E12: What PTs should know about Carbs, Protein and underfueling in running injury Recovery

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<v Jimmy>Welcome to the Physio Insights podcast presented by Runeasi. I’ll be your host, doctor Jimmy Picard. I’m a physical therapist, running coach, and team member here at RUNNES. On this show, we have real conversations with leading experts digging into how we recover from injuries, train smarter, and use data to better guide care. Whether you’re a clinician, a coach, or an athlete, we’re here to explore what really matters in rehab and performance.

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Let’s dive in.

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<v Jimmy>All right, Rebecca. Welcome to the Physio Insights podcast. Really excited to have you. I’ve been looking forward to this one. You come at this from a unique perspective where you’re bringing sports performance, nutrition, and even some psychology behind fueling to this conversation.

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Really excited. Before we dive in, do you mind just giving the listeners a brief introduction to who you are?

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<v Rebecca>Sure, the elevator speech. So my name is Becca McConnell. I’m located in the Kansas City, Missouri. We always have to clarify that. And I am a duly licensed sports dietitian and eating disorder specialist supervisor as well.

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So I think you said that beautifully. I not only look at the science, but also the relational piece of how nutrition, training, our health impacts us. And like most of us got into this after a lived experience as a college athlete being like, what could I do to kind of push the envelope with my performance? And it worked in the short term, but then I pushed a little too far and started having some consequences as a result, which is why I love to specialize in rents.

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<v Jimmy>Yeah. So you have a personal story back there. What sport was this? What sport did you play?

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<v Rebecca>Basketball.

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<v Jimmy>Awesome. Is that common to see eating issues in basketball?

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<v Rebecca>Common is a hard word. I think too many teams, we get stereotyped. Yes, there’s higher risk because of energy expenditure but in my years of doing this, you name the sport, I probably have had somebody that’s had under fueling or disordered eating.

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<v Jimmy>Yeah, wow. Okay. Well, why don’t we get started with kind of the big picture here and talk about food’s role in healing. So, coming from a PT background, when I see patients like especially their initial evaluation, my focus is often on load management, what’s going on at the tissue level, the mechanics, biomechanics, that kind of thing is there as a component. I’m often like asking questions about it, but my expertise like quickly ends there.

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So can you just talk about food’s role in healing?

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<v Rebecca>So with those three keys that you just said, I always try to pair nutrition with that. So like load management makes me think about, will they have the energy to get the stimulus that you’re wanting from that physical therapy, right? Otherwise, it’s a wash. They’re not going to get out of the adaptations that they need. And then from the soft tissue management, that’s where I kind of use the term tame the flame.

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What can we do to decrease that inflammation from that injury, right? Or work with the inflammation to help it heal. And then what was your third one? I was trying to get it all in my head.

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<v Jimmy>Maybe biomechanics?

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<v Rebecca>Biomechanics. So then I talk a lot about like the neuromuscular piece of it and how, you know, well fueled brain is our cadence. It is our mechanics and so we see people start to have a breakdown in that when they start to go into an under fueled state.

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<v Jimmy>There was a study that just came out looking at neuromuscular effects of low energy availability. I forget the researcher, anyway, yeah. So you’re bringing all of this to the table. So yeah. So where does if I have an injured athlete, I’m suspecting they’re under fueling.

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What do you feel like I should do with them? Should I refer them out? Should I try to address it myself? What do you typically where do you start?

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<v Rebecca>So maybe do the nudge in the beginning. If you bring up to them like, hey, it seems like for the amount of activity you were doing, you weren’t probably feeling adequately, which also means that your body probably isn’t in the best nutritional place to help you heal from this injury and get in. I’m afraid that that’s going to slow your return. So if you use those keywords, right? They don’t want to have their injury prolonged.

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They don’t want to have it happen again. So that will tell you if they’re ready in that appointment to set up with a dietitian. A lot of times, having been a mom with an athlete that got injured, I saw it firsthand how overwhelmed you are with the amount of appointments. And so it may be you have to nudge them a couple weeks later to get that set up. But I do think it’s really important for the PT to refer that out because you don’t know what you don’t know and so it might be you get to dig in a little bit deeper and they want to have their safe spot where when they go to PT, that’s what’s being focused.

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It’s not going to be nutrition or sleep or anything like that. Obviously, you’re inquiring about it. I’m also always cognizant of people’s finances and sometimes people now have some online programming from dietitians that can help athletes through that time if they’re not able to afford meeting one on one with the dietitian.

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<v Jimmy>Got it. Yeah, we’ll come back to that financial component at the end because that’s something I wanted to ask about. But if we go back to, yeah, foods role in healing and this idea of tame the flame. I’ve heard you say that before. I like it.

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It’s catchy. Can you talk more about it?

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<v Rebecca>Yeah. So, you know, anytime like a a cut, right, you’re gonna feel heat on it. You’re gonna you’re gonna notice that it gets inflammation. It might even be a little woozy with fluid. Same things happens within our tissues.

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Now granted UPTs are gonna say like, that that scientifically does not make sense, but that’s my layperson way of teaching that. So then we want to help our body on have anti inflammatory foods if we need to, supplements to help decrease or tame that flame, and then we also want to make sure that we have those building blocks there. So for example, if it’s like a ligament tear, then that’s where collagen could have a place because it’s going to help with new connective tissue growth. It’s also going to fuse some of those ligaments together in that scar tissue. And then we want to be able to continue to support that through adequate carb, protein, fluid, looking at things that might interfere with the recovery process like sleep.

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That’s a big one that tends to get overlooked when you’re in pain and you’re not able to be active and your mood’s down. That can interfere. So I I kind of look at all the barriers that might be coming up, what could be the role of nutrition in there to help support them, and then we stage recommendations from there.

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<v Jimmy>Are there specific foods or supplements that you’re using to tame the flame?

