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SPORTS NUTRITION FOR FOOTBALLAn evidence-based guide for nutrition practice at FC BarcelonaGatorade Sports Science InstituteIan Rollo James CarterAsker Jeukendrup

FC Barcelona Medical DepartmentMª Antonia Lizarraga Franchek Drobnic C. Daniel Medina

SPORTS NUTRITION FOR FOOTBALL: AN EVIDENCE-BASED GUIDE FOR NUTRITION PRACTICE AT FC BARCELONA

AUTHORS

CONTRIBUTORS AND EDITORS

Ian Rollo Asker Jeukendrup

Ian Rollo and James Carter are employees of the Gatorade Sports Science Institute, a division of PepsiCo Inc. The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of PepsiCo Inc.

FC BARCELONA, 2018©. BARÇA INNOVATION HUB

PEPSICO INC, 2018©.

James CarterMa Antonia LizarragaFranchek DrobnicC.Daniel Media Leal


Sports nutrition for football: An evidence-based guide for nutrition practice at FC Barcelona

Gatorade Sports Science InstituteIan Rollo James Carter Asker Jeukendrup

FC Barcelona Medical DepartmentMª Antonia Lizarraga Franchek Drobnic C. Daniel Medina


“If you want to get better you must train hard every day, but without the right nutrition, it will not be possible.”

Lionel MessiFC Barcelona#10

6 Summary

7

SUMMARY


E. Editor’s biographies

0. Introduction tothe Guide

1. Player Energy Balanceand Body Composition

2. MicronutrientRequirements for Football

3. Protein Requirementsfor Football

4. CarbohydrateRequirements for Football

5. Fluid Requirementsfor Football

6. DietarySupplementation for Football

7. Nutrition forFootball InjuriesP 8

8 Nutrition for Football Injuries

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CHAPTER 7


NUTRITION FOR FOOTBALL INJURIESRegardless of the level of participation, injuries are an unfortunate aspect of football activity.

An injury may strike a football player who plays the sport either for health and enjoyment or for professional purposes (Tipton 2010; Wall et al., 2015).

An injury is defined as any physical complaint sustained by a player that results from a football match or football training, irrespective of the need for medical attention or time loss from football activities. An injury that results in a player receiving medical attention is referred to as a “medical attention” injury, and an injury that results in a player being unable to take a full part in future football training or match play as a “time loss” injury (Fuller et al., 2006).

ootball is a contact sport and competition against opponents, either in training or matches, exposes the player to a greater number of challenges and tackles (‘contacts’). Therefore, it is not surprising that increasing the volume and intensity of football specific play is associated with an increased risk of injury (Bacon & Mauger 2016; Malone et al., 2016). The process and duration required to return to play following injury is complex and will depend on the classification of injury (Valle et al., 2016).

One important consideration in the return to play process is nutrition because it is one method to counter the negative impact of an exercise-induced injury (Tipton 2015). Thus, this chapter will first focus on common injuries in football before discussing the nutritional considerations for injury prevention as well as those interventions to complement the physical rehabilitation program.

The incidence of outdoor football injuries is among the highest of all sports, particularly for adult male players. An elite football team with 25 players in the squad can expect approximately 18 muscle injuries each season. Muscle injuries account for 31-46% of all injuries in football, in comparison with sprain/ligament injuries and hematoma/contusion/bruise injuries, which constitute 18% and 16% of all injuries respectively (Ekstrand et al., 2011; Ekstrand et al., 2011).

Each season, 37% of players will miss training or matches due to muscle injuries (Ekstrand et al., 2011). Half of the injuries will be minor, causing absences of less than a week or up to three weeks. However, as many as eight or nine injuries may be severe causing absences of more than four weeks. The incidence of injury in elite players has been reported to range between 25-35 per 1,000 match hours, and 6-7 per 1,000 training hours (Ekstrand et al., 2011). In comparison, the incidence of injury in elite youth players per thousand hours has been reported to be less during matches (n=16 injuries) but similar during training (n=6) (Nilsson et al., 2016). Almost one-third of all injuries in professional football are muscle injuries, with the majority (92%) affecting the four major muscle groups of the lower limbs: hamstrings 37%, adductors 23%, quadriceps 19% and calf muscles 13%.

