Energy Deficiency, Supplements, and Nutrient TimingBY : STEPHANIE HORVATH , MS , MAED , RDN , CSSD , LDNDIRECTOR OF SPORTS NUTR IT ION UNIVERS ITY OF TENNESSEE

My Background

School Work

Indiana Notre Dame

Kent State Illinois

Virginia Tech Tennessee

Position statementPosition Statement, updated in 2016

Key Words: Evidence-Based Analysis

A Joint Effort from: • Academy of Nutrition and Dietetics • Dietitians of Canada• American College of Sports Medicine

Training VS. Competition Goals

In Training: Adapt the body to develop metabolic efficiency and flexibility

In Competition: nutrition strategies focus on providing adequate substrate stores to meet the fuel demands of the event & support cognitive function

Athletes get this confused—sometimes do something “special” for competition, because it will give them an “edge” when in reality,

Competition should be like training◦ May need a little more carbohydrates to handle nerves◦ More protein if it will be a multi-event day

◦ (swimming, track, baseball, softball)

Special Cases

Fatigue, Loss of Appetite, Cramping

Type 1 DM

Eating Disorders/Disordered Eating

Stress Fractures

Energy Availability

Energy intake in relation to the energy cost of exercise

EA has been defined as the amount of ingested energy remaining for bodily function and physiological processes such as growth, immune function, locomotion, and thermoregulation after the energy required for exercise/training has been removed

From the ACSM Female Athlete Triad Position Statement

How is it calculated?

Energy Availability

Calculate by:

Subtracting energy expenditure during

exercise from energy intake adjusted for fat-

free mass

Energy availability=

Energy intake- Exercise energy expenditure/fat-

free mass (kg)

Energy availability thresholds:

An energy availability if at least (45 kcal)/kg fat-free mass/day is recommended to maintain

adequate energy for all physiological functions

Reduced or sub-clinical energy availability ranges from 125-188 kJ (30-45 kcal)/kg fat-free mass/day. This is suggested as a tolerable range for athletes

aiming for weight-loss as a part of a well-

constructed dietary and exercise regimen over a short time period.

Low energy availability is defined as less than 125 kJ (30 kcal)/kg fat-free mass/day and suggest an unsafe energy level for optimal body function;

this, in turn, may lead to unfavorable health outcomes and sports performance.

Example Calculation of EA

• 60 KG BODY WEIGHT (BW), 20% BODY FAT, 80% BODY FAT

• (=48.0 KG FFM), EI=2,400 KCAL/DAY, ADDITIONAL ENERGY EXPENDITURE FROM EXERCISE = 500 KCAL/DAY

• EA=(EI-EEE)/FFM=(2,400-500) KCAL-D/48.0 KG=39.6 KCAL/KG FFM/DAY

• DECREASED EA BELOW 30 KCAL/KG IS ASSOCIATED WITH PERTURBATION OF REPRODUCTIVE FUNCTION AND BONE METABOLISM

Low Energy Availability, Defined

LEA occurs when an individual has insufficient energy to support normal physiological function after the cost of energy expended during exercise has been removed

Your body starts to adapt it’s physiological systems to compensate

for lowered calorie intake (or higher

calorie expenditure)

Mountjoy M, Sundgot-Borgen J, 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;48(7):491-7.

“Scientific evidence and clinical experience around the effects of low energy availability shows that several body systems in addition to the reproductive and musculoskeletal systems are affected, and that men are at risk as well as women.”

What Does Low Energy Availability Impact?Relative Energy

Deficiency in Sport = RED-S

The syndrome of RED-S refers to impaired physiological functioning

caused by relative energy deficiency and includes but is not limited to impairments of metabolic rate,

menstrual function, bone health, immunity, protein synthesis and

cardiovascular health1.

Can impact male athletes, too!

LEA, Low Energy Availability

Can occur intentionally or unintentionally

Regardless of etiology…

macro- and micro-nutrient deficiencies

unfavorable physiological changes

harmful health outcomes

suboptimal sports performance

LEA is Difficult to Assess

Low Energy Availability Is Difficult to Assess but Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes.

