Understanding and Preventing Relative Energy Deficiency Syndrome (REDS) with Dr. Melissa Novak

This paradox , as I view it , is the trust , interaction and communication gap that exists between fitness professionals and our medical community . This podcast is all about closing off that gap by disseminating the latest , most evidence-based and most engaging information in the health sciences . And to do that , in episode 124 , we're joined by Dr Melissa Novak .

Dr Novak is a sport medicine physician and one of her areas of specialty and one of her passions is something that's referred to as REDS . So this is Relative Energy Deficiency Syndrome and you may have heard of this before , described as the female athlete triad .

But REDS kind of broadens this topic and I think this is a really important conversation for us to be having , because a lot of the symptoms of REDS that we traditionally think of , you know , just influencing , you know , athletes that are training at ridiculously high volumes could even be happening to the clients that we're working with .

And , as Dr Novak mentions in the podcast . She considers us all athletes , people who are active , people who are moving , and so being aware of this and knowing what the symptoms are and then knowing how to handle it appropriately is really a professional obligation for anyone that's working with people who are training hard and potentially under fueling their body .

But lots of great information in this episode from Dr Novak . Any information we'd like to share with you can be found on the show notes page . That's by going to wellnessparadoxpodcom . Forward slash episode 124 . Please enjoy this conversation with Dr Melissa Novak Today . We're delighted to be joined by Dr Melissa Novak . Dr Novak , thank you so much for joining us .

But I actually heard Dr Novak speak about the topic we're going to talk about today last year at a Medical Fitness Association event on the West Coast and I found the topic very , very fascinating then and I think it's going to be a great conversation for our audience .

But before we jump in and start talking about REDS , why don't you just give our audience a little bit of an idea of your background and provide some context for the discussion ?

I am a sports medicine physician , which means I went to medical school , then I went and did a family medicine residency as my core training and then I went off and signed up for another year to do a sports medicine fellowship , and so I did my fellowship at the University of Utah , my residency at the University of Minnesota and my medical school training at

Midwestern University in Chicago . So yeah , so I am sports medicine . I currently practice in Portland , oregon , at Oregon Health Science and University . That's our major academic center in Oregon and I work as a team physician .

I work in the clinic , but then I also have a team physician gig that I do too for a division one university in Portland , portland state , and then I am our associate fellowship director , meaning I'm also in charge of the academia and the learning of our upcoming sports medicine physicians .

So I do that as well , in addition to my day job of seeing patients on a day-to-day basis . Let's see . What else can I tell about ?

And then probably the follow-on to that is what really got you interested in the topic that we're going to talk about today , reds .

You know , like I would sign up to to work at a triathlon or a marathon or something , or you know , or , or was that working ? Uh , in the training room with the athletes at um , in the high school , um and or . I had this interest in exercise and pregnancy . And so I was like , gosh , if you're pregnant , like what do you need to do for exercise ?

And this is , you know , 15 years ago , when we were still like , well , my gosh , do what you did before , do we know ? It's not true , you know ? And um , and then he was like , well , aren't you going to do a sports fellowship ? And I I kind of sat and I was like , well , but I just do those things for fun .

And he's like , well , wouldn't that be a good career , something that was fun ? And um , probably some of the best advice , uh , I've received from my academic advisors throughout the years ever . So , yeah , I took that leap and I jumped into sports medicine . I've always been athletic , if you will , but I needed to not be that as my career .

I wasn't going to make any money doing anything in athletics . I , um , I was a you know , I I did every sport imaginable , but I wasn't good at any of them if you will , yeah Um , but I had a really good time .

You know , looking back at my own journey of endurance athletics , that's where I found myself in most things . You know , I didn't know that was a starting thing back there , but I had my own journey with that and I continue . Today I've signed up for a triathlon . I can't say that it's going to be fast .

I now have three children , three C-sections in my past , so we will see what happens in July . So I had my own training journey and learned about my own mistakes .

While I was in the middle of learning about all of this , right , and during my fellowship , I worked with a mentor , um , elizabeth joy , and so if you get down and start reading some of the papers and some of the foundation um stuff that we know about , about this , she's on many of those papers and so she introduced this topic to me , um , during my

fellowship , um , and it it just continues to show up everywhere I go . It continues to show up . Everywhere I go , it continues to show up , and if you look for it , you will find it . If you don't look for it , it'll stay down there buried away .

More , I realized that there was a need for education and information about this topic , and so that's kind of like how I ended up into my journey into this .