In competitive matches, 43% of all muscle injuries have been reported to occur during the first and final 15 min of a game (Rahnama et al., 2002).

FOOTBALL INJURIES

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These observations reflect the intense engagements in the opening stages and the possible effect of fatigue in the final stages of a match. Thus, specific nutrition strategies to delay fatigue during games may also have an important role in injury prevention (Medina et al., 2014). Football specific activities lead to both transient in game and post-match fatigue that is linked to a combination of factors, including dehydration, glycogen depletion, muscle damage and neuromuscular fatigue (van Beijsterveldt et al., 2013).

The magnitude of competitive exercise-induced fatigue is dependent on intrinsic and extrinsic factors. Extrinsic factors include the result, quality of the opponent, match location and playing surface; whereas intrinsic factors include training status, age, gender and muscle fibre type. Both intrinsic and extrinsic factors have the potential to influence the time course of recovery from fatiguing exercise. Furthermore, some authors have proposed that players may experience chronic fatigue as a consequence of insufficient recovery time between games (Ekstrand et al., 2011; Schwellnus et al., 2016). This makes the monitoring of fatigue highly complex and no one factor is definitive in the management of a player’s recovery (Nedelec et al., 2012).

In football, the demands placed upon professional players are high. The increased fixture schedule coupled with the reduced recovery duration between competitive matches contributes to increasing injury risk (Dellal et al., 2013). In addition, any mismanagement of training load or training intensity

between games may also confound this risk (Malone et al., 2016). It has been suggested that when the recovery time between two matches is 72 to 96 h, there is sufficient recovery time to maintain the level of physical performance. However, 72-96 h recovery time between matches may not be long enough to maintain a low injury rate (Dupont et al., 2010).

During periods when the schedule is particularly congested (i.e. two matches per week over several weeks), the recovery time allowed between two successive matches lasts three to four days, which may be insufficient to restore player homeostasis. As a result, players may experience acute and chronic fatigue potentially leading to underperformance and/or injury (Nedelec et al., 2012; Rollo et al., 2014).

For example, in elite European football, players play between 51-78 games a season, averaging 1.6 to 2 matches per week (excluding friendly games). Specifically regarding FC Barcelona, 80% of the professional squad averaged 65 official competitive games throughout seasons 2010-2013 (Medina et al., 2014). Dupont and colleagues (2010) reported a 6.2-fold higher injury rate in players who played two matches per week compared with those who played only one match per week.

Consequently, during congested schedules, recovery strategies are commonly used in an attempt to regain performance faster and reduce the risk of injury (Nedelec et al., 2012).

Muscle injuries are among the most common injuries in sports and continue to be a major concern because of training and competition time loss, challenging decision making regarding treatment and return to sport, and a relatively high recurrence rate (Valle et al., 2016). Muscle strength loss and atrophy markedly appear within five days of immobilization due to a rapid increase in muscle protein breakdown (MPB) followed by a decrease in muscle protein synthesis (MPS). Around 150 g of muscle mass is lost per day, equivalent to 1 kg/week, with type II muscle fibres being the most susceptible to atrophy ( Wall & van Loon, 2013). After ten days, muscle loss is mainly caused by MPS inhibition, basal and post-prandial, causing atrophy and functional loss.

The decrease in MPS, even post-prandial and known as “anabolic resistance”, is conditioned by inactivity and injury. Cytokines and catabolic factors, such as myostatins, block the processes in a similar response to aging-related sarcopenia (Wall et al., 2013). Thus, the effectiveness of protein ingestion is impaired and even in the presence of adequate levels of amino acids, protein synthesis is clearly inferior to the situation of no injury. The key issue seems to be muscle stimuli, since anabolic resistance will remain as long as muscle stimulation is lacking. Of note are methods such as percutaneous electro-stimulation and training the uninjured limb or other muscle groups that can exert some cross effect to diminish the anabolic resistance (Farthing et al., 2009). The use of electro-stimulation may be considered prior to bed time protein feedings to increase the