Int J Sport Nutr Exerc Metab. 2018 Jul 1;28(4):403-411. doi: 10.1123/ijsnem.2017-0313. Epub 2018 Jun 12. DOI:10.1123/ijsnem.2017-0313

Summary: Based on cross-sectional analysis, current reproductive function (questionnaires/blood hormone concentrations) appears to provide a more objective and accurate marker of optimal energy for health than the more error-prone and time-consuming dietary and training estimation of EA.

What EA calculations lack

Although the negative effects of low EA on hormonal function are robustly detected in controlled laboratory settings, our study clearly demonstrates that the real-world measurement of EA, via dietary and exercise recording is challenging and lacking in sensitivity as a diagnostic tool for the presence of low EA.

Even thought an EA assessment has appeal as apparently low-cost, low-technology, and a noninvasive text, in reality, it carries a large burden in terms of athlete compliance and practitioner time.

Insights on Practical Applications

Colleague:

"Finding your sweet spot"

I have a checklist of physical/mental symptoms for the athlete to be more aware if possibly their energy balance is off

We tend to get caught on the numbers when the symptoms tell the story.

Diet Culture

Fight Diet Culture Every Day

Especially prone to misinformation, marketing

They want to perform well, thus compromising their ability to decipher what is good and bad

Especially adhere to the personal testimonial approach

Fad Diets

Often, way too low in carbohydrate (trendy)

Remember the position statement has high performance athletes at 50-60% of their diet from carbohydrates◦ Ex: 4000 kcals ◦ 2000-2400 kcals from CHO◦ How many grams of carbohydrates? 500-600g PER DAY◦ Don’t shy away from them

Paleo, Whole-30 Diet

Cuts food groups entirely

Not scientifically proven to be a better diet than a high-performance diet

Good points: focus on vegetables, whole-foods

Bad points: cut dairy, grains (B-vitamins, riboflavin, niacin, fiber, calcium, etc)

Steer athletes away from these diets

Liquid Cleanses

Far too low in calories

Not good during any of the training phases

Extremely low in fiber, nutrients (no grains, dairy)

Quick fix for a long-term, larger problem

Why To Steer Athletes Away from TRENDY DIETS

Be weary of any diets that cut food group

As the professional, you MUST focus on evidence-based analysis, peer-reviewed information

Any diets That cut food groups in an effort to cut calories or create a calorie deficit—is not helpful for athletes Competing

All Foods Fit

Fueled vs. Under-fueled

Calories and injury-prevention

Having a little more on board seems to be better than less

RED-S◦ Men and Women Affected ◦ Stress-Fractures, Mental Fatigue, Bone Health Disruptions

IOC Consensus Statement: Dietary Supplements and the High Performance Athlete

Published on March 14th, 2018

Highlights

There is no single definition, either legal or within nutritional science, of what constitutes a dietary supplement

“A Food, food component, nutrient, or non-food compound” that is purposefully ingested in addition to the habitually consumed diet with the aim of achieving a specific health and/or performance benefit.

IOC Consensus statementPrevalence of, and rationale for, use by athletes

Assessing the evidence base for supplement use ◦ The effectiveness of sports foods might be hard to isolate when they are

used within the general diet to meet everyday energy needs and nutrient targets

Supplements used to prevent or treat nutrient deficiencies, used to provide a practical form of energy and nutrients, and that indirectly or directly improve sports performance

Adverse affects

Contaminants due to manufacturing practices ◦ Metal, Lead, Broken Glass

Failure to address what in their supplement would be an adverse affect ◦ Number of Hospitalizations, but some less severe

Small prohibited substance, ineffective dose for performance, causes positive drug test ◦ The IRONY!

Supplements

Help athletes see/realize the cost-to-benefit ratio

They are of greatest value when added to a well-chosen eating plan

Example, even sport “foods” like sports drinks, sport bars, sports gels, protein supplements, etc. the cost is than whole foods, and may be used unnecessarily or in inappropriate protocols

“Typical Day”What is typical?

Busy schedules: with academic strain, group projects, balancing a social life, film/video, supplemental workouts, recovery time, lifts, rehab/preventative injury training

However, we try to encourage athletes to get on an eating schedule as much as possible

SOLID NUTRITION IS ABOUT TIMING!

Macronutrients

Carbohydrates

ProteinFat

• To a certain extent, any three of the energy-producing nutrients, carbohydrates, fat, and protein can provide the body with needed energy on a short-term basis.