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<v Rebecca>So, omega threes have a great place. So if they can at least get like three servings of fatty fish a week or incorporating like walnuts and things like that, it’s great. But most of time, they may need a supplement during that time, like a high quality one, like from Nordic Naturals or Clean. They have ones that are designed straight for sports and performance. I’m a big fan of tart cherry juice concentrate.

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They’ve done studies looking at that on delayed onset muscle soreness, gout arthritis. So we know it not only helps with the muscle soreness, it has to have some sort of role in the anti inflammatory pathways as well. But what’s also cool about it is it’s a natural source of melatonin. So one ounce of tart cherry juice concentrate has about five milligrams of natural melatonin. So it helps with getting them to sleep as well.

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<v Jimmy>Yeah. So is that something you want because it’s got melatonin or actually with any of these supplements? Or is this long term use or is this just when they’re kind of inflamed and they’re not irritable state?

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<v Rebecca>So, I kind of leave that up to them. I’m like, when I recommend supplements, I always look at risk to reward and luckily those are two that really don’t have much risk. So, they could continue on the fish oil. Now, we might bring down the dosing when they’re recovered from their injury, but same thing with like tertiary juice concentrate. Downside is usually it’s about $32 for month’s worth.

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And so, I may tell them, hey, when you get in the off season and you’re recovering, take a break from taking it. Or, you know, as you’re ramping up and you don’t feel like your training is leaving you a sore, then maybe you can take a break from that but there’s not going to be harm in you taking that long term because there’s a it’s kind of like creatine, there’s a multitude of different benefits that can come from yeast that supplement.

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<v Jimmy>I just actually bought some myself last week because I have this knee joint diffusion and it’s been super cranky and I was blown away by my sleep improving.

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<v Rebecca>So when my daughter had that, she had a grade three ankle tear, all sides had involvement, it actually dislocated and bone bruised off the court. I mean, she did a nuisance and the worst part of it was she could not sleep at all and then they wouldn’t, which I understand, they wouldn’t prescribe any pain meds. So then she did a lot of ibuprofen and Tylenol to try to control the pain, then her stomach started getting upset like, oh great, now we can’t take pain. And then luckily somebody said to me, Well, time for mom to do what she does best. And I was like, I’m not even using my own sports nutrition knowledge on my own kid.

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And so she wasn’t a fan of the liquid at first because it is really tart, but then I found that they had some black cherry gummies and she came in that next morning. I remember saying, because I hate to admit this, but I actually did sleep a lot better last night and I was

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<v Jimmy>like,

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<v Rebecca>I guess Simone does know a few things.

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<v Jimmy>Yeah. Like I said, I was blown away. It was like night and day. I I typically sleep well, but I slept like a rock. We have a four month old at home and I did not wake up once and my wife is a little upset about that.

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<v Rebecca>Well, can take some tart cherry

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<v Jimmy>I know. I I offered it to her and she was like, it brings up a whole another. She was worried about something else. So alright. Back to food and healing.

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So we’ve mentioned a few supplements, but I’ve heard the term food first and things like that. Like, do you where do you feel like food versus supplements? How do we balance the two if we’re thinking about healing?

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<v Rebecca>Right. There’s so much nuance to that because, yes, obviously when we get it from foods, it’s more bioavailable, which means that we absorb more of key nutrients. We also get a well rounded source of nutrient, like protein powders, we may only get whey where if we have a filet mignon or a fish, we’re getting different amino acids and other fats, etc. That’s in there. But when somebody is recovering from an injury, we don’t necessarily want their body to have to work that much harder, especially since I specialize in reds, a lot of my athletes are coming to me with like a bone stress injury and we’re recovering from reds.

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And so, you know, if iron is low and vitamin D is low, then that means that body is having to work harder, even if we’re in a low energy state because the iron and vitamin D is low. So it makes logical sense to say, well, let’s help support that so that body’s not having to work harder and then it’s easier to get the energy deficit deficit corrected.

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<v Jimmy>Got it. So there’s a role for both. There’s a role for, yeah, trying to focus on foods, there’s a role for the supplements when the time’s right. So one kind of pattern that I see often, I’m curious if you see this as well, but it’s, I got an injured athlete in the clinic for their evaluation and their background. I’m hearing signs of under fueling whether it’s intentional or unintentional.

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They’re here in my office because they’re injured. Their exercise volume has like gone to the toilet. It’s 50%, it’s zero, it’s whatever. They’re under fueling now because they’re not exercising. And then they’re in this kind of like vicious downward spiral of under fueling, not healing well, continuing to under fuel.

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I had a woman in here yesterday actually referred her to you, but she when we started talking about this, she said something like, I’m not gonna tell you what I ate today because you’re gonna kick me out of your office if I do. I’ve seen this pattern. I just like you to yeah. Speak on that. How what do you see that and how do you handle that?

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<v Rebecca>Yeah. And I always try to approach it with how can I open that conversation with as little shame as possible? Because of course, the way our culture shoves weight focus and nutrition focus, when they’re not able to do activities like, Oh my gosh, I can’t eat because I’m not able to move my body. Not understanding that an injury is a workout, right? Like you’re trying to recover and heal, which increases energy demands.

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And like, for example, a bone stress injury, you’re going to need more calcium and vitamin D and K2 and magnesium to help build new bone matrix. And so I will talk about how there’s three steps to this. First is, and I like to use things in financial analogies, if you’re not paying the bills, then the body’s not going to build back its foundation the way that it should. So there’s going to be holes in it or it’s going be really slow to get built back. Then we start looking at the variety of nutrients with our macronutrients.

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Are they protein pacing, meaning that they’re not doing like an 80 shake and then all of a sudden they’ve gone six or eight hours without protein? I’ve had that with a lot of my athletes when they’re recovering. How can we get that consistent throughout the day? Then to make sure they’re not forgetting the carbohydrates because that’s the one that our culture is associated with weight and body changes, but carbs have a role in cortisol, in our inflammation, our sleep, our hormone production. Then last but not least is the fine tuning and adding on for that tame in the flame.