MUSCLE INJURIES


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incorporation of amino acids into the activated muscle (Dirks et al., 2016). From a nutrition perspective, the use of some supplements such as leucine, may partially attenuate the decrease in MPS through the activation of mTOR (van Loon 2012). Leucine is an essential amino acid found in greater amounts in proteins of high biological value (i.e. whey protein). The ingestion of three grams of leucine, isolated or contained in protein, is capable of activating MPS in muscle resistant to insulin (Katsanos et al., 2006). Food also offers a good source of leucine; for example, 3 g of leucine can be found in 25-30 g of whey protein, 140 g of chicken or 170 g of fish.

The catabolite of leucine, beta-hydroxy beta-methylbutyrate (HMB) ingested at 3 grams per day has also been reported to be an effective supplement in the activation of MPS (Molfino et al., 2013). When injury results in obligatory bed rest, the ingestion of HMB in similar quantities has also been reported

to reduce the degree of muscle loss. Therefore, HMB ingestion may be considered in the preservation of muscle mass in the injured player (Wu et al., 2015)

Unfavourable lipid profiles (pro-inflammatory) due to excesses in the diet of trans-fat, saturated fat and excessive omega-6 fat from vegetable oils should be avoided. Instead, players are encouraged to regularly eat foods, such as oily fish, for a source of omega-3 (Simopoulos, 2007). Furthermore, the daily ingestion of 4-5 g of fish oil has been reported to improve muscle sensitivity to anabolic stimuli, resistance exercise and protein. Therefore, the ingestion of omega-3, in combination with the ingestion of protein and HMB may be effective in maintaining muscle mass (Smith et al., 2011; Smith et al., 2011; McGlory et al., 2016), especially in the immobilised player (Zwart et al., 2010). Nutritional compounds to stimulate muscle growth and or prevent muscle

loss continue to be investigated, these include, amongst others, curcumin (Drobnic et al., 2014; Franceschi et al., 2016). However, these compounds are typically investigated in clinical or elderly populations.

We encourage both more research and case studies to be shared on the use of novel “bioactive” compounds in young athletic populations, such as footballers. Finally, it is important to note that regardless of the phase of injury, players are encouraged to sustain an adequate level of hydration (Chapter 6). A summary of fundamental and potential nutrition strategies to consider following an injury are displayed in Figure 8.1 (for a detailed review see Wall et al. (2015).

Modify Energy intake

Hydratation 5-7 ml/kg BM

Protein 20-30 g/meal 4-6 meals/day 30-40g before sleep

Omega 3 Fish Oils (4g/day)

HMB (1,5g x 2/d)

Vitamin D

Creatine (20g/d x 5d, 5g/d

FUNDAMENTALS CONSIDERATIONS

< Figure 8.1. Nutrition interventions that are fundamental and of consideration to the injured player. For a comprehensive review, see Wall et al. (2015).


12

In comparison to muscle, the science of nutritional interventions to improve soft tissue function is in its infancy (Baar 2015). The physiology of tendons and ligaments is different to muscle (Kjaer et al., 2009). This is because tendons and ligaments have limited blood flow, and they are dependent on nutrient delivery though bulk fluid flow (Baar 2015). Thus, nutritional interventions to improve soft tissue function need to be different and independent to those designed for muscle. Studies in vitro have reported that providing the amino acid proline with Vitamin C may improve collagen synthesis (Paxton et al., 2010).

These initial findings have recently been substantiated in an athletic population. Specifically, the ingestion of gelatin has been reported to be effective in increasing circulating concentrations of the amino acids glycine, proline, hydroxyproline, and hydroxylysine (Shaw et al., 2016).