• However, our goal is to provide energy in the most efficient form for the body.

All three are needed, and important in the

diets of high performance athletes

Eating Schedule #1 Swimmer• Whole-grain Cereal & Milk, banana, plenty of water5:00am

• Practice starts, hydrate before and during. Practice ends around 8:30-Recover in locker room with Chocolate Milk or Protein Shake6:30am

• Breakfast in Dining Hall: Veggie Omelet w/ Cheese, Whole Grain Toast, Fresh Fruit w/Berries, Water9:00am

• Subway: Large Grilled Chicken Sub with Veggies, Olive Oil, Lettuce, Tomato, etc

12:00pm

• Trail Mix/String Cheese & Fruit/Apple and Peanut Butter/Greek Yogurt2:30pm

• 2nd Practice, End with recovery again3:00pm

• Training Table: Citrus Grilled Salmon, Wild Rice, Parmesan Asparagus, Spinach Salad, Fruit, Water/Milk

6:30pm

8:30pm • Pre-bed Snack: Homemade trail mix, ½ sandwich, or light snack like popcorn

Important Points

Eat every 2-3 hours- very important to recovery: Recovery in anabolic window-eat within 30 minutes THEN 2 hours later have another meal/snack

Significant body composition improvements seen in breakfast eaters who haven’t eaten breakfast in the past

◦ Show they are leaner, motivates them to keep a healthy habit going

Eating Schedule #2 Baseball Athlete • Breakfast @ Smokey’s: Omelets, eggs, bacon, English muffins,

oatmeal, cereal, grits, fresh fruit 8:30am

• Snack: Beef jerky or Protein bar10:00am• Lunch w/ Team Grilled BBQ Chicken, rice, steamed broccoli, Greek

yogurt and fruit, Gatorade and water12:30pm

• Film/Meet in Team Room1:15pm

• Batting practice, practice grab Clif Bar2:30pm

• Recovery RTD, snacks from fueling station 4:45pm

• Chipotle Burrito Bowl with Brown Rice, Chicken & Steak, Cheese, Black Beans, Veggies, Lettuce, and Guacamole5:30pm

•Bowl of Cereal in Dorm Room, Weight shake to maintain weight (Peanut Butter, Extra Protein Powder w/ Carbs, Milk, and Greek Yogurt)8:30pm

Training Table MenusSalad Bar

◦ Cottage Cheese◦ Lettuce ◦ Lots of Toppings

Proteins:◦ Peppered Flank Steak◦ Lemon-Crusted Tilapia◦ Honey BBQ Chicken◦ Roasted Garlic Pork Loin

Starches:◦ Sweet Potato Mash◦ Baked Potato◦ Brown Rice

Vegetables: ◦ Mixed Veggies◦ Broccoli◦ Green Beans

Desserts (Yogurt or Pudding Parfait Bar):◦ Low Fat Pudding (Chocolate or Vanilla)◦ Low Fat Yogurt (Vanilla or Blueberry)◦ Greek Yogurt◦ Fruit: Strawberries, Pineapple, Cantaloupe◦ Cookies, Brownies

Nutrient TimingThe right snack, at the right time,

can aid an athlete in the right way.

What is the most time-consuming part of nutrient timing?

Developing, planning, and implementing the plan

CompetitionIt is typical for athletes to “all of a sudden” pay attention to their nutrition right before a competition or game

Don’t be that athlete

Superstitions are one thing. Trying something completely new and different is another. ◦ WORST possible time to experiment with new foods ◦ Why? If you don’t tolerate something well- your food is hurting instead of helping you!

Nutrition Prior to TrainingTrial and Error

◦ Unfortunately, there isn’t a whole lot of room for “error”◦ Better than testing the waters before a game/race/competition/match/meet

It’s a guessing game, what works for one may not work for the other

Depends on the training session◦ Time of Day◦ Aerobic/Anaerobic (Cardio or Weight Training Session)◦ Intensity ◦ Duration

Your Body & YouKnowing your body

It is the only way to know what is going to be the best and work the best for you

For some, it is hard to eat (fill-in-the-blank) “in the morning” or “before workouts”

