Triathlon training can positively affect health and fitness. But men should be aware of warning signs and symptoms that can occur when your energy expenditure exceeds your nutritional intake. Expert nutritionist Dr. Krista Austin outlines how REDs (Relative Energy Deficiency in sport) and LowT (low testosterone levels) can impact reproductive, psychological, and bone health. Ironman Champion and Director of Endurance Sports at the UCAN Company, Matt Bach, also shares his personal experiences with low energy availability and overtraining. Dr. Austin provides recommendations for assessing your health and what to do if you recognize some of these symptoms in your own training.
TriDot Podcast .046: The Impact of Triathlon Training on Men’s Health This is the TriDot podcast. TriDot uses your training data and genetic profile, combined with predictive analytics and artificial intelligence to optimize your training, giving you better results in less time with fewer injuries. Our podcast is here to educate, inspire, and entertain. We’ll talk all things triathlon with expert coaches and special guests. Join the conversation and let’s improve together. Andrew: Welcome to The TriDot Podcast, everybody! On the last episode we hosted a quality conversation for the ladies about female athlete considerations for training and nutrition. Today it's the men’s turn to learn all the nuances of nutritional & hormonal health for us to consider. Our key guide for this talk is our resident nutritional expert Dr. Krista Austin. Krista is an exercise physiologist and nutritionist who consulted with the U.S. Olympic Committee and the English Institute of Sport. She has a PhD in exercise physiology & sports nutrition, a master's degree in exercise physiology, and is a Certified Strength & Conditioning Specialist. Krista, thanks so much for coming on back to back weeks now! Dr. Krista Austin: Thanks for having me, Andrew. I’m excited about this one because we’re actually going to talk about the guys this time, which I think is much needed. Andrew: Also joining us is...now, this is a new name for our podcast, but certainly not for folks connected to the endurance sports industry, is triathlete Matt Bach. Matt is the Director of Endurance Athletics for UCAN. He is an accomplished athlete with an Ironman Maryland victory and 72nd overall finish in Kona on his resume. Matt earned his MBA from Temple University and worked on Wall Street as a trader for 9 years before making the move to working for UCAN full time. And, Matt, we are so happy you’re there, The TriDot team and the UCAN team have a great relationship. Matt, it’s your first time on the podcast, how ya feeling? Matt: Great! I’m excited to finally be out here. It’s been fun interacting with all of you and the team over at TriDot and with Krista over the years, too. So it’s really an honor to be on here. Andrew: It’s going to be great today. And who am I? I am your host, Andrew the average triathlete. Voice of the people and captain of the middle of the pack.Today we’ll get going with our warm up question before moving onto our Main Set conversation about the specific health and nutrition needs of men. Then we’ll cool down with some UCAN insider information from Matt Bach. It’s going to be a great show. Let’s get to it. Time to warm up! Let’s get moving. Andrew: One of my first ever triathlons was a local sprint in October of 2014 called the Monster Tri. Being called the Monster Tri, and occurring in late October, naturally costumes were encouraged and I fondly remember being passed at one point by a guy in a full on plush penguin costume. At the time that this podcast first airs October is just around the corner, which made me think of all the 5ks, marathons, and local tris that will inevitably encourage athletes to costume up! So Krista, Matt, for today's Warm Up question, what costume would you choose to rock if racing a Halloween-themed race? Matt, it’s your first time on so I will start with you. Matt: I think I would draw from one that I’ve actually raced in already, which is Peach from Mario. Andrew: Really? So not peach the fruit. Peach, the Mario princess. Matt: Yeah, so I once did a race...it was actually in the winter so it wasn’t even a Halloween race, but for whatever reason (I don’t even remember the reason) people were dressing up so I decided...well, my wife and I decided to do this race. We had a Mario costume and we had a Peach costume and we’re like let’s suit up. And then we’re like wait a minute, why should I be Mario and you be Peach? Let’s switch it. Let’s be a little wacky. So she dressed up as Mario and I dressed up as Peach in a full-on dress. I think it was a couple or two miles or something. Andrew: What kind of looks did you get from fellow racers on the course as Peach? Matt: Oh, a lot of looks. I even had a wand. I held a wand up, so I looked quite fabulous. Andrew: Do you have a picture of this? Matt: I do...I might have to send it to you so we can include it. Andrew: Please do. I will have coach Elizabeth James, who helps with our social media accounts. I will send this to Elizabeth and she will gladly post that of Matt Bach in the Princess Peach outfit on the channels. I’m super glad I decided to ask this question while you were up because that’s a doozy of an answer right there, my friend. Matt: You can’t take yourself too seriously, right? Andrew: Exactly. So, Dr. Austin, what would you choose to dress up as? Would you choose Princess Peach? Dr. Krista Austin: No, I wouldn’t choose Princess Peach. Um...I forgot about Princess Peach, actually. So it’s a good thing Matt reminded us. I would actually probably dress up like Wonder Woman. Andrew: Nice. Dr. Krista Austin: She was a big hero for me when I was growing up. It’s either that or Strawberry Shortcake. So, one or the other. Andrew: One of my first thoughts in thinking about this question was I thought it would be so funny, especially for the triathletes out there who follow pro tour cycling, which, Dr. Austin, I know you do. I thought it would be funny to go as Chris Froome, but particularly thinking back to the occasion where he...One of the tour de France stages a few years ago where he was in a wreck, right at the end of the stage, his bike was not rideable and the finish line was right there. There wasn’t a support vehicle in sight. So he ran, famously, the last couple hundred feet to the finish line of a Tour de France stage. So there’s famous images of Chris Froome in the yellow jersey running down the road in his cycling cleats and I was like well that would be really funny because you could dress up as Chris Froome for all 3 stages of the triathlon then run the run course in your bike shoes like Chris Froome. But we’re going to put this out on social media alongside the picture of Matt Bach dressed as Princess Peach and we’re going to ask you, our listeners, what would you do? Maybe like Matt, this is something you’ve already done and you can chime in with a picture of yourself on the race course in costume. Or maybe it’s something you’re just now thinking of because I brought it up today. We want to know from you--what do you want to rock as a costume for a Halloween-themed race? On to the main set. Going in 3…2…1… Andrew: Our main set today is brought to you by our good friends at UCAN. 