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So like, what can we do to help support the body on top of our foundation?

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<v Jimmy>Can you elaborate on the bank or the money analogy?

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<v Rebecca>Yeah. So that’s how I teach about reds is, you know, for every activity you do, it’s a withdrawal from your bank account and that doesn’t always have to mean your sport or training or physical therapy. It could be a stressful day at work, house full of kids on a snow day, your brain’s probably going to need more and so to match that deposit, so many people don’t understand that even strapped to this chair, we still have to eat anywhere from 1,400 to 1,800 or 2,000 calories, not even doing the activity. Yeah. And so providing that education first and then telling them if you don’t have that, somewhere that body is paying the bills and the health of your connective tissue and your bone and having nice muscle for strength as a luxury, the body’s gonna be like, if I can’t get my bills paid, I’m just gonna use those savings accounts and use that energy.

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<v Jimmy>Yeah. So how do you help educate the patient? So I’m just thinking when I see somebody here clinically and I’m suspecting they’re under fueling and I’m trying to help them realize that even though they’re exercising less right now, that there’s this huge need to continue to eat. Do you have strategies, like, to encourage this? How do you, like because, yeah, like one thing to just say, hey, yeah, you need more fuel, your body’s healing.

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But I feel like most of the time, maybe it’s just because it’s coming from me and it needs to come from somebody like you. I feel like personally it falls flat. But yeah, what do you think?

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<v Rebecca>Well, and I wonder when you’re approaching that conversation, is it in the beginning where that injury is still pretty raw to them and they’re depressive because they haven’t been able to go do what they love, which might also be their community if it’s a team, if it’s a running group. And so I will actually tell people like, don’t necessarily bring up the negative, like spin it as I want you to do everything possible to help your body heal. Yeah. So let’s get everybody involved if we can. And I know this dietitian will probably help us fill in some holes to help us right now, but also for your greatest comeback ever, you know, like really get them hyped

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<v Jimmy>And about

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<v Rebecca>then I approach it to you, I’ll be like, all right, I know right now you’re not being active, but the last thing we want to do is wait to focus on nutrition when you’re fully cleared and you’re in a deficit because it’s not going to go well. So now is a better time because you’re not running as much or lifting as much to try to work on the nutrition, rather you’re training for an hour or two hours or even more than that a day.

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<v Jimmy>Yeah. Are you ever encouraging people to increase their caloric intake while they’re injured?

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<v Rebecca>Yeah. Especially if they’ve came in in a deficit and we know that, which a lot of them are going to be that, you know, six, eight weeks is going to come a lot faster than they think it is. And so if you’re already back to being active, it’s hard to then have the digestive capacity to increase your nutrition to make it a habit. So matter of fact, when a lot of athletes are doing their like walk, run, return program, I’m like, that’s the perfect time if you’ve never practiced taking in fueling or if you struggled with it. I know by guidelines, don’t necessarily have to have nutrition in, but gosh, that’s gonna be a lot easier to get that down because if you’re out for a mile walk and your stomach revolts, it’s a little bit better than being out on a 22 miler and having that happen as well.

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<v Jimmy>Yep. Yeah. So you brought up the term reds. For those unfamiliar, can you just talk about that for a sec?

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<v Rebecca>Yeah, so it’s relative energy deficiency in sport but as you can tell, I like the bank analogy. So I use the word deficit so it helps people understand it’s that mismatch of energy coming in to energy expending, or again, the deposits versus the withdrawals. And so, some missteps that people have is they assume it’s like very restrictive diets that somebody is not eating and that’s just not the case. So you’ve got end of the day energy availability and so a mismatch of two fifty to 400 calories over five days is enough that we start seeing hormonal dysfunction. That’s not much.

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<v Jimmy>No, can you say that one more time because that’s a little shocking.

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<v Rebecca>Uh-huh, so a two fifty to 400 calorie difference between what you need and what you’re taking in over five days Yeah. Lead to hormonal dysfunction.

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<v Jimmy>And like two fifty calories, that’s like a snack.

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<v Rebecca>So the theory behind this, and that’s exactly what it starts really simple with they’re rushing around and maybe they start skipping a snack, practice time got moved, etcetera, or seasons, we kind of eat different according to seasons. So if somebody starts eating a lot more soup when it’s cold, it may not be as calorically dense as something they were eating before. So that is supposedly the amount of glycogen that’s usually stored in the liver and the liver is the one that gives the immediate energy and fuel to the brain. So if that’s being depleted, then the brain kind of lags and then that sends emergency signals down to our bone, to our sex hormones, to leptin, which is secreted from our adipose tissue, and then we start to slowly see dysfunction. And then what’s crazy is so many people like, well, wouldn’t it make sense that I would start getting more hungry if I was under fueled?

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And you will beginning, but then the brain starts to flip into hibernation mode and it was like, well, if the bear is going to be sleeping in the cave, it’s not going to be foraging and eating, right? It’s hibernating. Well, our brains aren’t too different from that and so those signals actually start to get muffled or even shut off and then they get even deeper in the energy deficit.

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<v Jimmy>Interesting. And then anecdotally, I’ve seen that and then it led to like weight gain. Is that something that you’ve seen or like can you explain that because it doesn’t make sense? It’s like we’re under fueling off in case I’m thinking of it was a lot. It was somebody that was breastfeeding, running 40 miles a week and consuming like 1,600 calories a day and then still gaining weight and ended up with a stress fracture.

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<v Rebecca>So that’s actually what led me to write my first book, Finding Your Sweet Spot was I had athlete after athlete coming in that wanted to lose weight. And then in our assessment, they were barely eating 1,200, 1,400 calories, but they were expending close to that. And I’d be like, we’re not going to focus on gutting your calories anymore. And then I would walk them through and I would show like, you know, as you went into more of an energy deficit, did you notice all these symptoms pop up? Your sleep disturbance, you’re constipated all the time, you’re struggling with your workouts.