We're going to talk about reds and I'll have you you know , again in a second , you know , restate what the acronym is , because I think we've known this is something somewhat different for so long in the female athlete triad , which doesn't really exactly encompass .

You know what this is and the fact that it can affect you know men , you know as well as women , and so I think you know men , you know as well as women , and so I think you know a number of our listeners have heard about the female athlete triad .

So that at least allows us to anchor it in like some sort of understanding of what we might be talking about . But let's let's again , you know , explain what the acronym means . And then how would you define REDS to help our audience understand it a little bit more ?

So , relatively , energy deficiency syndrome is almost as simple as saying is you don't get enough in um to put out what you're trying to put out right , your ins and your outs , your intake and your output have to match and if they don't , your battery's just gonna go dead . Right , you've got to charge your battery and that's kind of like .

I think that like kind of like huge bird's eye view of looking down on it .

You'll look at these or you'll work with these athletes and you know they'll be telling you that I'm working so hard , I'm working harder than I've ever , ever worked before , that I'm working so hard , I'm working harder than I've ever , ever worked before and I'm just not seeing , I'm not seeing any gains .

You know , or or they hear , they hear things from the media that they're supposed to look a certain way or act a certain way , or eat a certain type of food or not eat a certain type of food , right , and , and you don't fuel your body , it will shut down , it will deteriorate , right and um , and it can spiral and happen so fast and you don't even know

what , what happened . You might even have thought you were doing the right thing , right , you know somebody , you lost a couple pounds and your coach was like oh my gosh , this is the best race you've ever done . You got your PR and they'll go . This is America , right . So some is good , more is probably better .

And suddenly you find yourself in the depths of like you just lost a little bit more and suddenly your body is not restoring for what was going in and what was going out .

You know conscious even than athletes on some level in some cases . So you know from your experience in sport medicine and I know it sounds like you work with some very high level athletes in some of the work you do .

How do you see this show up and maybe like the adult athletes or kind of the adult exerciser that maybe is an enthusiast that goes too far , is that ? Are those things that you see ?

I do work with some high level folks . I have athletes who are professional , professional athletes . I take care of , like I said , the Division One NCAA athletes . I take care of the ballet in town .

I take care of all sorts of folks who , yeah , we would traditionally view as these are the athletes , but I would argue that we are all an athlete and I also take care of all the rest of us , right , you know , I never like shined above anything anywhere in my athletic ability , but I would call myself an athlete as well , too , right , and I would call the

person who is trying to get back in shape and learn what exercise is an athlete . I would call the person who works in a job that has a repetitive injury , um , I would call them an athlete too . The , the activities that they're doing um bring on health and activity , right , anybody who's trying to be active um can be an athlete , and so this does .

This does affect um , it does affect the general population as well too . I would , I would say , your traditional sense of um athletes under pressure , um , um , to perform in a certain way , might act , might be more at risk , right .

So they're , they're driven for performance pressures , um , for whatever reason , to to um to make their bodies look at a certain way , less so than maybe some of the average mainstream of us are . But then we all also , we all also have this internal pressure , right .

So there's external pressures that they're subject to , but we are all subject to the internal pressures .

And if that's feeling like you need to lose weight and suddenly you drop a bunch of weight and you try to increase your exercise and you find that your legs feel like you're walking through quicksand , and you find that your legs feel like you're walking through quicksand , this has affected you too , right ?

Your energy levels are not at the right place , and so it is important , I think , for everybody to know and also that's part of , like you know , the saving an athlete , but achieving your best , right , so you can achieve your best . If you're trying to force your body into a composition that it might .

It might not be appropriate for and you know , one of my my favorite um quotes um is from um . Someone named Lewis Green , who's an athletic trainer and author , talks a lot about body positive stuff is um . Athletes come in all shapes and sizes and everyone needs to know this right Like powerful , powerful stuff .

You know you can have somebody who is super tall and super muscular standing right next to somebody who is very lean not as much muscle on them and they both might be runners .

Are you going to hurt yourself in the way we used to think about , like just the athlete triad , where we had bone health issues or menstrual cycle issues and things like that ?

Or you're thinking about , gosh , if you're not getting enough energy in and enough energy out , because this affects all of our body systems , right , this affects all of our body systems , right ? And so , now that we've expanded this to talk more about , include relative energy deficiency syndrome and include more of the entire body when we think about this , right ?