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The human body is a complex biological machine.With a variety of inner working systems that can be affected by our food intake and training output. We want to balance both of these to fuel healthy training that makes us stronger athletes. Fueling improperly, or training in unhealthy amounts, can have huge biological consequences. And so today we are here to talk through all the considerations male athletes need to take in order to stay healthy. Matt, Krista, as we dive into this conversation I wanted to just, with Matt’s first time on the podcast, give everyone a quick introduction to who he is. Because, Matt, I feel like you and I are kind of kindred spirits in a way. I was working in live television training for triathlon on the side. I became a big believer in TriDot and now somehow I’m on staff talking about triathlon full time for a living. You were working on Wall Street training for triathlons on the side. You became a big believer in UCAN nutrition products and then you made the jump to full-time UCAN staff, talking about triathlon full time. So tell us about your journey as a triathlete and how it led from Wall Street to UCAN. Matt: That’s a really interesting parallel. I didn’t even know the full story on you. But, fantastic. So my story...I started out as a runner. In 2010 I did my first triathlon. I noticed that as I went longer in triathlon I got better relative to the competition, so I went up from the sprint to the olympic distance to the half Ironman distance in 2011 to the full Ironman distance in 2012. I did Placid my first time and then I did Placid and Louisville and Kona in 2013. And in all four of those first Ironman events I had nutritional problems. While I was doing those Ironman events I was working on Wall Street, so triathlon was very much a hobby. Then those nutritional problems I had in those first four events...what I mean by that I had GI distress and bloating and stomachaches and porta-a-potty stops I didn’t want to be making, all sorts of bad things. And because I have all those issues and the sugar overload, I stopped taking in fuel and then, of course, low and behold, 45 minutes later I’m bonking and on the side of the road joining the “Ironman Death March.” And so it was very frustrating because I was going into these races really fit and ready to crush it, but I was being held back by nutrition. So it was in 2014 that I finally said alright, I put my foot down. I’m done with this. I need to figure out a better way to figure this out and get nutrition stuff nailed down. So I reached out to a sports nutritionist and started working on cleaning out my daily diet, but also implementing UCAN into my approach, which I had never heard of at the time. But my sports nutritionist recommended that I try it. So I went out and bought some. I trusted her. I started using it and noticed I had this long-lasting energy that the company was talking about. I noticed on my longer workouts I didn’t have GI distress. I noticed I was looking forward to my next bottle of UCAN whether than dreading my fifth bottle of sugary sports drink or my seventh gel or whatever it might be. So that was all good and good signs that this might be a successful thing. Then at Ironman Maryland about 3.5 months later in 2014, it was my first Ironman where I had no GI distress and no bonking issues and my first time using UCAN. I was able to actually run really strong off the bike. Better, much much closer to my potential. I ran 20 minute PR, 3 flat off the bike. Went 8 hours and 51 minutes, which was a 51 minute PR for me, and I ended up winning the race, as you mentioned winning Ironman Maryland. Andrew: Not winning age group, you won out of everybody. An overall win. Matt: Yeah, an overall win. That was the first Ironman race that had no pro field. But it was an overall win against the field with a huge PR, with no GI distress, and that, for me, was this big big epiphany moment where I was like why doesn’t everybody know about UCAN if it can do this for me? Why isn’t everybody already using it? Especially because there’s so many people out there suffering with GI distress and low energy and the bonking issues on the course. It was kind of mind-blowing for me that they’re not at least giving it a shot. So, yeah, that’s how I kind of came to UCAN and then after that the company brought me out as a sponsored athlete for three years, which was fantastic. I was just overjoyed to be able to spread the word about the company and about the products because I believed so much in them and still do. Then last January is when they brought me on full time to lead the charge and spread awareness and education of UCAN in the triathlon world. Since then they’ve expanded my role to encompass endurance, encompass running, and cycling, and all that, as well. So I’m the director of the endurance business now. That’s my journey. Andrew: Well, we are all for it. It’s no secret that myself and Elizabeth and Jeff Raines and many of us on the team and on the podcast love UCAN and use UCAN. So we’re excited to have you with us today. So, Matt, Krista, we’re here today to talk about men’s health. It’s really become a greater focus over just the last 10 years. Thinking back to last week’s conversation, this started really over 30 years ago when there was an equivocal focus on women’s health was really when men’s health started to get studied. Why is that and what finally made it okay to talk about some of the things we’re going to discuss today? Dr. Krista Austin: You know, it was one of those things where, I guess, just in the field of health and looking at what we believe people should be capable of that men were kind of put on this pedestal. I’m not trying to be sexist in any of this, but they were put up there and said they should look a certain way, they should be this lean mean machine. It was how we perceived men. We wanted to portray a certain image about men that I think at the time was okay. For some reason a huge gender bias was put out there and they said we’re just not going to study it. We really don’t have an interest in it. But then over the last 10 years, as we’ve delved into this whole concept of what is known as REDS (Relative Energy Deficiency Syndrome) what researchers started to find was that this isn’t just something that women experience. In fact, this is something that males experience, too. But how do we know if they have it? Oftentimes, for many men, one of the reasons we have not looked at it closely is because when you start to look at the clinical signs, it means we’re going to talk about topics that men usually don’t like to bring up. And they go, why do you want to ask me some of these questions? What does this have to do with my endurance performance? My triathlon performance? It’s like...well, it has something to do with it because it’s about how well you fuel your body and how hard you’re training. So I would say it’s the last 5 years and even the last couple years, really, that we have this much greater understanding because the research has now been done in men to show that they, too, can suffer from low energy availability. They’re now included in our statements with regards to REDS. Andrew: So last week on our women’s health episode we talked a lot about REDS. Since it’s at the core of both of these conversations for both women’s and men’s health, catch our guys up to speed. What is REDS and what does it entail? Dr. Krista Austin: REDS stands for Relative Energy Deficiency Syndrome. In females, we characterize that by a caloric intake of less than 45 calories per kilogram of fat free mass, muscle mass. I just want to admit to the guys that we are using the female reference