SPORTS NUTRITION Deficiency in Sport and Describe Symptoms of an Athlete Suffering for Injury Prevention and Healing from Relative Energy Deficiency

4/14/2017

Objectives

1. Explain the role of nutrition in injury prevention and for promoting recovery in the injured athlete. 2. Delineate between the Female Athlete Triad and Relative Energy SPORTS NUTRITION Deficiency in Sport and describe symptoms of an athlete suffering For Injury Prevention and Healing from relative energy deficiency. 3. Utilize science-based nutrition recommendations for counseling

Val Schonberg athletes about recovery and injury prevention and incorporate the Registered Dietitian information learned into practical interventions. Board Certified as a Specialist in Sports Dietetics NAMS Certified Menopause Practitioner

Smart nutrition makes a difference! Running on Empty: Consequences of Poor Nutrition . Poor recovery Improve Performance . Strength loss Enhance Muscle strength . Endurance decreases Help with Concentration . Chronic Fatigue . Soreness, joint pain Decrease Fatigue . Injuries, stress fractures For Growth and Development . Micronutrient Deficiencies (anemia) Reduce Injury rates University of Minnesota Women’s Gymnastics . Respiratory Infections You cannot out-train 2016 Big 10 Champions . “Overtraining Syndrome” (or out-supplement) . Decrased coping skills and depression a bad diet!

To Prevent Injury… Role of Nutrition in Injury Prevention

• Provide energy and nutrients to the athlete’s body during exercise • Prolonged, or Intense Training Sessions exert significant metabolic demands on the body: • Deplete fuel stores • Loss of body fluid and electrolytes • Changes to the hormonal milieu • Damage/disruption to skeletal muscle and body proteins • Recovery strategies from the stress of exercise • Refuel • Rehydrate • Repair  Maximize training-induced physiological adaptations

Beelan, et al. Nutritional strategies to promote postexercise recovery. Int J Sport Nutr Exerc Metab, 2010.

Daily Habits: A Foundation to Prevention Relying on . Low energy intake decreases availability of protein, carbs and fat for tissue Supplements: repair and recovery Potentially a “Red . Low carb (thus low fiber) diets may compromise the immune system, GI function, and increase risk for injuries Herring”? . Inadequate glycogen stores  increased reliance on fat/protein  protein breakdown  soft tissue injury . Avoiding foods or food groups resulting in nutrient deficiencies, i.e. calcium and iron . Cycle of under-eating and over-eating (i.e. skip breakfast, skimp on lunch and “blow it” at night)  overconsumption? . Alcohol intake inhibits recovery

Objectives Female Athlete Triad

1. Explain the role of nutrition in injury prevention and for promoting •Low Energy Availability recovery in the injured athlete. •Menstrual Dysfunction 2. Delineate between the Female Athlete Triad and Relative Energy Deficiency in Sport and describe symptoms of an athlete suffering •Bone Health from relative energy deficiency. 3. Utilize science-based nutrition recommendations for counseling athletes about recovery and injury prevention and incorporate the information learned into practical interventions.

American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc., 2007.

Higher Incidence of Bone Stress Injuries With Increasing Female Athlete Triad–Related Risk Factors

• 259 girls and women were followed for 12-months “There were significantly higher foot and ankle injury incidence rates and • Anthropometrics, eating attitudes and behaviors, more missed time in female athletes and women's sports.” menstrual function, sports participation or exercise activity, and pathological weight control behaviors were assessed. • 10% incurred a bone stress injury • Single factors significantly associated with the development of a BSI included: • ≥12 h/wk of purposeful exercise  Over half (58%) of participants reported having an injury in the past year. • BMI <21.0 kg/m2  For every extra day off training due to injuries participants were two times • low bone mass more likely to be at risk for LEA • The strongest 2- and 3-variable combined risk  In the past 3 months the majority (78%) had exercised at least once a month factors were for greater than 60 min to lose or control their weight, and nearly half (46%) • low BMD + ≥12 h/wk of exercise were also at risk for LEA • ≥12 h/wk of exercise + leanness sport/activity + dietary Barrack, et al. Higher incidence of bone stress injuries with increasing restraint female athlete triad-related risk factors: a prospective multisite study of exercising girls and women. Am J Sports Med, 2014.