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And so I always talk about reds in like three different we have the emergency response in the beginning and that’s that five day window where they get into a deficit. And then the body kind of moves into, well, let’s dim the lights in the house to conserve energy. So things start, they’re still working, but they’re sluggish. So that’ll show up a lot in people’s digestion patterns or training adaptations may not respond. Then we get to the third, which is the emergency one and the brain and the body are brilliant.

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So what they do is they’re like, Hey, we don’t have enough energy coming in. We’ve hit our safety threshold on our savings account. So that’s liver and then that’s our body fat and that’s our muscle. And most people are like, Well, deplete the body fat. We don’t need that savings account.

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But they forget it’s an active endocrine organ. So the brain is not gonna let that go too much past. So then we start shifting and we use muscle as energy. So you’ve got a body composition change that will start to happen where people will actually maybe increase their body fat, but they lose muscle mass. And remember, our muscle is more thermogenic, meaning that it requires more energy in a daily basis.

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So you’ve got that piece of it. And then the thyroid comes in. So a lot of people may suspect or think they have clinical hypothyroidism. But what it does is it’s like, we can’t have this nice v eight engine, we need to conserve our metabolism down to a v six or a v four. And so T3 will start to drop and so we actually see less activity from our thyroid gland.

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<v Jimmy>And so all of that is just from under fueling.

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<v Rebecca>Mhmm.

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<v Jimmy>Low energy availability.

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<v Rebecca>Yep.

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<v Jimmy>And at what point does like bone health start to get affected? Is that early on in this phase? Is it later?

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<v Rebecca>It’s a little bit of both. You know, it used to be called the triad and the triad was amenorrhea. So three months of consecutive loss of cycle or now they’ve switched it to less than six periods in a year. And then it was, I believe, two bone stress injuries and then a weight change. Well, like you just alluded to, a lot of individuals either maintain their weight or they gain weight, so that doesn’t include them.

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But bone and blood cells recycle or go in like three months. So if we define amenorrhea as three months that they haven’t had any turnover of hormone cycle, that means bone’s been implicated. So it’s beneath the surface, but that’s where I teach a lot of my females to look for if all of a sudden their cycles are getting longer or shorter, if their bleeds are getting lighter, or if they notice difference in some of their PMS symptoms to just flag it and pay attention and make sure there wasn’t anything from a fueling stress or sleep standpoint because by the time they’re amenorrhea, they may have six months or more of bone loss that’s been occurring.

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<v Jimmy>So from a PT screening perspective, like asking questions about loss of period, menstrual function, things like that, but then also it sounds like GI, questions about the What GI what should I be asking there?

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<v Rebecca>May I ask you like, has there been anything that’s impacted? That’s a good question. I gotta think about it. A lot of times if you just ask them, do you have healthy digestive patterns? And of course, most of are gonna say yes, and then ask them, how do you know that to be true?

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Because they’ll sometimes they’ve compensated for so long that they’re not aware that they actually don’t have a healthy GI system. And then you can put some terms to it, like going to the bathroom daily and feeling like you got everything voided out. Do you struggle with bloating that continues on and interferes with your hunger for the next meal? So that one’s a little tricky to kind of give in like one or two questions, but with like the menstrual cycle, what I’ll encourage providers to ask is, when was the last time you remember having consistent menstrual cycles? If they say, Oh, I have my month perfect.

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But if they’re like, Oh yeah, it’s been two months, but also like, it was forty days in between that one. So that gives you a timeline where to flag, what changes maybe happened and then look at how long. So in reds, I talk about the runway. So the runway can be how long they’ve been in energy deficit, but it also can be how steep a deficit and that tells us how long we’re going to have to take to get recovered.

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<v Jimmy>What happens if the client or patient is on birth control and like how do I make sense of that?

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<v Rebecca>Yep, because fifty percent of our females are on birth control. So looking for, there was actually a pretty good article recently that talked about that and kind of leaning on the thyroid hormone T3 more for an indicator, looking at lipids, and then kind of really looking at sleep quality, digestion, etc. Because you can’t go off hormone panel at that point an indicator. But sometimes too, they may even notice some changes to their cycle even on birth control that indicates that they’re in a low energy state.

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<v Jimmy>Gotcha. Okay. And then going back to GI dysfunction, does it go both ways? Like, will they get constipated in or could they also have just like frequent when I was in college, maybe TMI here, he had a sacral stress fracture my first year in college. It was definitely under fueling.

00:25:17.220 –> 00:25:31.715
I believe I would like to say it was unintentional. I was training like 100 mile weeks running a ton, but I had to go to the bathroom all. Like every run, I was stopping multiple times and I’m now looking back, I’m wondering if that was like a sign that I was under fuel.

00:25:31.715 –> 00:25:55.215
<v Rebecca>It could be. It also could be if that stress fracture was already starting to occur. So one of the things I don’t step into the role of PT, but one of the questions I ask, have you ever had a lower back injury, pelvic or issues with tightness in hips? And the reason for that is that’s that pelvic floor that is on like the outside of the GI tract. So I talk about it as like a factory belt.

00:25:55.215 –> 00:26:26.105
So if there’s tightness or if they’ve had like an injury that the body kind of remembers as a trauma, then that means all those smooth muscles get involved when they activate it. So sometimes people get like that urge to have to go to the bathroom or maybe they do. So that’s one separate issue. Another can be so irritable bowel syndrome, which is supposed to be changing its name to gut brain axis dysfunction, has an overlap of reds with some studies saying sixty five percent, others saying up to eighty.

00:26:26.105 –> 00:26:40.750
<v Jimmy>Well, I mean, so at that time in my life, I had a colonoscopy, I went through all this stuff and was diagnosed with IBS. Yeah. But I didn’t wasn’t told I didn’t really have there was nothing for me to do about it at that point. At least That nobody gave me anything to do.