range still to understand your level of REDS. So it just kind of gives you an idea of how far we still need to go in this area. Relative Energy Deficiency also considers not just energy intake, but how much your carbohydrates are actually available to your body. So if you have low carbohydrate availability you can have REDS. It also includes low bone density, a reduced resting metabolic rate, low testosterone, and even disordered eating, which oftentimes most people would say guys don’t have that, right? What we have learned is that we also have to acknowledge that in men that even they can have a very unhealthy psychological perspective of their body weight and composition. Even given the fact that they are males, they may be carrying an excessive training load that is contributing to them having REDS. Andrew: It’s so interesting to me that this didn’t really get studied or looked at until scientists started looking at women endurance athletes because they felt women’s endurance athletes might be prone to some health issues due to the training, but they’ve just assumed that male endurance athletes were fine and could handle the training. So we’re just now starting to look at this. So when did the concept of REDS and low testosterone in male athletes first get brought to the forefront? Dr. Krista Austin: It first got brought to the forefront, I would say, 35 years ago by the best researcher in this area, Dr. [Anthony] Hackney. In a recent Tweet, he actually talked about the fact that he and Dr. Sue MacConnie. talked about low T in male athletes over 35 years ago. They talked about the potential causes of it, including energy intake versus energy expenditure. When they gave the information to the audience he said it was just crickets. And by “crickets” what he means is that there just wasn’t any interest. It was total silence. They covered it really well. They know they covered it as well as they did the females. And it was just that no one really wanted to have any interest in it. So it went to the wayside. He continued with his research. He continued to document both males and females and gave us a lot of the insight that we have today. But it just wasn’t brought to the forefront. I know, for me, back in the day when I started with United States Olympic Committee as an intern, our focus in the late nineties was really on the over-training syndrome. We would measure both cortisol and testosterone in males and we didn’t ever really think about this whole concept of REDS. Over-training can be a part of it, we just said these guys must just be capable of working so hard that they’re over-training. We didn’t think about what we thought of in women. I will say this--when I was getting my PhD the entire focus that I had was completely on females. We weren’t really thinking about the males like we should. Even though I would be involved with sports where we were working both with the women and the men. The women would show up and we had issues with their menstrual cycles. That would also be readily highlighted. Whereas, conversely, in the males I would have the coach come to me and the guys would be getting out of the van from wherever they went to train and practice, maybe it was cross-country practice. He’d say, “Krista, do you smell that?” I would smell what he was smelling...in fact, it was ammonia. He’d say, “What is that?” Andrew: Oh, so it wasn’t just sweat and body odor. Dr. Krista Austin: No! I said well, if it’s ammonia, I believe that’s what I’m smelling then the guys are breaking down muscle mass. I said, “We probably need to check and see if your guys are eating well.” Have you ever had a group of college guys...their idea of prepping for training was to have a couple Pop-Tarts. They’d go do the run they were supposed to do and then they were across the street as soon as they showered going to the burrito shop, the pizza shop, and they would eat. They’d have the big old burrito from a place like Mo’s and they’d get some chips and queso or they’d go over to the pizza shop and have these two gigantic slices of pizza. While that’s good, they love to eat, they weren’t necessarily meeting their energy demands. They weren’t meeting their carbohydrate demands. I remember that even for myself when I was trying to get my PhD and had such a huge focus on women’s health as part of it, we just really didn’t pay attention to the signs we were getting from the males at that point in time. It would really be about eight years after I started in the field that I would have my first male athlete with reduced bone density in his pelvis. I would sit back and say, “What caused this?” You begin to realize that even the male athletes, especially male endurance athletes, could have REDS. Back then we actually just used to refer to everything as the female athlete triad, which consisted of low bone density. So, all of a sudden, you have a male in front of you that also had it. It just wasn’t something we focused on. They’re guys. They love to eat. They must be fine. Andrew: Yeah...so Matt you have firsthand experience with much of what Dr. Austin just went over. From REDS to low T, over-training, under-fueling. So walk us through your story and how your career has been affected. Matt: Yeah, sure. First I want to say that’s some really interesting color that Krista just shared on how this all came about. Why for so many decades people aren’t aware of this. Even today, so many people aren’t aware of it. I wasn’t, like I’ll describe in a moment with my own story, I wasn’t aware what was going on for many years, probably. Definitely for several months I couldn’t figure it out. It’s not something that’s really spoken about. Something else there, too, is a lot of guys just write off some of the symptoms of REDS because they’re just training hard and they’re like I’m just training hard, that’s what happens. But with women, if they lose their menstrual cycle or period, they know it’s very obvious something is up, something is wrong. For men, we don’t have that so it’s not as obvious. It’s not as apparent. So many of the symptoms that you might experience could be related to over-training. So my own story I definitely have some personal experience here, just looking retroactively. Looking way back I feel like in high school I was probably unknowingly under-fueling while on the cross country and track teams. I know for lunch I would eat very little because I knew that if I ate a bigger meal at lunch that I would have it sitting heavy in my stomach three or four hours later at practice. So I would often eat very light lunches, then I would come home and eat a whole bunch. So what Krista was just mentioning after practice eating a whole bunch of burritos I could totally relate to that. But I was still likely under-fueling at that time. I had no idea I was under-fueling. The only hint that I had was one friend did mention to me, “You need to make sure you eat a proper lunch. Otherwise you might not get better as fast as you want to get. You need food to fuel you as you improve and you need that to recover.” I kind of just fluffed it off at the time. Looking back, he was right. He had a good point. So then in 2011, many many years later from high school throughout...that was the first thing. Then years, years later in 2011 I began training at a high level of triathlon. From 2012 continued through 2015-2016...In 2012 to 2014 I think I experienced some symptoms of REDS, but I didn’t know it. I had no clue. I think I had some fatigue and a low libido