Furthermore, the ingestion of gelatin (15 g ingested with 50 mg Vitamin C) 1 h prior to exercise increased blood markers (amino-terminal propeptide of collagen I) related to increased collagen synthesis (Shaw et al., 2016). Although more research is required, the ingestion of gelatin is a promising nutritional intervention to improve both the function of connective tissues and speed the recovery from musculoskeletal injuries. Furthermore, this intervention may be of great relevance to those populations who experience a high incidence of ligament injury, such as female players (Celebrini et al., 2012; Celebrini et al., 2014) (De Ste Croix et al., 2015).

The awareness of concussion (traumatic brain injury) in football is growing. This is due to those Institutes dedicated to understanding, preventing and treating concussion (for example: Sports Legacy Institute 2007, Boston University; Azheimer’s Disease Center), as well as popular media reporting the concern of parents of juvenile players participating in football in the United States.

The incidence rate for concussion has been reported to be 1 per 1000 playing hours for men and 3 per 1000 player hours for women (Dvorak et al., 2007) and a similar rate has been described at FC Barcelona (Muñoz et al., 2015; Drobnic et al., 2016).

CONNECTIVE TISSUE INJURY

CONCUSSION Thus, in comparison to muscle injuries the incidence of concussion in football is low (Faude et al., 2017). Nevertheless, players, coaches, and medical staff should be aware of the signs, symptoms, and evaluative techniques of concussion (Delaney et al., 2002; Broglio et al., 2010). To this end, we have included discussion on potential nutrition interventions relevant to concussion.

A concussion is characterised by any alteration in cerebral function caused by a direct or indirect force transmitted to the head (Delaney & Frankovich 2005; Delaney et al., 2014; Partridge 2014). It is important to players and staff to recognise the symptoms of concussion, which include: a brief loss of consciousness,


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The hypothesis of injury prevention in football, from a nutrition perspective, is to avoid fatigue. This is because physical and mental fatigue are likely to impair decision making and the ability of the player to be reactive to the physical demands in football (Chapter 2). Strategies involving hydration, diet and sleep have all been reported to be effective with regard to their ability to counteract the mechanisms associated with muscular fatigue (Nedelec et al., 2012). Details of sleep and other methods important for recovery have been comprehensively reviewed (Halson et al., 2003; Halson 2013; Nedelec et al., 2015; Nedelec et al., 2015).

Excess body fat causes more mechanical stress in weight-bearing football activities, thereby increasing the risk of injury. Interestingly, abdominal fat (assessed by DXA or abdominal circumference) has been reported as a better predictor of muscular-skeletal injury than body mass index (BMI); this correlation increases with age (Nye et al., 2014). In addition, excess body fat may also decrease the skeletal muscles ability to regenerate post injury (Akhmedov & Berdeaux 2013). Therefore, the management of body fat is an important consideration both as a preventative and regenerative strategy. It is important to note that although BMI is frequently used for the general population, players with low body fat and high muscle mass are classified “overweight”. Thus, the use of BMI to monitor body composition in football players is inappropriate (Chapter 2). Body composition varies during preseason; a general decrease in abdominal fat mass and increased lean mass in the legs are typically observed (Devlin et al., 2016)(Sutfatton et al, 2009). Conversely, during a long period of injury an overall decrease in lean mass is noted, with more marked changes in muscle atrophy and fat deposition in the injured region or segment (Reinke et al., 2009).

PREVENTATIVE MEASURES

BODY COMPOSITION

light-headedness, cognitive and memory dysfunction, vertigo, tinnitus, blurred vision, difficulty concentrating, amnesia, headache, nausea, vomiting, photophobia and/or a balance disturbance. Delayed symptoms may also be evident through fatigue, personality changes, depression, lethargy and sleep irregularities (Aubry et al., 2002; Delaney & Frankovich 2005). Full pathology of concussion is beyond the scope of this chapter. However, any player who experiences concussion or has a history of concussion should report this to their medical team.

To date, there is little evidence regarding nutrition interventions and concussion and those that are recommended are based on results from rodent studies which have provided antioxidant and anti-inflammatory compounds (Mills et al., 2011; Tipton 2015) as well as recent studies investigating the remodelling and restorative processes of long term cognitive function (Pu et al., 2016). Based on the available literature firm nutritional guidelines cannot be made.