00:26:41.550 –> 00:27:03.910
<v Rebecca>Was in college, I started having a bunch of digestive issues and it was like, oh, take your MiraLAX or oh, it’s because you’re a stressed college student. It was about and I’m not blaming them. I mean, I’m going to age myself that I’m 45. That was not like it was just a few years ago, but looking at it from when did that start? How did those symptoms come up?

00:27:03.910 –> 00:27:12.950
So it can be constipation, it can be diarrhea. Another thing that most people don’t understand is if you don’t go to the bathroom and then all of a sudden you have super loose stools, that’s still a form of constipation.

00:27:13.030 –> 00:27:14.470
<v Jimmy>What? That’s weird. Yeah.

00:27:14.685 –> 00:27:55.045
<v Rebecca>Well, again, I love a lot of reframes. Well, think about it if like your plumbing gets packed, right, and it finally breaks through, then you have a lot of fluid that’s pushed that out, breaking the the dam as well. And why that’s so critical is if that factory build is not up and working properly, then that’s gonna skew their hunger, that’s gonna skew their ability to get adequate fueling and and fullness, and it’s gonna lead to more body distress. And so it’s really important to make sure we tackle that. And I send mine to a lot of PTs to try to get some better, like motility by strengthening or loosening up their core back as well.

00:27:55.350 –> 00:28:03.670
I’ve had a lot that have had hip and back issues that they never put together was related to that contributed to their GI issues.

00:28:03.910 –> 00:28:05.670
<v Jimmy>Yeah, that’s interesting.

00:28:08.390 –> 00:28:41.425
<v Jimmy>I’d like to take a moment to thank our sponsor, Runeasi. Runeasi is a running and jumping analysis tool that helps provide objective data on things like impact loading, dynamic stability, and symmetry. I’ve been using it in the clinic for the past three years and I love how easy it is to add to my evaluations. Not only that, but it backs up my clinical reasoning and helps me with my decision making process when I’m doing exercise prescription. So if you’re a physical therapist or running coach, head on over to runeasi.ai and book a demo.

00:28:41.505 –> 00:28:43.185
If you’re lucky, it will be with me.

00:28:43.825 –> 00:28:47.425
<v Jimmy>Alright. So I didn’t know we were gonna talk this much about poop.

00:28:47.905 –> 00:28:49.985
<v Rebecca>It’s a nutritional byproduct. That’s what I always call

00:28:49.985 –> 00:29:19.965
<v Jimmy>my No. It’s important because I do I guess, like like we both experienced it. I know my wife has a history of some eating disorder and I to me, it’s like a warning sign when I see her going through some of this some of this GI distress. I’m like, makes me question her a little bit and I need to refer her out. But switching gears, you brought up we talked a little bit about like protein and carbs but if we dig into the macros here, protein on social media influencers are like, it’s everywhere.

00:29:20.205 –> 00:29:42.705
One gram per pound body weight seems to be what everybody is talking about. Anecdotally, I’ve seen a lot of stress fracture patients who are coming to me and like when I dig into their their nutrition, they think they’re crushing it and they’re telling me they’re putting protein first. It’s like the first thing they’re thinking about, they’re hitting their goals, but it seems to be coming out of cost. Will will you talk about that?

00:29:42.705 –> 00:30:01.440
<v Rebecca>Yeah. Absolutely. I mean, I’ll shut up after. I always joke like proteins like the Marsha, Marsha, Marsha, the halo, right? That has and it doesn’t need to be demonized, but I think that people have taken it to the extremes and I always think about our personality traits in most of our clientele, they’re very type a, right?

00:30:01.440 –> 00:30:37.555
So, you know, if you tell them to do something, they’re going be like, oh, a little bit more would be even better. And so that’s what’s happened with the protein. And then what we’ve seen is in the last fifteen years with social media’s rise, you know, it used to be experts were the face of recommendations, right? It would be somebody who is a well known researcher that has studied protein for decades. Now what’s happened is somebody that fits the thin ideal for our culture or very fit or a well known athlete comes out and they start spewing some recommendations and say, Hey, look what I did, you can have this.

00:30:37.875 –> 00:30:56.610
And then it’s become wildfire. And so people now flip from experts to influencers. So protein, just like carbon fat, has its own range. So when people go off the one gram per pound, that’s like the upper upper limit. Where if you’re an endurance athlete, your predominant fuel source is going to be carbohydrates.

00:30:56.610 –> 00:31:25.630
Of course, we protein in there. But if you’re so full and satiated from a high, high protein diet that you can’t get your carbon fat in, that’s not healthy for you. And going back to I talked about the end of the day energy availability. There’s also two other components to it. There’s within day energy balance, which means that you want to typically not go longer than three to four hours without fueling because cortisol is the key to opening up the savings account.

00:31:25.955 –> 00:31:57.335
Cortisol is not bad, but if we’re constantly having to use that, that means we’ve created an inflammatory state. So we see less iron absorption during that time. That’s where athletes start to get the case of the niggles and having more like tissue that’s getting irritated. Then the third piece and the new kid on the block is low glucose availability. So before we hopped on, you were talking about the study and I love it because they were the first to separate out, Everybody always thinks it’s related to low energy availability.

00:31:57.335 –> 00:32:31.395
So they had a study group that had low energy availability, but adequate carb. They had one that had adequate carb, and I got to test my memory on this, and adequate energy, and then they had a keto diet. And what they found was the keto diet had the same bone turnover markers and not one of them was actually higher than the one that was adequate carb and low energy availability. So from there, they pulled glucose has its own role in especially bone stress injuries even when somebody has adequate energy. So when somebody is protein maxing, they probably are not getting enough carbon.