and, like I said, I wrote it off to the hard training and only realized that in hindsight. But when I really started experiencing it was in March 2015. I had some unexplainably real fatigue and low libido in March of 2015. It’s what precipitated me to start looking into it further and figuring out what is actually going on here. It just...at the time I was 29 years and old and there’s no way I should be having these libido issues and this fatigue… Andrew: You could tell there was a problem at that point. Matt: I’d be coming home from the training or on the train from New York City because I was working on Wall Street and I would be getting off the train and feel so, so sluggish, but I would have a hill workout to do that evening. I could barely get myself to stand up and get off the train in time before the doors closed back up again. I was so fatigued. It was really, really weird. For awhile I just wrote it off, but I finally couldn’t do that anymore. I had to figure out what was up. In March of 2015, it was right around the time I was making a dedicated push to become even leaner. I was already maybe 148 pounds, just right around 6 feet tall. So already quite lean, but I was trying to make this extra push to become just even a couple pounds lighter as I was prepping for Kona in 2015, so I think that is what precipitated me to have these symptoms rise to the surface in a bigger way. So then it was in the next few months from March through August I was researching and trying to figure out what was going on. I tripped upon Cody Beals’s blog. He’s a pro triathlete you may be aware of. Andrew: Yeah, absolutely. Matt: He’s a very transparent guy like me. He’s experienced issues like this. He wrote about it in one of his blogs. I said wow, this felt very similar to what was going on with me. Andrew: That was the first time you’d read anything like that, right? Matt: Yeah, up to that point I didn’t know what was going on. I just didn’t know. So when I read his blog it was really eye-opening and it sounded so much like what was going on with me that I had to figure...get to the bottom of it. So I went and saw my doctor. I had bloodwork done for the first time in August of 2015. This is when I had my testosterone levels tested for the very first time. I had to ask the doctor to have the testosterone levels checked and he wouldn’t really agree right away. I had to continue to urge him that this should be done because I think there’s something going on here between endurance training and...He had no idea that there was a link between endurance training and under-fueling and low testosterone or hormone disturbances or REDS. He really didn’t know anything about it. That said, he was a primary care physician so he doesn’t really have a depth of knowledge in a lot of areas, so I was like okay...I just needed this bloodwork done just to check. He eventually agreed and said let’s do it. He tested it. I had 153 total testosterone. For reference, the normal is between 300 and 1,000 and the average for a male at 29 years old is 650ish, give or take. So I was pretty severely low. Typically symptoms start to appear for people at something like 300 or under. It’s different for everybody, but, for me, that seems to be about right too. I was obviously experiencing those symptoms and obviously had low testosterone. My primary care physician didn’t even believe it so he had me retest I think 3 days later. He made sure that all the conditions were optimal for high testosterone levels and I came back I think it was almost identical, the number. So his eyes were opened to the fact that this could actually happen. Then I did Kona two months later in October of 2015. Still, I placed 72nd overall. My training was still great. I was still hitting the numbers. So performance wise I wasn’t having a massive detriment, but I felt pretty terrible. Andrew: It’s incredible that you had that kind of a result at Kona just knowing, considering what your low testosterone levels were. So once you were through the dance on the big island, what did you do to get your health right again? Matt: Yeah...my decision prior to Kona was, okay, I’m going to keep this in the back of my mind that this is going on. I’ll try to not over-train and try to make sure that I am eating enough. So I did pack on a couple extra pounds, but I wanted to remain very lean and very strong and very everything, well-trained going into Kona because it was only 2 months away. I had already been dealing with it for several months or even years so I might as well stick it out here, see how well I can do at Kona and then figure this out, really get to the bottom of it. So after Kona I stopped training completely for about a month. I reached out to an endocrinologist who...an endocrinologist specializes in hormones so I figured they would definitely know about the link between endurance training and under-fueling and low testosterone and be familiar with REDS. So she knew nothing about it! Again, I was completely shocked that she knew nothing about it. She just wanted...I think her clientele is typically guys in their fifties, sixties, and seventies who come to her looking for exogenous testosterone. It might be because of how they feel or it might be because… Andrew: She had never encountered an elite athlete at 30 years old? Matt: I don’t think so...I told her testosterone is banned by WADA and USADA. It’s a performance enhancing drug. I said I can’t do that. I need natural methods to restore my testosterone levels. I’m not going to take the exogenous testosterone because it’s banned. I said this is the constraint that I’m working in, can you help me with some natural methods? She really didn’t know of any natural methods so I left and didn’t call her back again. I moved on. So that’s when I linked up… Dr. Krista Austin: Just so you know, Matt, that’s actually really common. Even if you’re a female. So what you experienced is not unusual. Endocrinologists are used to an older population and they’re not used to a young man or a young woman walking in and saying I may have REDS or I can’t take or I don’t want to take exogenous sex steroids. Matt: Absolutely. That’s a good point. It is really pretty common and I think it must all come back to the fact that there’s a huge demand, market demand for older gentlemen who want help with their testosterone level, but it’s still pretty rare that you have a 29 year old walking in with low testosterone. I was still a little bit surprised that as an endocrinologist that maybe she wasn’t keeping up with the research or what was going on out there to not know it existed. Maybe she hadn’t really worked with people like me before, but I figured maybe she would at least know that it was possible. So that surprised me. That was eye-opening. Andrew: So, Matt, what did you...when you went to her and she couldn’t really help you, where did you go from there? Matt: Then I ended up getting linked up with Dr. Ruth Johnson in New York City. She helped me use natural methods to help me recover from low T. She knew of the condition, she knew about REDS. She knew about it on the female side of things and she had worked also with some males. Dr. Ruth Johnson is an internist so she works with...she’s very good with blood markers and with supplementation, natural supplementation to help live a healthier life. So she was encouraging me to sleep more, to train less, to eat more, to bring up my body fat percentage to higher levels and prescribed a number of different natural supplements