For others it is easy and they face no troubles at all

Routine, routine, routine

Suggested Pre-Training FoodsCereal and Milk

◦ Can be easily digested◦ Watch for what dairy does to your system◦ Stick with skim milk (low-fat)

Pretzels

Fruit w/high water content/Applesauce

Dried Fruits/Fruit Cups in their own juice ◦ Digests easily for some, high carbohydrate content

Foods to Avoid Prior to TrainingFoods high in fiber

◦ Raw Vegetables (Ex: Carrot Sticks)◦ Fiber One Bars

Spicy/Acidic Foods ◦ Hot/Peppered Food

Pure Protein (Whey, Beef Jerky, etc)◦ May or may not tolerate well ◦ Harder for your body to break down

Dairy? ◦ Some can, some can’t

Trail Mix/Peanuts/Too Much Peanut Butter◦ High in both fat (healthy fat) and fiber◦ Difficult for your system to breakdown

Foods you have aversions to, or anything you haven’t tolerated

well in the past.

Eating while training Arguably one of the best times to be fueling

Physical AND Mental edge

Literally can make or break a marathon, triathlon, ironman, ultra-marathons

Easier if you have a halftime, a break in play/timeouts, or “heats” in races

Personal PreferenceFueling during competition or training will come down to personal preference

Often easier to start with liquids

Sometimes you will find you need something “heavier” if the intensity of the workout is known beforehand, or if under fueling took place during the day

Start with GatoradeNever ate or drank during practice before?

Gatorade is a good first step

Easily digestible, electrolytes, carbohydrates

Absorbed easily, and can be taken on the fly

Typically, fairly available where ever you go/travel

Experiment on your ownAlways good to experiment when doing workouts/training on your own

Summer, breaks from school, extra “supplemental” workouts

Practice may or may not be the best time

Doesn’t have to be big to be great5 pretzels

½ of a banana

8oz of Gatorade (3-4 sips)

.9oz package of 100% fruit Snacks (Welch’s or Mott’s)

Good things come in small

packages

RecoveryPlanning is key

30 minute window- what are you typically doing in the 30 minute window?◦ Talking as a team? Stretching? Showering? Running to class?

Where can you go, what can you pack?

Maximizing the Recovery Window 30 minute window and 2 hour window

2 hour window--- ideally recovering with whole grain/complex carbohydrates, fruits/vegetables, low-fat dairy &/or animal protein or with a balanced protein-containing meal

Once you master the 30 minute window timing, think about when and where you will fuel 2-3 hours later

Quick Recovery Options Chocolate Milk

◦ Tons of Research ◦ Natural Source of Protein and Carbohydrates ◦ Casein and Whey Protein Source

Greek Yogurt Protein BarFruit and Nut Butter/Jerky/String CheeseCereal and Milk

DOES NOT HAVE TO BE THE SAME THING EVERYTIMEVariety is actually good for your body

Recovery is Mental and Physical Take the time to fuel and refuel your body properly

Try to MINDFULLY eat

Try not to rush through meals, try not to study and eat a meal (doesn’t mean you can’t eat while studying, but take 20 minutes to eat a meal)

Eat with your friends!

Not One Size Fits AllIt can be easy to paint a broad brush stroke

Examine, observe, think, use clinical judgment

The more I see, the less I know◦ Each case is Particularly Unique

Nutrition Pillars

All Good things Take Time

Nutrition & Behavior

Is environment stronger than willpower?

Quick & Convenient culture

Sometimes nourishing yourself takes time

Self-care, not self-control

Intuitive Eating

Hunger/fullness scale

Appetite vs. Hunger◦ Implications with sleep

Some Thoughts to keep in mind

Nutrition is an art as well as a science- we do not eat in a vacuum

Strive for Strong Plates, not perfection

Savor your food

References

Position of the Academy of nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: Nutritionand Athletic Performance. J Acad Nutr Diet. 2016;116:501-528.

Maughan RJ, Burke LM, Dvorak J, et Al. IOC consensus Statement: Dietary Supplements and the high performance athlete. Br J Sp Med 2018; 0:1-17.

Nattiv A, loucks ab, manore mm, et al. American College of Sports Medicine Position Stand. The Female athlete Triad. Med Sci Sports Exerc. 2007;10:1867-82.

• Mountjoy M, Sundgot-Borgen J, 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;48(7):491-7.