So from the athlete's perspective , we're decreasing their training responses . We're decreasing your recovery time . So if you're not fueled properly and you're not going to recover as quickly as you would if you weren't fueled properly , it affects your cognition and performance skills . It can decrease motivation . It can decrease your muscle strength .

It can decrease your endurance performance and decrease power strength . It can decrease your endurance performance and decrease power , and that's . You know , that's sort of like , when you look at it , affecting the athlete and how they're thinking about it . Those of us in medicine think about it all .

The wheel gets bigger if you start looking at that right , and so you can impair your reproductive function . You can get impaired bone health and so people start getting stress , fractures and other bone injuries that can happen . The GI system gets all messed up .

It turns out like you don't get enough food in and your body's hormones start thinking I don't need food , I'm not . My hunger cues are all off . And so now you know people are talking about oh , I'm doing intuitive eating and eating when I feel like I'm hungry . If you've been starving yourself , your body's not cuing you correctly . That's like whoa huge .

Suddenly you're like I can't follow my own internal clock right . We'll see mental health issues happen , so we'll see depression . That ends up happening and it was talked about for a while about does depression lead to body image concerns and things like that .

But we're now actually seeing you also can get depression and anxiety and those things that are triggered from the actual act of not getting enough caloric restoration .

It's all great news , but if you're not fueling yourself properly , it's really hard , really hard to stop and rest and get that good , proper sleep . And I don't know , have you ever been overtrained or under fueled ? Do you know if you've ever experienced something like this before ?

If we're not properly fueled , kind of amazing and crazy all at the same time , right , um , we can have , like , like for the our younger folks , impaired growth , um and development can start happening , like I'll see kiddos that start falling off their growth curve . That's why they'll get referred to me .

Um , if kind of all the other like things have been ruled out and we see our immunity function decrease , right , so , like we know that exercise is good for us , like I mean , here we are today talking a little bit about some of the bad things about exercise , but let's not forget that exercise is amazing and it is really good for us .

And , on the like , day-to-day process , like it's going to keep you from getting the common cold and it's going to keep you your immune system strong and fighting . But if you are over-trained and under-fueled , your body can't keep up and that immunity then then does decrease . And so then we do see repeated , we receive repeated infections and things like that .

We also see repeated um , musculoskeletal injury other than just um , other than just , uh , like the bone health injuries that we'll see .

We'll see more overuse injuries and things like that that'll start showing up and , um , you know , and you know , people will be like gosh , I just like , I just can't get out of this rut , like I'm either sick or I'm hurt and I don't understand . That's you .

You might want to start thinking about what you're putting in your body and how much you're you're restoring and what you're eating , um , and how much energy you're putting out . Um , and I think , too , like thinking about especially our young folks and thinking about how to help them with this .

You know , they're hearing , they're hearing our generations and the generations kind of before us talk about they heard all about how the carbs were the enemy , right , we've all heard that one . Well , it turns out , did you know that ? You could be ?

You can , you can be restoring your body and eating enough , and if you're avoiding all the carbs , you could still get reds . Um , it turns out , our body needs the energy and needs to be fueled when you're exercising .

And you know I say that lightly , liz and it is super important to eat our eat our vegetables and our fruits . Um , you know we're getting a lot of great um great vitamins and things from there , but if we don't , we don't get our protein in and we don't get our carbohydrates in , um , our body it doesn't , it can't fuel itself properly .

Um , on just some of those things and I think that's a big one I'll see with , with our young , young folks , um is that you know they're , they're feeling really , really proud , um , and because they they've eliminated a lot of all this junk food or something that they they perceive to be bad ?

Um , but you know , carbs aren't the enemy , sugar is not the complete enemy . You know , it's all in moderation , right , but like our bodies have to have that fuel and our brain needs it too right , our brain needs it too so .

As many of you know , the wellness paradox is all about closing off the trust , interaction and communication gap between fitness professionals and the medical community , and no organization does that better than the Medical Fitness Association . They are the professional member association for the Medical Fitness Association .

They are the professional member association for the medical fitness industry . This is the industry that integrates directly with healthcare in many facilities throughout the entire country . The MFA is your go-to source for all things medical fitness . They provide newsletters , webinars . They even have standards and guidelines for medical fitness facilities .

They do events around the entire country and , most importantly , they are one of the more engaging networks in the entire fitness industry . I personally have benefited from the network that I've developed through the Medical Fitness Association and I highly recommend that all of you that are interested in solving the wellness paradox engage with the MFA .

