SPORTS

NUTRITIO

N

F O R HE A LT H P

R O F E S S I ON A L S

Dr. Orion Hunter Levi 2015

SECTION 1

F R O M FO O D T

O FU E L

CARBOHYDRATES (CHO) – 4 CAL/GRAMSimple Carbohydrates Monosaccharides Disaccharides

Complex Carbohydrates Oligosaccharides Polysaccharides

SIMPLE CARBOHYDRATESMonosaccharides• Glucose• Predominate form in nature; basic building block of other carbs

• Fructose• Sweetest; found in fruit

• Galactose• Often bound with glucose to form lactose (in milk)

• Bound by glycosidic bonds to form more complex molecules

• Body uses glucose; so convert fructose and galactose

DISACCHARIDESLactose• Glucose + Galactose• Dairy (milk, yogurt, ice cream)

Sucrose• Glucose + Fructose• Table sugar

Maltose• Glucose + Glucose• Malt sugar

Honey is a natural form of sucrose that is made from plant nectar and harvested by honeybees, which secrete an enzyme that hydrolyzes sucrose to form glucose and fructose.

Oligosaccharides and Polysaccharides

Oligosaccharides• Chain of 3 – 10 simple

sugars• Fructooligosaccharides

• Found in fruits/veggies• Commercially produced

as low-cal sweetener• Mostly indigestible

• Help relieve constipation, improve TG levels, decrease foul-smelling stool

Polysaccharides• Hundreds of monosaccharides bound together• Starch

• Produced by grains and veggies• Amylose

• Small linear molecule of tightly packed glucose molecules

• Mostly resistant to digestion• Amylopectin

• Larger, highly branched chain of glucose molecules that is easily digested

• Cellulose• Low viscosity starch made of long chains of

glucose; structural component of the cell wall in plants that is indigestible to humans

• Fiber• Largely indigestible 2/2 lack of enzymes to disrupt

glycosidic bonds• Some fiber Is fermented in large intestine for

energy to flora• 1.5 – 2.5 cal/gm

• Glycogen• Polysaccharide that is a highly branched chain of

glucose molecules• Chief carb storage material in animals formed and

stored in liver and muscle

COMPLEX CARBOHYDRATES

CARBOHYDRATE DIGESTION

PRO-DIGESTIO

N ENZYMES

CARBOHYDRATE METABOLISM

• Glucose C02 + H20 + ATP• Liver: 90 gm glycogen• Muscle: 150+ gm glycogen• Excess carbs adipose tissue

HORMONE REGULATIONInsulin• Postprandial rise in BG• Aids in cellular glucose uptake• Promotes conversion of carbs into fat for LT storage• When sugar is abundant and glycogen stores maximized

Glucagon• Low BG levels• Increase BG levels• As glycogen levels decrease, glucagon metabolizes fat from storage

for fuel to help conserve glycogen and maintain BG levels

GENERAL CARBOHYDRATE RECOMMENDATIONS• Acceptable Macronutrient Distribution Ranges (AMDR)• Range assoc. with reduced risk for chronic dz while still providing adequate intake of

nutrients (ie vit/min)• For carbs: 45% to 65% of total cal intake

• Recommended Dietary Allowances (RDA)• Amount of nutrient known to be adequate to meet the nutritional needs of nearly all healthy

persons• For carbs: 130 gm/day• Min based on brain needs (so need more for body reqs)

• Academy of Nutrition and Dietetics/ACSM• Carb needs for athletes: 6-10 g/kg (2.7 to 4.5 g/lb) of body wt daily• Depends of total daily energy expenditure, types of exercises performed, gender,

environmental conditions to maintain BG levels during exercise and to replace muscle glycogen

GLYCEMIC IN

DEX

A N D GLY C E M I C

LO A D … O H , A

N D FI B

E R

GLYCEMIC INDEX• Ranks carbs based on their BG response; based on reference amt

(50 gm)• High GI• Enter bloodstream rapidly large BG spike insulin spike

muscle glucose uptake and fat deposition in adipose tissue• From 2 – 4 hrs postprandial, residual effects of insulin spike can

lead to hypoglycemia• Low GI• Digested slowly small BG increase small insulin boost

GLYCEMIC LOAD• Accounts for portion size• Glycemic Load (GL) = GI x grams of carbs ÷ 100• A food can have high GI but a low GL• i.e. carrots have high GI, but 50 gm carrots = 4 cups, but since

serving size is ½ cup, then GL is low• Carb foods that are also mod to high in fat or protein, fiber, and other nutrients and that are min processed may have a high GI and low GL• Benefits of Low GI foods• Weight control• Decreased risk of diabetes and CVD• Usu more nutrient dense• i.e. 16 oz soda has same amt of carbs as 2 med-size apples