that I could take that might help. The verdict is very much out on whether the supplements do anything or not, but I figured for the most part, it wasn’t going to hurt to take them. For instance, taking something like a relatively low dose of zinc, from what I understand, might help with testosterone levels. It completely might not. It hasn’t really been proven out in the science, but as long as you’re taking a relatively low dose of it, there’s not really any harm that could be done there. We were monitoring my blood markers to see if my zinc levels were going to go too high, in which case I think it could be detrimental, but my zinc levels never went up very high. The same thing with strength training, I picked up a lot more strength training and lifting heavier weights because it might help. Again, Krista would know this way better than I would, but these types of things they might help, but the science is still very much not solid that it does and hasn’t really been able to prove it. But I figured, hey, it couldn’t hurt, I might as well do some strength training. Then it was in 2016, early 2016, that I discovered I had a stress reaction, which is a precursor to a stress fracture in my femoral neck on my right leg. And that’s a big bone. It’s not supposed to have stress fractures or stress reactions very easily. But Dr. Sylvia Hesse who is an orthopedic doctor, put the pieces together. She knew about my story of low testosterone. She knew that I had this stress reaction in my femur. That’s why I went to her. She figured I might have low bone density. Again, she was another doctor that was actually aware of REDS and aware that this could exist in males. So she put the pieces together and she had me do a DEXA scan. It confirmed that I had low bone density and still do to some degree. I have osteopenia. At the time I had a Z score of negative 2.0, which is pretty low and that’s why the activity, the running I was doing was causing this stress reaction because my bone density was very low. I was actually on crutches for several months recovering from that. When I learned that I completely pulled the plug on my endurance training. I did strength work as I could, once I recovered from the stress reaction. It was really scary. One thing is fatigue and low libido. You can kind of deal with that for awhile and it’s not going to be too terrible, but when it comes to bone density, if I crush myself and impair my bone density now when I’m 29-30 years old, what are my bones going to look like when I’m fifty, sixty, seventy years old? Am I going to be crippled? Can I even walk around? So I was really, really concerned. That was the impetus for me to do nothing for awhile. Over the many months after that I was able to get my T levels to return to normal. I’m now smack in the middle of normal. It took me maybe...oh, jeez...maybe six months to a year before I was really able to return to normal, asymptomatic state and resume some endurance training without feeling like I was going to dive back down that rabbit hole. Andrew: Yeah, we’re thrilled to hear about your progress. I know and admire how much you’re able to take your story and use it to let other guys know that this can be an issue. I know, for me, again, giving Dr. Austin credit that I didn’t even know that we needed this episode. I didn’t know this was a problem. You see on tv from time to time commercials for low T centers and low T, take this pill…”Men! I’m former pro athlete so-and-so and here’s my low T”...I don’t know, I just always assumed it was something for older men. You know, older, unathletic men that were dealing with this problem and I had no idea that endurance sports and multi-sport could induce it or cause it in young men. So, Matt, thank you so much for sharing your story. Dr. Austin, for Matt, it was noticing high levels of fatigue and it was the eye-opening experience of reading pro-triathlete Cody Beals and his experience that made him realize that something wasn’t quite right. So what are some of the tough questions that an athlete just has to ask themselves in order to understand whether they may have REDS or some other impact on their health? Dr. Krista Austin: Yeah, so this is where guys typically get a little gun-shy, just to be honest with you. I think if Matt had known this he probably could have said very early on when it was occurring that something might be changing. He talked about one of those factors, which is libido. As young as he was and really until males are well into their fifties or what have you, the libido is pretty constant. It’s relatively high. The second thing that men need to pay attention to is their morning erections. Your frequency of those and what is normal, maybe what is not as normal for you is something that you should take note of. If men are married, I often tell their spouses, “One of the biggest things you can pay attention to is how frequently does he have an interest in sex with you?” And if you sit down and try to talk with guys about this topic it’s something that all of a sudden they blush, they turn red, they go why is she even going there? Dr. Austin, I’m not that way… Andrew: Don’t ask me that! Dr. Krista Austin: Yeah...you know, you also have to ask questions about when they do have sex are they having any issues? Oftentimes, for me, when young men come to me for a nutrition consult it’s because, these days at least, their coach has referred them because they don’t know. They said I don’t know how I should look at this in my male athletes. They’re not comfortable asking their male athletes whether or not they’re experiencing any signs or symptoms of low energy availability or over-training. So they turn around to me and they go, “I think they should do a nutrition consult with you.” Typically, for most males I’ll tell you it is after a stress fracture. That’s when the flag really does go up and most coaches will turn around and say, “Maybe we should do something about this.” Andrew: Yeah, that tracks with Matt’s story exactly. Matt, for you, that was a primary concern. It was a red flag when you said man, something could really happen with my bones. I don’t want to mess with that. Dr. Krista Austin: That’s what’s unfortunate. Even with all of our knowledge today and the fact that Dr. Hackney started documenting this over 35 years ago, it’s still not something that we have learned to readily pay attention to in the male athlete or even in a male that undergoes maybe high levels of stress, in which they need to be cognizant of how their bodies’ reproductive system is actually functioning. Andrew: So what are the primary concerns for the health of a male athlete that we should be aware of with low T and REDS? Dr. Krista Austin: You know, they’re very similar to the female. First and foremost, it is your impact on your reproductive health. We measure reproductive health based on the concentration usually of testosterone. Then if men are having issues helping their wives get pregnant or what have you, we take it a step further and look even moreso at their sperm count, motility, quality of the sperm. On a day-to-day basis, we just went over--how do you know that your reproductive health is good? That is your testosterone levels, libido, overall ability to have a healthy sexual life. Then, also, the morning erections in and of themselves gives men an indicator that, I would say, is equivalent to a woman having her menstrual cycle whether it’s regularly there. The second part is just the impact on psychological