00:32:31.395 –> 00:32:57.005
<v Jimmy>Yeah. So from my recollection, was that, yeah, they were adequate calories but low carb and it had detrimental like, it increased bone absorption and decreased bone, like, laying down of new bone. Yeah. So it had this, like, double whammy negative effect on bone health. I guess there’s nuance here because if we’re talking about endurance athletes, carbs are king that you just said, they have to have a big seat at the table.

00:32:57.005 –> 00:33:01.965
What about if I’m dealing with like a primarily like a strength athlete? Is that still true?

00:33:01.965 –> 00:33:30.805
<v Rebecca>So they might actually be the one exception that does the one gram per pound because, you know, for focusing on the bulk of your training being stimulus to grow muscle, then yes, you would need protein, but we also want to reiterate that carb has its role and so does fat. And so what I’m trying to remember my timeline. So we no longer in the sports nutrition world use percents from calories. Like if you were to look up dietary guidelines, they may say 25% of your daily calories

00:33:30.805 –> 00:33:31.205
<v Jimmy>should And be

00:33:32.245 –> 00:34:09.820
<v Rebecca>what they did was they shifted to it being related to your weight and your sport. Why that is, is because it makes sense, right? A taller power athlete is probably going to have more muscular frame and isn’t going to need as much glycogen as our ultra runner, right? So they’re going to need to have obviously enough protein to sustain protecting their skeletal mass and their immunity, but the predominant source is going to be carb. And so that’s where we look at the guidelines as to what do they need from their sport and then what characteristically is needed from that body mass, not from an aesthetic piece but from the performance piece as well.

00:34:09.980 –> 00:34:13.340
<v Jimmy>Yeah. Alright. So again, there’s there’s nuance. So it depends. It depends.

00:34:13.340 –> 00:34:21.435
And then also like, what about aging? Like, if we’re an older athlete, does protein does protein become more important or is it still the same?

00:34:21.435 –> 00:34:40.290
<v Rebecca>Great question. And that’s a subgroup that is really at risk for reds because there’s so much confusion as especially a female goes to the transition of perimenopause to menopause, it’s the largest growing group of endurance athletes as well and then they’re shoved with, don’t gain weight, do this for your belly fat, etcetera.

00:34:40.290 –> 00:34:48.195
<v Jimmy>And fear because they fear like that they’re not going to be able to lose any weight if they end up gaining it, they’re going have a hard time losing it.

00:34:48.195 –> 00:34:59.235
<v Rebecca>So I hate to admit this because I already said all my ages, but we start actually seeing a shift in the building of skeletal and muscle mass at age 32 to 35.

00:34:59.235 –> 00:34:59.555
<v Jimmy>Woah.

00:34:59.750 –> 00:35:32.150
<v Rebecca>I know. So as they hormonally lose that anabolic stimulant, because estrogen will slowly decline over time and progesterone, then that makes sense why they’re going to lose the ability to build muscle. So yes, at that point, they would need a little bit higher protein content and then we focus on making sure they’re getting a lot of like the branched chain amino acids, specifically leucine, that helps turn muscle on. And I always talk about that in food forms. I never throw somebody out and go like, Hey, go get your leucine, Jimmy.

00:35:32.150 –> 00:36:06.810
It would be like, Here’s some food sources that we can work in. And then again, just telling them like the recommendations, like one point six grams per kilogram or one point eight, and then I’ll give that to them and we’ll have like a visual handout that tells them what those portionings would look like and to pace it. So, you know, your skeletal mask can only use so much at one time. You know, a football lineman may be able to tolerate 60 grams at a sitting, but, know, a soccer player may only be able to tolerate thirty five to forty grams. So how do we get that in throughout the day so that way it’s nice and balanced?

00:36:06.810 –> 00:36:08.730
Then that’s specifically for protein.

00:36:08.810 –> 00:36:21.945
<v Jimmy>And since you brought it up, the patient that comes in menopause age female, should I be like and they’re an endurance athlete, are they they are at a greater risk or are they at a greater risk for low energy availability?

00:36:22.025 –> 00:36:41.755
<v Rebecca>Yeah. I mean, one, they’re not going to have the energy expenditure of a menstrual cycle anymore. So that does decrease. But I look at it from a social standpoint, how much pressure is put on them. But from an injury standpoint, they’re even higher at risk because now we don’t have the estrogen and progesterone that helps stimulate anabolism.

00:36:41.755 –> 00:37:02.890
So our bone, our muscle, and a lot of times when progesterone declines, that’s the health of connective tissue and ligaments, which is why a lot of women get that pain that they talk about, the achiness. So risk for reds categorically is not higher, but injury risk is. And so you can see how the chicken or the egg conundrum.

00:37:02.890 –> 00:37:14.015
<v Jimmy>Yeah. And then do you feel like this makes your role, dietitian’s role, like even more important? Like if I’m seeing a patient like this, I should definitely be digging into nutrition and then probably referring out?

00:37:14.015 –> 00:37:44.775
<v Rebecca>Well, of course, I’m going to say that as I know. But I look at it is I want them to be able to do activities until they’re a 100 years of age. And we do start looking at quality of life. If they have a hip fracture and we’re talking about somebody who’s really active in their upper sixties or seventies, what’s going be the outcome of their life moving forward? If we can help prevent that, we know that that’s more years of life, that’s more connection with their community and also being able to do things they love.

00:37:44.775 –> 00:38:03.130
Because my mom had a stroke a little over a year and a half ago, was super active and just to watch how much that impacted her to not be able to go out for the walk or the run or ride her horse like she used to and so that’s near and dear to me that I want people to do that as long as they want to.

00:38:03.370 –> 00:38:28.950
<v Jimmy>Yeah. So while we’re on this topic of dietitians referring out to dietitians, how does somebody like me find a good dietitian to work with or to refer out to? I feel like this world, it’s a little confusing. We talked briefly about this, but like the difference between like, as I’m looking for somebody to refer, there’s dietitians, there’s nutritionists, what’s the difference? How do I know there are credentials I should look for when I’m looking for somebody to refer out?