Functional Fiber• Nondigestible carbs

isolated from food or added to food products, with potentially beneficial health effects• Improved GI sxs, wt loss, dec

cholesterol, colon ca prevention• Food labels:

• Isolated nondigestible plant carbs• Resistant starch, pectin, gum

• Animal carbs• Chitin, chitosan

• Commercially produced carbs• Resistant starch, polydextrose,

inulin, indigestible dextrin

Dietary Fiber• Nondigestible carbs and

lignins that are obtained naturally from plant foods• High viscosity (soluble) fiber

• A type of fiber that forms gel in water; may help prevent CVD and stroke by binding bile and cholesterol, diabetes by slowing glucose absorption, and constipation by holding moisture in stools; includes gums, pectin, psyllium seeds

• Low viscosity (insoluble) fiber:• Fiber that does not bind with water and

adds bulk to the diet (includes cellulose, hemicellulose, and lignins found in wheat bran, veggies, and whole grain breads and cereals); important for proper bowel bowel function and reducing sxs of constipation

FIBER = FUNCTIONAL FIBER + DIETARY FIBER

KEY POINTS1. Carbs serve many important functions in the body such as providing energy to fuel activity, sparing protein catabolism,

facilitating good cardiovascular and digestive health (fiber), and providing flavor to foods.

2. Carbohydrates are made of long chains of monosaccharides. All carbs can be converted to glucose in the body and used to provide or store energy. Carbs are stored as glycogen (90 g in liver; 150 g in muscle). Any carbs consumed beyond what the body can use or store as glycogen can be converted to fat.

3. Carbs provide 4 cal/g, except fiber, which passes through the body largely unabsorbed. Fiber provides 1.5-2.5 cal/g.

4. Natural and artificial sweeteners are made of carbs and are added to foods to increase palatability. Nonnutritive sweeteners contain 0 cal/g (nutritive- 4 cal/g).

5. Most ppl should consume 45% to 65% of total cal from carbs. Athletes need near the higher end with the rec from ACSM and ADN of 6 - 10 g/kg of body wt (or 2.7 – 4.5 g/lb) daily based on total energy expenditure, exercise type, gender, and environmental conditions.

6. The highest quality carbs are high in fiber and low in GL.

7. GI is a measure of BG response after consuming a carb. GL is based on how many gms of a particular carb of a given GI are consumed.

8. High GI carbs are rapidly absorbed by the body and cause a spike in blood glucose and insulin levels. Low GI carbs are more slowly absorbed and cause a much smaller, more gradual increase in glucose and insulin.

9. Fiber helps to improve health by delaying gastric emptying, improving cholesterol levels, regulating bowel movements, increasing feelings of satiety, and more. Most ppl don’t consume the recommended 14 g/1000 kcal consumed.

10. Carbs are the body’s preferred energy source during exercise. Restricting carb intake to < recommended amts will negatively affect athletic performance.

11. Carbs in and of themselves don’t contribute to wt gain or interfere w/ wt loss.

Large biological molecules, or macromolecules, consisting of one or more long chains of amino acid residues. Proteins perform a vast array of functions within living organisms, including catalyzing metabolic reactions, replicating DNA, responding to stimuli, and transporting molecules from one location to another. Proteins differ from one another primarily in their sequence of amino acids, which is dictated by the nucleotide sequence of their genes, and which usually results in folding of the protein into a specific three-dimensional structure that determines its activity.

PROTEIN

Complete protein

• A food item that contains all essential AAs

• Generally animal products

• Also plant-based soy, quinoa, chia seeds, buckwheat, hemp, flax seeds

Incomplete protein

• A food item that does not contain all essential AAs

• Generally plant products

PROTEIN QUALITY

WHEY PROTEIN

PROTEIN DIGESTION AND ABSORPTIONDenaturation- the process of unfolding a protein by destroying its

quaternary, tertiary, and secondary nature

AS WITHIN, SO WITHOUT

PROTEIN SYNTHESIS

PROTEI

N CATABOLIS

M

PROTEI

N DIGESTION

1) Stomach- HCL acidifies stomach, triggering activation of pepsin

2) Pancreas- secretes proteolytic enzymes into small intestines

3) Small intestines- trypsin further breaks proteins down into di- and tripepides cleaved into single AAs blood liver