health. When we have over-training or low energy availability our body typically has lower blood glucose levels, it’s not as rested. And we have hormones like cortisol and prolactin that become very elevated. Actually, they’re in part of what inhibits the ability to actually produce that testosterone. So we’ve talked about a little bit of this on the women’s episode. When we elevate our stress hormones we then inhibit via prolactin the ability for a hormone known as luteinizing hormone to be pulsatile and to actually help us make testosterone. And so, oftentimes, because testosterone goes down and cortisol stays high, prolactin stays high, your sleep gets disrupted, your mood gets disrupted, and training starts to go downhill. When training starts to go downhill and you’re not performing, there’s an even greater impact on a lot of men’s psychological health because they’re not able to achieve the goals they want to achieve in sport or life or whatever it actually is. Andrew: And they probably struggle to understand why. Dr. Krista Austin: Oh, yeah, they’re sitting there going, “What’s wrong with me? Surely I don’t have anything wrong with me.” I’ve seen that for years and years now where they go, “I just didn’t know anything was wrong until things went really wrong.” Kind of like in Matt’s case, they’re impacting their bone health and they really don’t know it. Oftentimes, males as they grow up, they develop a pretty significant bone density. They’re usually very healthy so it’s hard to get their bones worn down enough to get the signal through a stress reaction or a stress fracture that says we are in fact doing harm. At the end of the day, the risks for men are equivocal to the risks for women with regards to reproductive health, bone health, and psychological health. Matt: One thing, if you don’t mind I’ll chime in here with a little more feedback...a little more on my story I didn’t share before. On the reproductive health side of things, my wife and I now have two wonderful healthy children, two and three years old. But when these issues were going on we were trying to have a family and it took us about two years to have our daughter because we had many, many months where nothing happened and we had two miscarriages early on. It was still brutal. We didn’t really know why. I ended up getting tested, she got tested. All of our tests came back normal, but my testosterone had been low throughout that whole period. It just so happened, maybe it’s coincidence, maybe it’s not...the month pretty much right around when my testosterone levels naturally turned to normal is the month that Lauren, my wife, was pregnant with Summer, our daughter. That was the one that “stuck.” I don’t know...maybe it was just coincidence because these tests told me everything was fine. So I don’t know...it’s...I’ll probably never know. But it very well could’ve been linked. Andrew: Yeah, that’s the one that finally stuck and Summer is still around today. Dr. Austin, as we learned last week in our conversation about women’s health, there’s a distinguishment between low energy availability and over-training. These are two things we needed to know about and look out for in ourselves. How does low energy availability occur and how is over-training different? Dr. Krista Austin: What we need to realize about low energy availability is that if we’re on this typical 12-hour eating pattern that most people are and we go to bed at night, when you wake up in the morning, technically you are in a state of low energy availability. So that’s usually why we like people to have breakfast in the morning. But, essentially, low energy availability is a lack of appropriate energy intake for the calories that you’re out burning between everyday life and training. Or it also can be defined by inadequate total carbohydrate intake. The reason that is so important is that people need to realize that just because the total calories are there doesn’t mean that you have the substrates necessary to help the body stay functioning. We’ve learned a lot about this area, actually, from studies of Ranger School. The U.S. Army has research that it’s done over the years to study the men that go to Ranger School. What they’ve showed us is that even with what we call adequate energy intake--so just enough to sustain life and give us the recommended daily allowance plus a little bit--is that when those men went through that rigorous school, they saw an elevation in their actual thyroid stimulating hormone. That is the marker that we use to say is the thyroid, which is the organ in your body responsible for producing the hormone that helps give you energy. Is it functioning normally? The other thing they documented was that those men had very, very low testosterone as they went through Ranger School. That has to do with the fact that because they didn’t give them enough energy, their body registered via the thyroid that they were in a state of energy depletion, which then told that thyroid organ to tell the pituitary it needed to increase a stress hormone known as prolactin. As I mentioned previously, prolactin actually is the hormone that will go in and inhibit luteinizing hormone and stop our sex organs from producing the sex steroids that we actually want and need them to. So that is where our real knowledge of low energy availability comes from is the studies in men going through Ranger School. They also documented how well they could replete them after Ranger School, which is several months versus the several years. You will hear of candidates going through that school and having bone related issues and things of that nature, where they don’t make it through that school because of how hard it is to be in low energy availability. Just so you know, just because you’re going through all this, it doesn’t mean that low energy availability is the only way it can occur. You also brought up something known as over-training. The difference between over-training and low energy availability is that in the over-training state, we’re just managing an excessive training load in relation to our recovery. In fact, our total energy intake usually matches our energy output. We’re fueling our body well, but the stress we’re placing on it, again, takes our hormonal system, elevates the stress hormones of cortisol and prolactin and can go in and inhibit the pulsatility of luteinizing hormone. Typically athletes will crash and burn a whole lot sooner underneath a method like this, at least from my experience. They’ll start to get the feedback that says, “I’m not hitting the performance sets in training that I thought I could. What is actually going on?” So we’ll call that usually over-reaching and not full-blown over-training. What’s important to actually understand is that both of these states, whether it’s low energy availability or over-training, may or may not be intentional. They may or may not be linked to an eating or body image disorder. In fact, for many athletes, and I think Matt highlighted this, it’s usually a lack of knowledge and education early on in the years that they spend training in which they end up not having enough calories or the right macronutrients in their diet to actually fuel their sport. So they end up with low energy availability and accidentally impacting their body. When people do excessive training, such as over-training, it can actually go in and inhibit appetite. So when they’re young kids, kind of like Matt described, you’ll go, have a really hard workout, sit down, mow