Although various supplements may be considered, the main compounds currently under investigation and of interest are omega 3 fatty acids and creatine (Ashbaugh & McGrew 2016). This is because the ingestion of high dosages of omega 3 fatty acids may improve the short term outcomes following concussion (Lewis 2016). This may be achieved via neurite growth, increased neurite branching, and subsequent synaptogenesis, resulting in enhanced synaptic function and improved neuronal repair after head injury (Kim & Spector 2013). Furthermore, supplementation with omega 3 fatty acids prior to sustaining a

concussion may protect against reduced plasticity of neurons and impaired learning (Wu et al., 2011). The ingestion of omega 3 fatty acids has been reported to normalise levels of proteins associated with neuronal circuit function and locomotor control after sustaining a concussion (Wu et al., 2011).

Finally, creatine supplementation may improve cerebral energetics (Pan & Takahashi 2007; Turner et al., 2015). This may result in improved cognition, communication, self-care, personality, and behaviour (Sakellaris et al., 2006) and significantly reduce the magnitude of symptoms such as headaches, dizziness and fatigue (Sakellaris et al., 2008). However, further research is needed on nutrition and concussion and specifically in football populations

Furthermore, recovery strategies involving the ingestion of protein, carbohydrate and fluid are discussed in chapters 3, 4 and 5 respectively. Thus, here we summarise those dietary considerations which may have direct or indirect implications for injury prevention.


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14 Body composition should be assessed at the time of injury, specifically the quantification total body mass, lean mass and fat mass (Chapter 2). Changes in body composition during injury typically involve increased body fat and decreased lean mass from an early stage (Wall et al., 2013; Wall et al., 2015). These changes are not always reflected in body mass, as body mass may increase, decrease or stay relatively constant depending on the ratio of lean- and fat mass change (Peterson et al., 2011).

Injury prevention models have been proposed based on the ratio of different tissues. Schinkel-Ivy and colleagues describe the ratio of components of the lower extremity; showing the ratio between soft and hard tissues, defined as “Tissue mass ratio”. This ratio differs according to sports and is believed to be optimized by adaptation to the type of stimulus or impact received (Schinkel-Ivy et al., 2014). Thus, this ratio may be of

consideration when planning nutritional interventions and in the prevention and monitoring of injury. Barbat-Artigas et al. (2012) reported that the fat mass to bone mass ratio of a limb correlates inversely with the risk of injury, being lower in non-injured athletes in comparison to those who have suffered injury (Barbat-Artigas et al., 2012).

Other indices such as “muscle quality index” correlate the muscle area of a limb and the force or power output (Fragala et al., 2014). This index may be a useful evolutionary parameter when monitoring changes in muscle mass and function in limbs during the development of a player or during a period of immobilisation and subsequent return to play. Finally, measuring body composition (Chapter 2) can identify muscle imbalances, especially in the lower limbs. Improved symmetry between the left and right legs may reduce the risk of injury and may also benefit performance (Rahnama et al., 2005; Hart et al., 2014).

The energy intake of the player should match the daily energy demands and the phase of recovery (Milsom et al., 2014) (Chapter 2). To recap, the energy cost of football is approximately 1,000-1,500 kcal for a 90-min game, depending upon playing position, tactics and body composition of the player. The amount of energy required may be adjusted to reflect the lean body mass (in kg) of the individual player. Global positioning satellite technology can be used as a tool to approximate the energy cost of daily training sessions (Ehrmann et al., 2016). An insufficient energy intake will not cover energy required for performance, training and daily living activities. Furthermore, it has been reported that energy intakes below 30-35 kcal/kg lean body mass (excluding exercise) accentuate fatigue, immune-suppression and the predisposition to injury (Loucks et al., 2011). During a period of injury, negative energy balances should be avoided to ensure wound healing is not slowed and muscle loss exacerbated (Biolo et al., 2007). For example, even increasing protein intake above habitual levels of ingestion is insufficient to maintain lean body mass, strength or physical performance during prolonged energy intake restriction in overweight older adults (Backx et al., 2016).