4) Liver- regulates distribution of AAs throughout body

MUSCLE PROTEIN CATABOLISMGlucose-Alanine Cycle

PROTEIN RECOMMENDATIONS• RDA = 0.8 g/kg/day• Academy of Nutrition and Dietetics, Dietitians of Canada, ACSM• Endurance athletes = 1.2 – 1.4 g/kg (0.5 to 0.6 g/lb) daily• Strength-training = 1.6 – 1.7 g/kg (0.7 to 0.8 g/lb) daily

• IOM = “no compelling scientific evidence to support active individuals increasing their daily protein intake above the RDA of 0.8 g/kg)

• AMDR = 10 – 35% daily caloric intake

PROTEIN AND ATHLETICISM• Carb:Protein = 3:1

• Encourages + nitrogen balance muscle synthesis, hydration, energy• 6 – 20 gm protein and 30 – 40 gm carbs post-workout (w/in 3 hrs)

• As little as 5 – 10 gm protein immediately post-exercise can promote optimal muscle repair

• BCAAs• Combats fatigue when consumed during workout• Leucine 45 mg/kg/day; Isoleucine 22.5 mg/kg/day; Valine 22.5 mg/kg/day (2:1:1)

• Vegetarians• Should consume 10% more grams of protein daily than recs

• Plant proteins not as readily digestible• Need complimentary protein-rich plant foods

KEY POINTS1. Proteins play many critical functions in the body, including serving as the major structural

component of muscle.

2. Proteins are made of long chains of amino acids. There are 9 essential AAs, including 3 BCAAs, which play particularly important roles in muscle hypertrophy, as well as 11 nonessential AAs.

3. Egg and milk are the highest quality proteins; they contain all essential AAs and are easily digested and bioavailable. Whey protein is rapidly digested and best consumed shortly after exercise to facilitate muscle regeneration. Casein is released slowly into the bloodstream and is best consumed prior to exercise to minimize muscle catabolism.

4. Proteins consumed in the diet are broken down into AAs. AAs are continuously recycled through the removal and addition of nitrogen groups. Monitoring an athlete’s nitrogen status provides a glimpse into whether or not s/he is consuming adequate amounts of protein. The goal is for the athlete to consume more nitrogen (protein) than is excreted.

5. Perhaps the best way to determine protein needs is through the AMDR of 10% to 35% of daily energy intake. When discussing absolute numbers, there is not scientific consensus on exactly how much protein athletes need. However, the ACSM and ADN rec that endurance athletes consume 1.2 to 1.4 g protein/kg body wt (0.5 to 0.6 g/lb) and that strength athletes consume 1.6 to 1.7 g protein/kg (0.7 to 0.8 g/lb).

6. Vegetarian athletes need about 10% more protein than their meat-eating counterparts.

7. It is best to obtain protein through whole foods. If a client is considering supplementation, s/he should be referred to an RD or MD. Non-physician or non-RD health professionals should not endorse or rec supps.

FAT FARM• 1 gm fat = 9 calories• Lipids• Fat or fat-like substance used in body or bloodstream; includes

fats, oils, waxes, sterols, TGs, all of which are insoluble in water

Cholester

ol

CHOLESTEROL AND STEROIDS• Cholesterol- fat-like, waxy substance produced in liver

and found in cell membrane of all animal tissues cell structure and integrity• Adrenals glucocorticoid (cortisol) and

mineralocorticoids (aldosterone)• Testes, ovaries androgens and estrogens• Liver bile acids• Skin cholesterol becomes cholecalciferol with sun

exposure, then converted to calcitriol (active Vit D)

Susceptible to oxidation, distributing cholesterol to inner lining of arteries, leading to atherosclerosis

FATTY ACIDS AND TRIGLYCERIDES• Adipose tissue is an endocrine

organ!!!• Leptin- a hormone produced by

adipose tissue that suppresses the appetite and increases energy expenditure; levels increase with increased fat storage

• Resistin- hormone secreted by adipose tissue that decreases cell sensitivity to insulin

• TNF-alpha- helps regulate fat metabolism and contributes to acute inflammatory rxns

LEPTIN

RESISTINTNFa

FAT DIGESTION AND ABSORPTION1. Lingual lipase- enzyme released from mouth that begins

breakdown of short- and medium-chain FAs2. Gastric lipase – further digestion of fat3. CCK – triggered by fat in small intestine; stimulates release of GIP