down on this meal that you think is pretty significant and think you’ve done a good job, but in all reality, your appetite hasn’t been strong enough to tell your body, “I want to go in and, in fact, I need to go in and eat more.” So there are two different ways that we can end up harming our reproductive health, psychological health, and bone health and it’s not always intentional. Sometimes it is. Some athletes will intentionally restrict food intake because they do have an eating disorder or a body image disorder, but we need to be cognizant that for many athletes, at least the ones I’ve worked with over the years, they just haven’t been told early on enough this is what you need to do to maintain your health and your overall bodily function, to be honest. Andrew: It’s so fascinating to me that when we’re depleting ourselves of energy and when we’re not taking in enough energy that our bodies can almost betray us without our knowledge by not cueing us to eat enough. We can think that we’re doing a good job, we can think that we’re eating enough to satisfy ourselves when, in all actuality, our body is in depletion. That’s so fascinating. Matt, when you think back to those early days you mentioned training for cross-country and track and getting competitive in triathlon back in 2011, do you think that low energy availability or over-training were big factors for you? Matt: Yeah, for sure. I think both played a role for me. I know that during 2012 to 2014, I don’t think I had much of a low energy availability problem, I think it was probably more the over-training, especially in 2013. I was kind of...I’m pretty sure I was over-training to some degree. So I think my T levels were reduced to some degree, but I wasn’t really experiencing strong symptoms yet until the other piece of the equation, the low energy availability came into play in 2015. That was really...like I said, because of that push to be more lean and I was still eating a lot relative to your average person, I was eating maybe 3,000 to 3,500 calories a day, but because of the huge amount of volume and training and stuff I was doing I probably required something more like maybe 4,000 to 4,500 calories a day. So I was running at this chronic deficit that caused me to have the symptoms float to the top and start becoming prevalent. Once I figured out what was going on I was able to, fortunately, take all those different measures to try to get things back in line by eating more and packing on some extra weight and sleeping better and all that. Andrew: Matt, knowing what you know now and being on the other side of it and hindsight, what do you wish that you could’ve done differently early on in your athletic career? Matt: I mean...I wish I was aware, but I guess what I would’ve done differently back then is if I was aware, what I would’ve done differently is get bloodwork done. Absolutely get bloodwork done. I had various points throughout my life to test hormone levels like testosterone and a number of the other hormones that Krista mentioned. If you have a baseline when you’re experiencing no problems then at least you can always look back to that and say this is what my normal is. Now I’ve embarked upon this big change in my training. Let’s say I’m taking on an Ironman and I want to see how that impacts my blood markers. A lot of us get into this sport because we want to be healthier, but there’s such a thing as being fit and unhealthy. I was certainly that for a little while there, for sure. So if you can test your hormones and test all of your blood markers before you embark on something, it might be a big giant change, too. If somebody decides they want to go plant-based or go be fat-adapted or take some sort of big approach--do one of the Paleo or who knows what it is--one of these diets out there. Before you do any of that I would suggest getting bloodwork done so you can see what your baseline is so you can see whatever that big change you’re making is, what kind of impact it has on those blood markers and see if you’re falling into this case of REDS. Andrew: Dr. Austin, for athletes listening who hear all of this information and they want to check in on themselves and see what state their bodies are in, how do you recommend assessing our current health? Dr. Krista Austin: For the males, I will tell you my first challenge to them is to start tracking on their overall sexual health. We’ve talked about what that consists of earlier, but I think for so many men I think that’s a challenge so I’m going to put that out there and say be honest with yourself; monitor that. Secondly, whenever I work with someone we take a good look at bone density because I know it’s so possible for that to be impacted and to do a very honest assessment of energy intake and expenditure. I ask the athletes to do that because we need to know if we have any potential for harming your health because you’re not fueling your body right. The other thing I like for athletes to do is to always be monitoring your training load. Not just the mechanical load, but also the cardiovascular load. The cardiovascular load is very closely tied into the endocrine system or the hormone system, like Matt mentioned. If we can tie that into your biochemical profile, the hormonal profile that Matt talked so much about, that’s also really great because then we know we’re possibly training too hard or not eating enough to impact that profile. Then every once in a while, it’s not always easy to get, we do make sure we do a resting metabolic rate test. Do they have a normalized RMR or is it slightly suppressed? Because that can also be an indicator that they may have REDS and that we need to take an additional look at what they have going on. So I think it’s just challenging the males to really take a look at these things and not blowing it off. And making your physician aware that you are an athlete. That’s one of the biggest things that I often run into when I put a call into their doctors. I say, “We need your help.” I’ve sent the athlete in and they go, “Oh, I didn’t know they were an athlete. I didn’t know they were training this much.” Usually it’s a great learning experience for the physician, as well, but I challenge everyone to make your doctor aware that you are a very active individual and what does that mean for you. Andrew: So someone goes in to get their blood work done or to get any of these tests done that you both have mentioned. If our results come back and we just have some abnormal results, levels that are off, whether it’s in our bone density or biochemical profile or our RMR, is that an indication that we have REDS or over-training? Dr. Krista Austin: It can be an indication that we have it, but it doesn’t necessarily mean that. What we have to understand is that it is possible even if you’re young, to have an actual endocrine issue or have an actual hormonal issue. It may be genetic, it may be something that they were born with. So we need to acknowledge that while we’re going to go check all the boxes on the training and nutrition side, we need the medical providers when they do see the alterations in bone density or biochemical profile, to work with us to help sort through what is really going on. Do they actually need to see an endocrinologist to have any of those factors addressed? So we just have to be cognizant that people may have an endocrine issue even if they are young. The older they get, the more likely they may have that, as well. Andrew: So with all the different bodily systems