It is important to also note that following injury, energy expenditure may be increased by 15-50% depending on the severity of the injury (Frankenfield 2006). Therefore, it is important to approach the recovery from multidisciplinary perspective to ensure any dietary modifications are appropriate to the classification of injury (Valle et al., 2016).

ENERGY INTAKE


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Nutritional interventions should be coordinated with the different phases of the recovery process to optimize the healing process. From this perspective, injury may be classified in two distinct phases: the immobilisation phase and the functional recovery phase (rehabilitation and re-training). During these phases muscle wasting and atrophy are commonly observed.

For a practical example, a case study published in 2014 reported the muscle loss and gain of an elite professional player in response to an anterior cruciate ligament injury. Importantly, the case study describes the nutrition practice which complemented the appropriate phase of return to play (Milsom et al., 2014).

NUTRITION IN THE DIFFERENT PHASES OF RECOVERY FROM INJURY

Low energy diets in which calories are not consumed via a variety of foods typically have low nutritional quality. Insufficient energy intakes combined with poor dietary choices increase the risk of players being deficient in micronutrients such as Vitamin C and minerals like iron, calcium, magnesium and zinc (Chapter 3). Interestingly, inadequate plasma vitamin D concentrations have been observed during the winter months in top-level football players (<30 ng/mL) (Morton et al., 2012).

Low vitamin D may affect bone metabolism and has been associated with alterations in strength and muscle components. Therefore, maintaining vitamin D status may be a consideration in injury prevention and the recovery process (Owens et al., 2016).

Dupont et al. (2010) reported that the injury rate increases according to hours of football exposure. However, the risk of injury is significantly increased when games overlap training with less than 72 h between them. In this circumstance (a recovery period under 72 h) it is necessary to emphasize optimal nutritional recovery strategies. Specifically, the restoration of muscle glycogen after exercise can be achieved by ingesting approximately 60 g of carbohydrates per hour during the first 2-3 hours (Rollo 2014). Protein intake is recommended immediately post exercise (0.3 g/kg BM, ~20-25 g), together with appropriate volumes of fluid to rehydrate, as covered in Chapter 6 of the current document (Laitano et al., 2014). Studies have reported the use of curcumin (Davis et al., 2007; Drobnic

et al., 2014) and “tart cherry juice” (Bell et al., 2016) as effective nutritional anti-inflammatory aids to reduce muscle soreness. Thus, these may be of benefit when recovery time between competitive matches is inadequate. However, evidence is currently limited, specifically to their application for injured players.

Finally, it is important to consider nutrition advice on what to avoid during injury. Beyond an excessive energy intake, alcohol intake should also be discouraged. This is because players may ingest excessive alcohol when unmotivated or seeking distraction from not being involved in the daily exercise routine of football (Tipton 2015).

Alcohol intake after training and competition reduces rates of myofibrillar protein synthesis even if co-ingested with protein (Parr et al., 2014). Therefore, the suppression of the anabolic response in skeletal muscle will impair recovery and adaptation to the rehabilitation program of the injured player.


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16

The acute injury phase is characterized by inflammation and, depending on the injury, immobilisation, reduced weight bearing and rest. The daily energy intake needs to be adjusted to the current needs, which are generally lower than before the injury due to lower activity (Milsom et al., 2014).

It is important to note that some metabolic stress injuries require an increase in energy requirements, such as bone fractures or walking with crutches. However, detailed discussion on how energy intake should be adjusted for specific injuries is beyond the scope of the current policy and professional guidance should be sought.

During the acute injury phase, a protein intake of up to 2 g / kg BM per day is recommended (Tipton 2010). Protein requirements can be achieved by either ingesting food or supplements containing protein of high biological value at regular intervals throughout the day (fractional dose of 25-30 g, Res 2014). One strategy is to ingest high quality protein sources, rich in leucine, between meals at mid-morning and mid-afternoon. Beside whey protein, this can also be achieved by ingesting a variety of protein sources, for example codfish and plant based proteins (Dort et al., 2012; Dort et al., 2013; van Vliet et al., 2015).