00:38:28.950 –> 00:38:57.240
<v Rebecca>Great question. So all you have to do is say, dietitian or nutritionist and watch which one’s cringe, you’ll know it’s a dietitian. So unfortunately, we are not protected because that means anybody can say they’re a nutritionist, which is confusing to the public when they hear that and they think, well, if you do nutrition for a living, then you should be a nutritionist. And so that doesn’t mean they have any credentials, any background. Doesn’t mean that there aren’t some brilliant ones that are out there, but dietitian means you’ve gone through an internship and you passed your boards.

00:38:57.615 –> 00:39:25.850
Now we take it a step further, there’s the CSSD, which is a certified sports specialist dietitian, which means they’ve had so many hours of working with active individuals and athletes, and then you have to take your boards every five years. I’m gonna say take it even a step further if you feel like, well, the most part if they have an injury, you probably want to rule out REDS. And so I think it’s helpful to have a REDS informed provider. I’m gonna shameless plug that I have a certification course on that. There’s plenty of people out there that are very well informed with REDS too.

00:39:26.010 –> 00:39:55.960
But I think a question that PTs can ask is like, tell me a little bit about your process and how you treat your athletes or individuals that you work with. And if it sounds like they kind of have a very strict way they’re approaching it, they’re probably not going to be the best fit. If they tell you how they look and treat and collaborate, that’s the other biggest piece of it, then that somebody that may be a good potential referral source and you can always ask your colleagues like, hey, do you know this person? Yeah. Be really honest if I don’t, if I feel like they’re great or if I feel like maybe not the best fit.

00:39:56.275 –> 00:40:19.740
<v Jimmy>Yeah. Because it’s even in the PT world well, not even in the PT world, but in the PT world when somebody asks for like a recommendation, it’s really hard because there’s such different levels even within PTs of who you kind of trust, how they treat, what you want, like sometimes you’re worried about what they’re gonna do because you don’t know them. So with PTs, we’re also licensed per state. Are you guys similar? Is it like you can only see people in your area or how does that work?

00:40:19.820 –> 00:40:41.000
<v Rebecca>Yes and no. So unlike PTs, there are, I forget how many states, there are several states that don’t have licensure law, which means that people can stay in there. The other piece is a dietitian can always apply for like a telehealth licensure in that state too. So it all depends case by case and several of us are also going to be licensed in multiple states as well.

00:40:41.080 –> 00:40:44.680
<v Jimmy>Okay. And then you personally, do you see patients all over?

00:40:44.760 –> 00:40:45.320
<v Rebecca>Mhmm.

00:40:45.320 –> 00:41:03.545
<v Jimmy>So as we kinda start to wrap up a little bit, one thing I’m curious about this is like language and how we talk to people. And it sounds like you yeah. You’re you’re very sensitive with when you’re approaching these subjects with patients. But one simple thing I noticed is like talking about you talk about fueling versus eating. Is this intentional?

00:41:03.545 –> 00:41:05.385
Like, can you tell me a little bit about that?

00:41:05.625 –> 00:41:33.735
<v Rebecca>A little bit because fueling to me feels like powerful, right? And you’re you’re fueling for the work that you’re doing, whether it’s your training, your PT, or even your job, right? Like, if I came in here under fueled, I’m gonna miss a lag and a question you’re asking me and be yawning and it’s not gonna be as good of a of an interview. So but we’ll talk about the process of eating. So I almost view eating more as the act of consuming the food and fuel is what you are consuming.

00:41:33.735 –> 00:41:54.210
<v Jimmy>Oh, I got it. Yeah. So as we wrap up, I think this was a great talk. We covered a lot from using fuel as food or fueling for injury, talked a bit about reds, low energy availability, protein, carbs, all the good stuff. Is there any is there one takeaway for if you want a listener, one thing to hold on to, what would you say here?

00:41:54.535 –> 00:42:27.345
<v Rebecca>Why wait? So I had somebody yesterday, I’ve been working with her, she had a horrible fracture that developed in a half marathon, but she was actually a cyclist and she’s in her sixties. And she really bought into this, came to see me yesterday and was commenting about how her first five ks back and she PRs. And she goes, I cannot believe the watts I’m putting out on the bike, how I’m feeling in recovering on my running and my biking. And then she paused and she goes, I wonder what this would have been like had I done this a long time ago.

00:42:28.065 –> 00:42:28.465
<v Jimmy>Yeah.

00:42:28.465 –> 00:42:46.490
<v Rebecca>Right? I mean, she’s still got forty plus years she can do that but I always challenge people, that’s what I waited till I was in college to start exploring what I was doing with my nutrition and regret that I shouldn’t have done it earlier because I could see the the impact that it had and so it’s the downside of being fed. Like, don’t listen to outside messages.

00:42:46.490 –> 00:43:03.175
<v Jimmy>Yeah. Or yeah. Why do you feel that it is? Because I do think like I believe in this, but I’ve never spoken with a dietitian. It’s like, a lot of us feel like maybe it’s it’s something we do every day, and a lot of people maybe like are me like me, we feel like we can do it ourselves, but there’s such nuance to it.

00:43:03.460 –> 00:43:26.315
Yeah. I feel like I, like, I was talking to my wife yesterday in preparation for this talk, I was like, man, I need to consult with a nutritionist. I feel like I just like you we’re just, like, constantly winging it, and you try to look up research or try to figure out how to do it, and there’s such competing evidence and like, it’s so confusing. Yeah. So I guess the only answer is to consult somebody like you and get a real plan.

00:43:26.315 –> 00:43:50.275
<v Rebecca>Well, I think thank God for interviews like this because I think a lot of people still don’t understand what a dietitian does. You know, I’ve got a loved one that’s getting ready to go through cancer and I told my husband, was like, that’s not my specialty but we’re gonna find somebody for your dad that can that can help us and I’m gonna sit down. So just like with PTs, there’s other specialty areas And I think you’re exactly right. It’s the nuance piece of it. I always say, I don’t treat diagnosis, I treat people.

