What We Actually Know About Macronutrient Ratios in HA Recovery

"I’m worried that I’ve already messed up."

This is one of the most common phrases we hear from clients with hypothalamic amenorrhea.

And the feeling is real. The shame they carry is one of the many reasons they often struggle to recover on their own. They feel the need to do everything perfectly and deeply fear making a mistake. Somewhere in their story, they learned that perfection was necessary to keep themselves safe.

Before we start assigning gold stars to carbs, fats, or protein, it's worth answering the question your client is probably asking (and maybe you are too): Is there actually an ideal macronutrient ratio for HA recovery? The short answer is no. We don't have evidence supporting one magic ratio that restores menstrual cycles, and no clinical guideline recommends a specific percentage of carbohydrates, fat, and protein for recovery. What the research consistently points to instead is restoring adequate energy availability. In other words, the body is much more interested in whether enough fuel is coming in than whether your client hit a perfect 45/30/25 split. Much to the disappointment of spreadsheets—and the delight of anyone who's tired of micromanaging their lunch. 

In your initial meetings, a good coach addresses the low-hanging fruit first. Food is one of those low-hanging fruits (pun absolutely intended). As Lisa Hendrickson-Jack, co-author of Real Food for Fertility, says, "Chronic under-eating and cycle health often do not coexist." Before diving into supplements, labs, or optimizing the optimize-y things, it's worth asking a much simpler question: Is this body actually getting enough fuel?

For women in their reproductive years, carbohydrates are critical. The body needs energy, and glucose is its preferred fuel for many tissues, including the brain. Carbohydrates are the most efficient way to provide it.

Unfortunately, many women who develop HA have been told to abandon carbs in the name of "health." Somewhere along the way, bread became the villain and cauliflower somehow got promoted to rice.

Lies.

Women who are cycling—or trying to cycle again—need adequate carbohydrates to support ovulation, menstruation, and everything in between. In recovery, carbs deserve to be the foundation of the meal. Gone are the days of fearing a piece of garlic bread next to your already carb-heavy pasta.

Yes, I said next to your pasta.

Let's not forget carbohydrates' sexy sidekick: fat.

Without fat, you'll probably find yourself eating the kitchen sink and still wondering why you're hungry. Everything tastes better when fat shows up anyway. It's the life of the party. Invite it. Just don't let it dominate the meal the way keto culture once convinced everyone it should.

"But what about protein?"

Ah yes. What about protein?

I'm sorry to report that the gym bros got at least one thing right.

Protein absolutely matters. During recovery, encourage clients to get as much of their protein as possible from whole food sources, particularly animal foods if they eat them, rather than relying primarily on powders and bars. A fist-sized serving at each meal helps provide the amino acids needed for tissue repair and hormone production while also making meals genuinely satisfying.

I know what you're thinking.

"So...I can just eat the protein and skip the carbs and fat?"

Nice try.

Here's the big picture: protein provides the building blocks for hormones and tissues, fat supplies essential fatty acids and supports normal hormone production, and carbohydrates provide the energy that allows the body to stop acting like it's stranded on a deserted island.

Should your client eliminate any of these macronutrients?

Short answer: no.

Long answer: also no.

What This Means for You as the Coach

Your clients will probably understand this intellectually (especially after you've gently pried their fingers off the protein powder).

What they'll struggle with is trusting themselves enough to actually do it.

They're being asked to eat foods they've avoided since approximately the last Ice Age. They're watching pants fit differently. They're sitting with uncertainty instead of chasing the next nutrition rule that promises certainty.

Knowing what to do is the easy part.

Doing it repeatedly while your jeans negotiate new terms is another story entirely.

And perhaps your hardest challenge? Helping clients let go of perfection.

As Dr. Brené Brown writes in The Gifts of Imperfection:

"Perfectionism is not the same thing as striving to be your best. Perfectionism is the belief that if we live perfect, look perfect, and act perfect, we can minimize or avoid the pain of blame, judgment, and shame. It's a shield. It's a twenty-ton shield that we lug around thinking it will protect us when, in fact, it's the thing that's really preventing us from flight."

That's where you come in.

Your job isn't to help your client create the perfect meal plan.

It's to help them realize they don't need one.

They don't need to eat at exactly the right times. They don't need to measure every fluctuation in their blood sugar. They don't need to optimize every bite they take.

In fact, much of recovery involves grieving the belief that perfection was ever keeping them healthy in the first place. Sometimes the most therapeutic thing a coach can do isn't provide another nutrition strategy.

It's helping a client believe they're allowed to eat lunch without earning it first.

Works Cited

Brown, B. (2010). The Gifts of Imperfection. Hazelden Publishing.

Hendrickson-Jack, L., & Johnson, L. (2024). Real Food for Fertility. Proov Publishing.

Gordon, C. M., Ackerman, K. E., Berga, S. L., et al. (2017). Functional hypothalamic amenorrhea: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(5), 1413–1439.

Loucks, A. B. (2003). Energy availability, not body fatness, regulates reproductive function in women. Exercise and Sport Sciences Reviews, 31(3), 144–148.

De Souza, M. J., Nattiv, A., Joy, E., et al. (2014). Female Athlete Triad Coalition Consensus Statement on treatment and return to play. British Journal of Sports Medicine, 48(4), 289.