be­come ir­reg­u­lar and you’re not on a con­tra­cep­tive method, don’t ig­nore it,” urges Keay. “Your doc­tor will ex­clude other causes first, like poly­cys­tic ovary syn­drome and thy­roid dis­or­der, then look at your nutri­tion in line with your train­ing.”

Ex­perts also high­light other signs that your quest to be­come lean is go­ing too far, even be­fore your pe­ri­ods show any changes. Per­sonal trainer Luke Wor­thing­ton rec­om­mends be­ing alert to phys­i­o­log­i­cal changes such as hair loss (a sign of in­ad­e­quate nutri­tion), in­creased body hair (a layer of soft downy hair) and a pot belly caused by in­testi­nal gas. Psy­cho­log­i­cal warn­ing signs are just as im­por­tant. “If you find your­self ob­sess­ing over a missed work­out, sched­ul­ing your en­tire life around ex­er­cise or meal prep and los­ing in­ter­est in sex, take them as cues that you may be too fo­cused on get­ting leaner in an un­healthy way,” he adds.

Loss of pe­ri­ods through too lit­tle body fat is re­versible. Your fer­til­ity is in­formed by a host of fac­tors, from your age to stress lev­els. Doo­ley says if you’re not un­der­weight and not los­ing weight via re­stric­tion, you’re likely to con­ceive un­less other med­i­cal con­di­tions are at play. He stud­ies the pos­si­bil­ity that un­re­leased eggs aren’t lost for good due to RED-S, but are stored, freezer-like, in­side your body.

Get­ting nor­mal men­strual func­tion back is, in fact, more food sci­ence than rocket sci­ence. The In­ter­na­tional Olympic Com­mit­tee’s re­port on RED-S found that the only strat­egy that has re­ceived sci­en­tific scru­tiny – and worked – was to add an en­ergy-rich sup­ple­ment (in the study, it was a daily liq­uid meal prod­uct of around 1255–2510kj) and a weekly rest day. The gen­eral ad­vice when you’re ex­er­cis­ing hard is to think about what you can add to your diet, rather than what you can take away.



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