(gastric inhibitory peptide) decreases gut movement and slows digestion

• Adipose Tissue Growth:• Hyperplasia- abnl increase in #

of cells• Hypertrophy- abnl increase in

size of current cells

• Two Types of Fat Cells:• White Fat- store fat and provide

thermal insulation• Brown Fat- help to generate

body heat; present in newborns; iron-containing mitochondria

FAT METABOLISM AND STORAGE

GENERAL FAT RECOMMENDATIONS• DRIs set AMDR of fat as 20% to 35% of total calories from fat• AI of linolenic acid (omega-3) is 1.6 and 1.1 gm/day for men and

women • AI of linoleic acid (omega-6) is 17 and 12 gm/day for men and

women• 2010 Dietary Guidelines for Americans:

• Fewer than 10% of calories from saturated fat• Less than 300 mg/day cholesterol• Consume more mono/polyunsaturated fats• Consume less saturated and trans fats• Avoid solid fats and added sugars

FAT AND HEALTH• Replace saturated fat with polyunsaturated fat whenever possible,

or otherwise with monounsaturated fat. Polyunsaturated fats lower LDL cholesterol and improve HDL:total cholesterol ratio, often by increasing the HDL component. Monounsaturated fats have a more neutral effect.

• Choose healthful fats over “low fat” foods that contain refined carbs, as these foods decrease HDL cholesterol, increase TGs, and overall worsen the atherogenic dyslipidemia assoc w/ obesity and insulin resistance.

• Consume omega-3 FAs in the diet at least 2x/week• Avoid trans fats, as they decrease HDL cholesterol and increase

total cholesterol.• Total fat intake and ratio of omega 3:6 FAs are not predictors of

heart health.• Exercise regularly to decrease LDL levels and prevent redux in HDL

assoc w/ a diet higher than recommended in total fat and saturated FAs.

FAT- WHAT TO TELL CLIENTS• Use liquid vegetable oils whenever possible• When solid fats are necessary, keep trans fats to a min.• Balance calories by limiting refined carbs and not through avoidance of

the healthy polyunsaturated and monounsaturated fats.• Limit saturated fats to less than 10% of total fat intake.• Dietary fats are never purely one type, but a combo.• Promote fruits, veggies, and whole-grain as ideal sources of carbs rather

than refined or processed carbs• Dietary patterns are more important than single dietary components. A

healthful eating plan includes fruits, veggies, unprocessed whole grains, fish, lean meat, low0fat dairy, and vegetable oils.

• Calorie balance should emphasize quality of food selection.

KEY POINTS1. Fats serve many important critical fxns in the body including energy storage, insulation, protection, transport of fat-

soluble vitamins, precursor to hormones, and cell membrane structure.

2. TGs consist of 3 FAs joined to a glycerol backbone. Both dietary fats and stored fats consist mostly of TGs.

3. Fat cells are called adipocytes. They are stored in the body as adipose tissue, a metabolically active endocrine organ that produces hormones that have been implicated in contributing to obesity and diabetes epidemics.

4. The major categories of FAs include saturated, monounsaturated, and polyunsaturated FAs. Polys (esp O-3 FAs) are the most heart-healthy fats, followed by monos. An emerging body of research suggests that saturated fats are not as bad for health as previously thought, though they are clearly inferior to the polys and monos. Polys that have trans fats are harmful to human health and should be avoided.

5. Dietary fat is digested and absorbed in the GI system. The digestion of TGs with short- and medium-chain FAs begins in the mouth and stomach, whereas the digestion of LCFAs doesn’t begin until the food has reached the small intestines. Fat digestion finishes in the small intestine, where lipid molecules are carried as micelles to the absorptive surface of the small intestine. Once the lipids are absorbed into the mucosal surface of the small intestine, they are reconfigured as TGs, phospholipids, and cholesterol. The lipids with short- and medium-chain Fas (the minority of Fas) can pass directly into the portal circulation and to the liver. The lipids with LCFAs, are carried as chylomicrons to the lymphatic system. The chylomicrons are carried to the liver, where TGs are repackaged into lipoproteins and transported primarily to the adipose tissue for metabolism an storage.

6. Fat is stored in large amounts in the human body. White fat cells serve as a reservoir of calories and energy. While brown fat cells- which are typically activate by cold- expend energy. Some researchers speculate that exercise may stimulate brown fat cells and may also act to convert some white fat cells into brown fat cells.

7. The AMD for fat is 20% to 35% of calories. The 2010 DGA rec that <10% of total calories come from saturated fat and that Americans consume less than 200 mg/day of cholesterol. The guidelines also advise Americans to avoid solid fats and added sugars (SoFAS).