Problems with Female Athlete Triad or FAT Relative Energy Deficiency in Sport (RED-S)

• Male athletes are affected – “It is Irrefutable” • LEA can also occur in male athletes in scenarios of high volume training, lean or weight- The International Olympic Committee (IOC) introduced a more demanding sports comprehensive, broader term: • Male athletes can suffer with: • Disordered eating “The syndrome of RED-S refers to impaired physiological functioning caused by • Disruption of Gonadotrophin Releasing Hormone and Luteinizing hormone (GnRH) and LH pulsatility, as well as lower sex hormone levels relative energy deficiency, and includes but is not limited to impairments of: • Impaired reproductive function Metabolic rate • Decreased immunity Menstrual function • Impaired bone health Bone health • Clinically, it is actually a syndrome, affecting multiple areas of physiological function Immunity Protein synthesis

Mountjoy M, Sundgot-Borgen J, Burke L, et al, The IOC consensus And cardiovascular health.” Mountjoy M, Sundgot-Borgen J, Burke L, et al, The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). Br J Sports Med, 2014. Deficiency in Sport (RED-S). Br J Sports Med, 2014.

Energy Availability “Relative Energy Optimal health Deficiency in Sport” Build bone Improve Strength “The amount of energy left over and Not having enough energy available for your body’s functions after available to do what you Prevent problems need to do… the energy expended for training is Avoid losing bone Maintain strength subtracted from the energy you take in Performance Consequences: from food”

Fatigue Depression Increased injuries Stress fractures

Margo Mountjoy et al. Br J Sports Med 2015;49:417-420

Immune “Relative Energy System Signs of Low Energy Availability Digestion Deficiency in Sport” Menstrual . Chronic fatigue, anemia, recurring illnesses and GI Function . Digestive disorders Warning signs: . Bloating Not having enough energy “I can’t take rest days” Cardiovascular Bone . Constipation Health available to do what you “I just have to do more…cross . Diarrhea training, Pilates, yoga” RED-S need to do… . Delayed gastric emptying “My mood is better when I do more” . Weight loss “Pulling away from relationships” Psychological Endocrine Health Consequences “I’m injured but it doesn’t matter… . Disordered eating or “fixated on eating right” i.e. if I go for walks… they are really . Irritability, mood changes or depression just very enjoyable because of the fresh Growth & air and sunshine. I just find it important Development Metabolic . Increased training but not improving performance to find ways to be outside…” Anemia . Stress fractures or repeated bone injuries

Gymnastics Dance Who’s At Risk for RED-S? Cheerleading Figure Skating Wrestlers Rowers Objectives Jockeys 1. Explain the role of nutrition in injury prevention and for promoting recovery in the injured athlete. 2. Delineate between the Female Athlete Triad and Relative Energy Deficiency in Sport and describe symptoms of an athlete suffering from relative energy deficiency. Swimming 3. Utilize science-based nutrition recommendations for counseling Synchronized Swimming athletes about recovery and injury prevention and incorporate the Cross Country Running information learned into practical interventions. Cycling (other endurance athletes) Volleyball Maybe Water Polo… Others???

Treatment for RED-S RED-S Clinical Assessment Tool (CAT)

RD • The RED-S ‘Red Light – Yellow Light – Green Light’ Risk Assessment and Return to Play (RTP) models

Family Psych • A functional model that is both simple to understand by the athlete and the clinician, and is relatively easy to implement in the ‘real world’

• Endpoints = red light “high risk” criteria and the yellow light “caution” criteria all Athlete apply to both male and female athletes (except for the two endpoints related to the menstrual cycle) Coach PT

MD/ Gyno Mountjoy M, Sundgot-Borgen J, Burke L, et al. Br J Sports Med, 2015.

Special Concerns Key Nutrients Promote “Everyday Nutrition”: Practical Tips Calcium Bone Health Vitamin D . “You may need to plan ahead” and “Give yourself permission” to eat Phosphorus enough food throughout your most active time of the day Protein (leucine) . Include protein at each meal and especially as part of a recovery snack Muscle/Soft Tissues after training or other athletic activity. Carbohydrate

. Aim for “3” fruit servings and “3” vegetable Antioxidants Immune System servings daily. Vitamins and Minerals Brain Omega-3 Fatty Acids . Drink water throughout the day. Carbohydrate . Increase intake of nutrients that are important Energy (anemia) Iron for healing, reducing inflammation, tissue repair and immune function and GI Health Fiber, Probiotics

Foods containing: Affordable/Shelf Stable Protein Ideas Calcium Iron

Omega-3 Fats Vitamin D

Breakfast Calcium (mg) 1 cup cooked oatmeal with 2 tbsp almond butter 110 Does the Timing of Protein Ingestion After Exercise Alter Rates of 2 scrambled egg(s) with ½ cup sautéed spinach 1 cup orange slices 40 Protein Synthesis?