00:43:50.435 –> 00:44:06.600
So it might be a parent that’s having to juggle two hours of sleep that they skew their hunger and fullness cues and they’re like, I don’t have the time to make home cooked meals, what can I do? That’s not stuff you can Google, but that’s what people have a tendency to go to try to Google.

00:44:06.680 –> 00:44:20.855
<v Jimmy>Yeah, or and they just jump on the bandwagons a lot like intermittent fasting, all that. We didn’t talk about that, but I’m sure you have an opinion there based on what you said in the day window of eating like every three hour yeah. Talk about that real quick while as we’re Yeah.

00:44:20.855 –> 00:44:35.190
<v Rebecca>So the within day energy balance. So trying to avoid going over three to four hours without feeling because more than likely that means you’re going to tap into your energy savings accounts which is through cortisol and inflammatory agents. So we want to try to prevent that.

00:44:35.190 –> 00:44:49.855
<v Jimmy>Yeah. So this is interesting because like I remember back in college twenty years ago, this was a thing like a lot of people recommended, but then now, in the past whatever five, ten years, it’s swung to this intermittent fasting and hey, don’t eat until after lunchtime and things like that.

00:44:50.015 –> 00:45:26.900
<v Rebecca>Well, and I think part of it, I I got on my soapbox on LinkedIn the other day and after listening to a podcast where they were talking about performance and then all of a sudden the conversation shifted and they were talking about weight management and obesity and other things and I’m like, those are two different populations. But if somebody doesn’t know better, because I’m always in reading research, they’re gonna think that that still pertains to them. And I think that’s a big factor why people get so confused when they hear diets and trends that they don’t even think about the outcome because intermittent fasting started with type two diabetes.

00:45:26.900 –> 00:45:33.220
<v Jimmy>Yep. And then keto was similar. It was like a very unique population, wasn’t it? Maybe like epilepsy. Yeah.

00:45:33.220 –> 00:45:47.075
And that’s yeah. It’s funny. We, like, take it completely out of context. I think the protein thing is one where, at least where I first heard it, if I look back, it was around sarcopenia and aging. And that was why there was this big push for such high protein.

00:45:47.450 –> 00:45:55.130
And then all of a sudden, you have the endurance athlete, the ultra runner, think like, they heard it, but out of context, and now it’s the thing that they’re doing.

00:45:55.130 –> 00:46:10.995
<v Rebecca>Which okay. I know we’re trying to wrap up, but see, you get me started on the stuff like this. That’s because the original RDA had it set. So you just talked about one gram per pound, which if we do things in kilograms is two to 2.2 grams per kilogram. The RDA is set at point eight.

00:46:10.995 –> 00:46:26.970
So they were just trying to get the elderly population with sarcopenia to get above that point eight because a lot of more below it. Yeah. So you see how the extreme. Then we get people that almost well, they more than double that thinking that that they need to increase their protein.

00:46:27.130 –> 00:46:49.900
<v Jimmy>I was just talking with my sister who is she exercises regularly but she was saying like, oh, I just heard because she’s trying to gain some muscle mass, she’s like, I should be eating one one gram per pound body weight of my ideal weight. So the goal should that I’m shooting for body weight. So I don’t know how much protein she’s eating, but she is eating over one gram per pound body weight.

00:46:49.900 –> 00:47:07.085
<v Rebecca>And I think what also happens is they’re getting it from a lot of protein fortified foods, which has its place, but that means that we’re losing some of those other nutrients that come in whole food sources, as well as what additives are going to be in those supplements as well.

00:47:07.085 –> 00:47:16.030
<v Jimmy>Yeah, last thing to just mention, you mentioned the certification course, is this who’s that designed for? And yeah, tell me a little bit.

00:47:16.030 –> 00:47:38.845
<v Rebecca>So it’s designed for providers. It was the first of its kind met through the Academy guidelines. So it’s ten hours, 10 CEUs, but it’s meant to take providers from awareness around screening and assessment to treatment to prevention and we do a lot of case studies in there. And it doesn’t have to be a provider. Actually, I have a mom right now that wants to do advocacy and so she’s actually been taking the course as well.

00:47:38.845 –> 00:47:46.210
But on my website, I have what I call the hall of fame, so the directory. So if anybody’s ever looking for clinicians, that’s a good place to start.

00:47:46.210 –> 00:47:48.530
<v Jimmy>Great and PTs are included in that, so like

00:47:48.530 –> 00:47:49.730
<v Rebecca>PTs is great

00:47:50.130 –> 00:48:05.375
<v Jimmy>and then you also another great resource you have is the book Finding Your Sweet Spot, which I think you can just get on Amazon or maybe your website as well. Great book. I just lent my copy to a patient, so she’s got that and is reading it. Hopefully, I get it back. But yeah.

00:48:05.375 –> 00:48:09.695
So and then social media, you’re active on Instagram and LinkedIn, it sounds like.

00:48:09.870 –> 00:48:11.310
<v Rebecca>I don’t do TikTok.

00:48:11.630 –> 00:48:17.550
<v Jimmy>Don’t do TikTok. That’s alright. Alright, Rebecca. Well, this is great. I appreciate your time, and thank you so much for coming on.

00:48:17.550 –> 00:48:18.670
<v Rebecca>Thanks for having me.

00:48:23.550 –> 00:48:28.945
<v Jimmy>That’s it for today on the Physio Insights podcast presented by Runeasi. Would you like

00:48:28.945 –> 00:48:31.905
<v Jimmy>to share an interesting case, insight, or have a

00:48:31.905 –> 00:48:36.785
<v Jimmy>thought about the podcast? Comment below and don’t forget to follow us for more episodes.