To find out more about the Medical Fitness Association , you can go to their website , medicalfitnessorg . That's medicalfitnessorg . Now back to today's episode . So I'm curious . I mean , you talked about one thing that you said earlier which I think is so spot on , and I would love to be able to link to that article on .

You know , we're all athletes , because I think that that is a really , really good point .

You talked about a constellation of all kinds of different performance symptoms , clinical symptoms , you know , for the frontline exercise professional that's listening to this podcast , is there a way for you to maybe , you know , consolidate a lot of what you said into maybe some hallmark things that they could be seen in the athletes that they're working with , or the

people that they're working with that says , hey , you know , this is a bit of a red flag , we better take a little closer . Look at this . Yeah , this is a bit of a red flag .

So stubborn reoccurring illnesses , colds , infections , things like that , that's a that's a big red flag . Or stubborn reoccurring injuries , soft tissue , bone injuries , things like that . I think , boom , those are the . That's an easy one .

People are going to , they're okay , offering those things up , right , they're going to talk about that , and so I think that's a big red flag that anyone on the front line can sort of like oh hey , you know that's great , like so you're doing all this exercise , did you change what you were doing ?

You know from like three weeks ago as far as your food intake , you know how has that changed ? And sort of like you can get a little bit more info from there , right ? So injury immunity , I think is one sign to really look at performance .

That's another one that people feel a little bit more comfortable talking about , and so they might say they've had persistent fatigue or maybe they've like plateaued , like right they've been . I've been doing all my stuff and I've working really hard and I like I see everyone else getting a little bit better and I'm just like not improving . My times are the same .

Maybe there's a little bit less or something like that , maybe a little bit like more difficulty concentrating or coordinating some of their like their sporting , sporting stuff and exercise stuff . So those , I think , are kind of like the , the two categories that are . You know you're going to maybe start probing if those things are there .

Other ones that are a little bit harder to get at , that are important to know how to get at , are a mood right . So somebody who's been a little bit more irritable maybe they're telling you they're down been a little bit more irritable , maybe they're telling you they're down and a little bit more depressed than normal or a little bit more anxious .

So those are things when you think about that quarter , that category . And then there's some hormonal things as well too . So not to forget the athlete triad , because that was also really important , it's part of this whole cycle as well too , and so if somebody is missing their periods , that is not normal and it is still getting told to people .

Gosh , I had a kid the other day who had said their coach said if you're having your period , you're not working hard enough . I mean , like , mind here , like this is just like awful , awful stuff .

You know , um , your period is a sign that your body is fueling appropriately right , like going to take that away if you don't have enough energy , because why would you have a baby if you don't have enough energy for your own body to to to , you know so .

So , um , missing periods , um , uh , or abnormal ones , Um , and then when we're thinking about , um , the men , it's a loss of erections .

So morning erections less than three times a week is is helping us know that that now , like gosh , are we over , um , over trained or something like that , or over exerting herself , not getting enough fuel , and that was a sign . So so we got the periods on the on the women's side and the erections on the male side .

So we do have some like physiologic signs from the hormonal stuff that we can ask about . Low sex drive in general , for both men and women . That can be a sign as well , too , in that hormonal category as well , and you know , these are things that you know .

They're on the radio all the time Like , oh hey , you have this and you have this and um , and I think it's important to put this all together right . So now you're looking at somebody who's exercising a lot they're maybe not feeling a lot and you're like , oh wow , and I have these hormonal signs .

That is where you can sort of like start thinking about some of that kind of stuff , the other things , the poor sleep patterns , insomnia , that sort of seems to have come from nowhere . That can be in that category too . And then kind of the last sort of spot the sign sort of think about things is the mindset .

So you know , if you're noticing that somebody has like major groups of food that they're just like avoiding , you know , and are they ? Are they eating gluten ?

It's either eating disorder or is it disordered eating . Right , and eating disorder is um more of that .

Mental health is involved in this as well too , and perhaps we get anxious when thinking about adding that food back in versus disordered eating , where it's like , gosh , you're supposed to be in school and you don't have time to eat dinner because you're going to go to see this movie .

And , gosh , you had breakfast in the car too , because you decided to do this extra , like a basketball thing , in the morning as well . But suddenly you found that you ate all three of your meals on the go .

You don't , you didn't really have any snacks in the day and you weren't trying not to eat , right , you just didn't take time to do it , you know , um , and so that's a little bit different , so that we call disordered do it , and so that's a little bit different , so that we call disordered eating versus eating disorder , and that's probably the thing the most .

And so I think what's really important for you asking about how do people spot these signs is because the biggest thing that we can do is provide education .