Lunch Study: Athletes provided 80 grams of protein Chicken Caesar wrap: Whole grain tortilla with 3 ounces chopped chicken breast, ½ cup romaine Bolus = 40 grams x 2 2 Tbsp parmesan and dressing 100 Intermediate = 20 grams x 4 1 cup strawberries Pulse = 10 grams x 8

Post-Workout Snack Protein shake made with 1 cup milk, banana 300

Dinner Stir fry with 3 oz. shrimp and vegetables that includes ½ cup (cooked) kale, ½ cup broccoli, onions, and carrots 80 1 cup brown rice Results: 1,000 Calcium mg 1,000  Distribution of protein intake is an important variable to Snack Areta JL, et al. Timing and distribution of protein promote attainment and maintenance of peak muscle mass. ingestion during prolonged recovery from resistance Sample Menu ProvidingMenuSample 1 oz. almonds , 6 oz. Greek yogurt, 1 apple 73 +300  20 g of protein was superior for stimulating muscle protein exercise alters myofibrillar protein synthesis synthesis. J Physiology, 2013. Estimated Total Calcium Intake ~1003 mg

What can I do with nutrition to heal Goals for a Nutrition Intervention faster? • Support muscle repair (muscle protein synthesis) • Preserve muscle mass • Maintain energy balance • Prevent unnecessary weight gain

. . . To Get Back in the Game!

BT Wall and LJC van Loon. Nutritional strategies to attenuate muscle disuse atrophy. Nutrition Reviews, 2013.

Notable Nutrients for Healing Nutrition for Optimal Healing Bromelain from Pineapple 1) Energy intake still a priority: don’t automatically restrict calories 2) Manage Inflammation: Spices (Turmeric, Capsaicin, ginger)

Eat more “anti-inflammatory” foods: Limit foods that may trigger additional inflammation: Garlic  Colorful fruits and vegetables  Highly processed foods  Foods high in saturated fats (fried food, red meat, etc.)  Healthy fats, such as those found in  Foods and drinks high in simple sugars (cookies, candy, salmon, tuna, nuts, seeds, olive oil and blended coffee drinks, energy drinks, etc.) Tart Cherry (dried/juice) avocados.  Alcohol Omega-3 Fats 3) Repair and Rebuilding: • Protein, fat, carbohydrate, fruits and vegetables, vitamin D and calcium Supplements that may help in the recovery process: • Fluids – facilitate blood flow and nutrient delivery to injured areas • Creatine Tipton, Kevin. Nutritional Support for Exercise- Induced Injuries. Sports Med, 2015. • B-Hydroxy-B-Methylbutyrate (HMB) – leucine metabolite

Optimizing Interventions During What Can You Do? Recovery in the Injured Athlete • Emphasize nutrition and health as a means to improved performance • Promote positive food and body talk • Reduce emphasis on weight • Education  Evaluate an athlete’s “willpower” vs “skillpower” • Avoid a focus on “single nutrients” and/or single nutrient excess • Offer food demos or cooking groups for practical strategies Tipton, Kevin. Nutritional Support for Exercise-Induced Injuries. Sports Med, 2015. Wall BT and LJC van Loon. Nutritional strategies to attenuate muscle disuse atrophy. Nutrition Reviews, 2013.

References and Selected Citations 1. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc., 2007. Thank you for listening! 2. Areta JL, et al. Timing and distribution of protein ingestion during prolonged recovery from resistance exercise alters myofibrillar protein synthesis. J Physiology, 2013. Questions?

3. Beelan, et al. Nutritional strategies to promote postexercise recovery. Int J Sport Nutr Exerc Metab, 2010.

4. Hunt KJ et al. Incidence and Epidemiology of Foot and Ankle Injuries in Elite Collegiate Athletes. Am J Sports Med, 2017. Val Schonberg MS, RDN, CSSD, LD, NCMP 5. Mountjoy M, Sundgot-BorgenJ, Burke L, et al, The IOC consensus statement: beyond the Female Athlete Triad— Relative Energy Deficiency in Sport (RED-S). Br J Sports Med, 2014.

6. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC relative energy deﬁciency in sport clinical assessment tool (RED-S CAT). Br J Sports Med, 2015.

7. Position Statement of the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and Athletic Performance. J Acad Nutr Diet, 2016. www.enlightenUnutrition.com 8. Slater J et al. Female Recreational Exercisers at Risk for Low Energy Availability. Int J Sport Nutr Exerc Metabolism, 2016. Find me on: 9. Tipton, Kevin. Nutritional Support for Exercise-Induced Injuries. Sports Med, 2015. Facebook: EnlightenU Nutrition 10. Wall BT and LJC van Loon. Nutritional strategies to attenuate muscle disuse atrophy. Nutrition Reviews, 2013. Twitter: @valschonberg