that can be affected by low testosterone, at what point do males require actual testosterone supplementation? Dr. Krista Austin: Once you’ve had the opportunity to address the training and nutrition side, you have to say if the testosterone is still low, is it possible for the athlete to go pursue whether or not if they have low T because of the fact that they have actual hypogonadism. We have seen this out there in males. I don’t know how prominent it is on the elite side of sport, but I know on the more recreational side, the age group side, especially as males mature, they will end up with actual hypogonadism. At that point it does need to be treated in order to maintain their health if that’s what they wish to do. Especially if they’re having significant symptomatology. I think what’s important when we talk about this area is we say what is testosterone supplementation because they have low T versus the image that we have in our heads when we hear testosterone--oh, those are steroids. That athlete is on steroids. In all reality, that’s not what the supplementation with testosterone is at that point when they truly have low T. It’s something that a physician may do to help maintain the health of their patient. It’s always possible to approach USADA and put in a therapeutic use exemption when they truly do have that issue and work through that process, regardless of the level they want to compete at. I believe even elite athletes can do that. I just don’t think true hypogonadism is prevalent at that level. Just know that you may across a male athlete that truly does have hypogonadism and we need to be conscious and considerate of that and respect the fact that they do need to be treated from a medical perspective. Andrew: So before that is even necessary, Dr. Austin, what specifically would you recommend male athletes do to prevent any deterioration of health in the first place? Dr. Krista Austin: I think it’s to have an honest talk with yourself. Listening to a podcast like this, Matt gave a lot of great indicators. Educate yourself. Know what your training load is. Know what over-training means for you. Know what your caloric intake versus output needs to be. And make sure you are tracking all the factors that could put you at risk as an endurance athlete. Going and getting a DEXA done so you know your bone density. Getting a biochemical profile and talking to your physician so they know that you are an athlete and they will put that little note in the back of their heads when they’re working with you that if they see something, whether it’s excessively low heart-rate or significant drop in body weight that they will turn around and say, “I have concerns possibly about your health. Let’s talk a little bit further.” I think that’s one of the most preventative things you can do is have someone externally, like a medical physician, who maybe doesn’t live and breathe the sport to the extent you do. Or maybe they are an active athlete and they understand the sport that much better. If they can give you that external, objective perspective each year or two years, I think that’s one of the best things we can do to help ensure our health is maintained. Andrew: Matt, just to wrap up our main set today, what would you want athletes listening today to learn from hearing your experience and what are you doing differently in your endurance training now? Matt: One main thing is regarding volume. Don’t fall into the trap that how good you are at the sport is linearly related to the volume that you do. I fell into that trap early on. What I mean by that is say you’re training three hours a week and you are at a certain level. And then you train six hours a week and you get better. And then you train nine hours a week and you get even better. So you start thinking, “Maybe all I need to do is keep increasing the amount that I’m doing and I’m going to get better.” But you get diminishing returns on that. You get up to 12 hours a week or 15 hours a week. For everybody it’s different. For everybody’s lifestyle and the stresses that you have elsewhere, whether it be work or family or whatever it is. Everybody’s tipping point is different. For me, I found that once I got up to around 12-15 hours a week, given my life and my genetics and all that, that was becoming a little too much. I was sort of plateauing at that point. I wasn’t getting any better. Beyond that, I was getting even worse because I think I was over-training and causing some of these problems with REDS. So remember that you want to have...and that’s one of the reasons I like TriDot so much...the whole philosophy there is you have quality over quantity. You’re still putting in volume and training, but you need to have that high quality training. The polarization of your training so that you can get better without spending countless hours out there not getting better. Andrew: Matt, I was going to say the same thing. You beat me to plugging TriDot before I could even beat you to plugging TriDot, so thanks for that. Great set everyone! Let’s cool down. Andrew: Well, it’s our very first show with Matt Bach on as a guest. Hopefully, Matt, it certainly won’t be the last. Matt, I would just be remiss as a fan of UCAN and a fan of your team to walk away from our first episode with you and not hear a little bit more about what the crew at UCAN is up to these days. Following you guys on social media, there have just been some great educational and entertaining events that you guys have going down. So tell our athletes for just a second about some of the fun stuff you guys have been doing and where folks can go for more content from Generation UCAN. Matt: We’ve had a lot of exciting things going on. Back in June, global running day was in early June. We had Dave McGillivray the Boston Marathon race director on the heels of the Boston Marathon cancellation on one of our panels. We had a panel a few weeks ago with Ryan Hall on this very topic that we were talking about today along with a sports dietician and a researcher who specializes in exercise-induced low testosterone. We also had panels during national triathlon week in the last week of June with some of the biggest names in triathlon: Mark Allen, Tim O’Donnell, Siri Lindley, Karen Smyers. We had several discussions on improving diversity in the sport of triathlon. You can follow us on Facebook and Instagram. Follow UCAN @GenUCAN. You can join our mailing list at UCAN.co if you want to be in the loop on these different events we have ongoing all the time. Looking forward to coming on again soon. Thanks again. Andrew: That’s it today, folks. I want to thank Dr. Krista Austin and Matt Bach from UCAN for talking about the specific nutrition needs of male athletes. Shout out to UCAN for partnering with us on today’s episode. Just like Matt said, be sure to follow Generation UCAN on social media for more great endurance sports and nutrition content. Enjoying the podcast? Have any triathlon questions or topics you want to hear us talk about? Head to https://TriDot.com/podcasts and click on submit feedback to let us know what you’re thinking. We’ll do it all again soon. Until then, happy training. Thanks for joining us. Make sure to subscribe and share the TriDot podcast with your triathlon crew. For more great tri content and community, connect with us on Facebook, YouTube, and Instagram. Ready to optimize your training? Head to TriDot.com and start your free trial today! TriDot – the obvious and automatic choice for triathlon training.