So you know what , as exercise professionals , should we be doing when we think some of these things are manifesting themselves in someone we're working with ?

Like you know , gosh , you know I , I know energy in and energy out has to be balanced , and when it's unbalanced , you know some of the things you're talking about , um , that that tends to happen , right , and so it just even getting that in there , right , and you don't .

You don't have to um , be a dietician necessarily to know that we should probably all eat three meals a day and a couple of snacks if we're , we're exercising , you know , and and I think those are fair things to to say Um , and you know , if they're , they're having some of the hormonal things or mood disturbances , like I think it's , it's , it's okay to

normalize those things in a way that um ask and have , encouraging them to follow up um with a healthcare professional who can address those things . Um , some of this is tough . I spend a lot of time educating healthcare professionals . That's one of the , the areas of which is what brought us to meet actually .

Uh , one of my areas of interest is educating people about relative energy deficiency syndrome or the athlete triad , and because there's a lot of times this and this happens probably more in our , our young , young girls is , you know they go in and they're like , hey , I'm not having my period yet .

And they're like , well , you know you're not 16 yet , like you have a little extra time and you do , but like trying to figure out what are they doing with the time right now , right , are they ? Are they exercising two times a day , two day practices and , you know , not eating dinner with families ? Like is there education that can , can happen there ?

I think is really um , is really important and um , yeah , is it . I mean this is overall education , awareness , advocacy for your , your athlete to , or and and or person that you're working with to to get some support on on these things and then just empower them .

I think that's the hugest thing , like empower them to be able to go in and ask a little bit more probing questions to make sure there's not something else going on .

So , before we get to the last question , is there any particular place that you might want to point people to to learn more about you , the work you're doing , maybe information on this topic ? Where should we point our audience to ?

Um , I , um , I also have , uh , which will link is um a website to um the freya project , which is um a little bit off of this topic but a spit , a spin-off I really my spin-off session , um , where we're we're looking um , and there's a little bit of my information on there too .

But I have a student that I am um working with , nakia Evans , who is the mastermind behind this project and really working on her scholarly work for her medical school education , and we're looking at the hormonal cycle and periods and when is the best time to be active and how much energy should we be using at certain points during the cycle , and everything too .

So we're looking at some of those things . So if you have that posted for us , that would be great as well too . And then Nikia has a lot of informational information and links that she shall send out If you put your email in no spam , I promise .

But if you want to participate in any research that we have in the future , your name will be on there as well too . So those are kind of the main places , I think , to be able to find me .

And , as we were talking before we came on the air , I think you've now invited yourself back without knowing it , in about a year to two years to talk about the findings of that study , because it is an adjacent topic very much to this and it's an area that and I don't want to go too deep in this but it's very , very under-researched in largely a

male-dominated research culture that doesn't necessarily think of things like this . So I think that's such a fascinating area , but again , I'm going to stop myself from going any further .

So , dr Novak , before I let you go and this is one of my favorite questions to ask to medical professionals , because you're part of this thing I consider the wellness paradox and I view the wellness paradox as kind of the trust , interaction and communication gap that exists between fitness and exercise professionals and the medical community .

Where we met at an MFA event , they're an organization that seeks to close off that gap . But if you , as a physician , could give the fitness and exercise professionals listening one piece of advice on how to close the gap off , what would that piece of advice be ?

They're amazing . But I also need to be like , hey , you want to start exercising . I should have that same referral network and I think we're working on it and we're building it . And I think , if you guys just keep pushing for that , because I think that is so important , that is so important .

And you know , within within our clinic at OHSU , we we have started trying to integrate um an exercise um as well into some of our stuff in our um .

One of my colleagues , rachel Benson , she is running what we call the active clinic right , where she's helping people get back into activity and exercise and and she'll use folks um , like you got yourselves as well too . We all do Um . But like , how can we , how can we integrate us all together a little bit more ?

Like you know , there's a gym across the street from me . I should be able to be like , hey , you know , jacob has this program and you know , like , go over there and work with him .

You know , like , right , I shouldn't , I shouldn't be able to hopefully hand you off to someone , and that I think that would be a great , a great thing , um , that we all work together because , um , as we know , exercise is the one of the best things , that it is medicine , it's yours , most things , so , um , so , us working together makes a lot of sense .

Forward slash episode 124 . Please be on the lookout for our next episode when it drops in two weeks , and don't forget to subscribe through your favorite podcast platform . Until we chat again next , please be well .