Although non-essential amino acids are not generally believed to be important for the regulation

In this phase the exercise workout is focused on the non-injured muscle groups. General guidelines include adjusting calories to lean mass and controlling carbohydrate intake, and choosing low glycaemic index foods such as vegetables and legumes.

Protein intake is prioritized after exercise (20-25 g/serving). Interestingly, this phase may benefit from creatine supplementation (Tipton 2010). Creatine loading has been recently shown to be ineffective in preserving muscle mass during immobilisation (Backx et al., 2017).

However, creatine has been suggested to help with the recovery of muscle mass following immobilization when supplemented individuals are compared to non-supplemented individuals. (Op ‘t Eijnde et al., 2001). An easy way to achieve this is to incorporate creatine into any smoothies or protein based beverages that the player is ingesting.

This phase is characterized by progressive hypertrophy and functional recovery. In long-term injuries this phase can be subdivided into regeneration, functional recovery and reconditioning, as discussed below:

ACUTE INJURY PHASE REGENERATION PHASE

FUNCTIONAL RECOVERY PHASE

of protein synthesis, studies have indicated that some of these amino acids can manipulate muscle protein metabolism during conditions of (chronic low-grade) inflammation or oxidative stress (Domingues-Faria et al., 2016).

For example, the amino acid glycine is thought to modulate the production of inflammatory cytokines; thereby reducing the negative impact of these cytokines on protein metabolism (Wheeler et al., 1999; Roth et al., 2003)Finally, protein intake prior to sleep is also recommended, in this instance 30-40 g of the slow-release protein casein is a good choice (Trommelen et al., 2016; Trommelen & van Loon 2016). Fat intake recommendations should be focused on omega-3 rich foods such as oily fish, dried nuts, olive oil and avocado, and excess omega-6 intake should be controlled, where possible, as well as other sources of saturated fat. As commented above, supplementing with omega-3 in doses of 4-5 g per day may also be relevant to the injured player.


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This phase involves a progressive return of the athlete to the field of play. The greater energy expenditure, as training volume and intensity increases, requires an increase in daily carbohydrate intake to about 3-5 g of carbohydrate/kg (Chapter 5). Appropriately formulated carbohydrate sports beverages are typically ingested during and after exercise to help meet player fuel and fluid requirements (Rollo 2014). After exercise, recommendations for protein (Chapter 4) are maintained.

In summary, the demands placed upon professional players are growing because of increased fixture schedules with less recovery periods between training and competitive match play, resulting in an increased risk of injury. Appropriate nutrition should be used in daily living and during exercise to avoid fatigue.

Recovery strategies are commonly used in an attempt to regain performance faster and reduce the risk of injury. The assessment of body composition is important for elite players. Abdominal fat is a good predictor of musculoskeletal injury and can be used as a monitoring tool during recovery from injury. Nutrition is among the key recovery strategies in professional sport and interventions for recovery should focus on adequate energy intake to meet the macro and micronutrient needs via foods and appropriate supplementation (Chapters 2, 3 and 7).

During injury, muscle protein synthesis is reduced by inactivity and, as a result, the muscle should be stimulated, in concert with the ingestion of suitable quantities of protein with high biological value. During recovery from injury the nutrition principles are not too different from those for optimizing protein synthesis in muscle.

Thus, recommendations for protein intake are similar to those discussed for healthy players (Chapter 4). However, it is important

In this phase previous recommendations, in line with optimal nutrition practice for the player, should be adapted to ensure, and help support, full recovery (advice on key macronutrients, protein, carbohydrate and fluid for football are discussed in previous chapters 4, 5 and 6, respectively).

FUNCTIONAL RECOVERY SUMMARY

RECONDITIONING OR ALTERNATIVE TRAINING PHASE

to consider overall energy intake, in relation to energy expended. Finally, we recognise that severe musculoskeletal injuries and surgeries are also associated with significant psychological challenges for the player (Gouttebarge et al., 2016). Thus, following injury, a multidisciplinary approach, which includes nutrition, is required for the clinical care and support of footballer


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