8. To optimize heart health, health professionals should advise consumers to replace saturated fat with polys or monos whenever possible. Replacing sat fat with refined carbs doesn’t benefit health. Trans fats negatively affect health and should be avoided. Research suggests that adopting a low-fat diet doesn’t improve health or facilitate wt loss when compared to a higher fat diet of equal calories.

9. Health professionals must be knowledgeable of the latest advances in nutritional science as well as the latest trends among consumers to provide reliable nutrition info to consumers.

VITAMINS, M

INERALS,

ELECTR

OLYTES…

…A N D W

A T E R …

VITAMINSOrganic substances obtained from plant and animal foods that are

essential in small quantities for normal growth and activity of the body.

• Exceptions for the food source rule:• Vitamin K and biotin produced by normal intestinal flora• Vitamin D self-produced via sun exposure• Niacin synthesized from tryptophan• Vitamin A synthesized from beta-carotene

The reference values1. Recommended Dietary Allowances (RDAs)- the daily dietary intake of a nutrient known to meet the

nutritional needs of 97% of healthy persons in age- and gender-specific groups. The Food and Nutrition Board, an entity of the Institute of Medicine, establishes RDAs.

2. Estimated average requirement (EAR)- an amount of nutrient known to be adequate to meet nutritional needs in 50% of an age- and gender-specific group.

3. Tolerable upper intake level (UL)- the maximum intake that is unlikely to pose risk of adverse health effects to almost all individuals in an age- and gender-specific group.

THIAMIN- VITAMIN B1• Essential for carb metabolism and plays role in nerve fxn

RIBOFLAVIN- VITAMIN B2 •Antioxidant protection

through its role in redox

rxns•Carb, AA, and lipid

metabolism

NIACIN- VITAMIN B3• Cofactor for over 200 enzymes involved in carb, AA, and FA

metabolism• Lean meats, poultry, fish, peanuts, and yeast• Muscular weakness, anorexia, indigestion, and skin abnormalities

are early sxs of niacin def. can lead to pellagra (see below)

PYRIDOXINE- VITAMIN B6Plays improtant role in protein metabolism, RBC production,

glycogenolysis, conversion of tryptophan to niacin, neurotransmitter formation, and immune system fxn.

Deficiency leads to decrease dneurological and dermatological fxn weakend immunity

FOLATE• DNA production• Red and white blood cell formation• Neurotransmitter formation• AA metabolism• Deficiency leads to megaloblastic anemia, skin lesions, poor

growth• Excess folate can mask Vitamin B12 deficiency

COBALAMIN- VITAMIN B12Rich sources: clams, oysters, milk, eggs, cheese, muscle meats,

fish, liver, kidneyDeficiency- megaloblastic anemia and neuro dysfxn-

demyelination parasthesias, burning feet, stiffness and generalized LE weakness

BIOTIN- VITAMIN B7• The ultimate “helper vitamin”• Typically bound to protein, carries and carboxyl group (-COOH)• Plays important role in fxns of pantothenic acid, folic acid, vit B12• Deficiency uncommon

PANTOTHENIC ACID- VITAMIN B5Present in all plant and animal tissuesForms integral component of coenzyme A and acyl-carrier

proteinessential for metabolism of fatty acids, amino acids, and carbs, and as well as for normal protein fxnessential for synthesis of acetylcholine

Involved in the production of steroid hormones, Vit D, Vit A, and cholesterol

VITAMIN C• Plays a role as an antioxidant• Necessary to make collagen• Deficiency leads to scurvy

• Causes dark purplish skin lesions and spongy/bleeding gums• Improves iron absorption, promotes resistance to infection, and helps with

steroid, neurotransmitter, and hormone production• Sxs of deficiency: impaired wound healing, swelling, bleeding, and weakness

in bones, cartilage, teeth, and connective tissues

VITAMIN A• Vision, growth, development• Development and maintenance of epithelial tissue (including

bones/teeth)• Immune fxn• Reproduction

VITAMIN D• Vitamin D3

(cholecalciferol) from sun, animals, supps

• Vitamin D2 (ergocalciferol) from plants and supps

CALCITRIOL

Responsible for vitamin D’s biological effects

VITAMIN EProtects against conditions related to oxidative stress: aging, air

pollution, arthritis, cancer, CVD, cataracts, diabetes, infection

VITAMIN K

MINERALS!!!

MORE MINERALS!!!

MACROMINERALSMajor Elements• Body requires 100+ mg daily• Calcium• Phosphorous• Magnesium• Sulfur• Sodium• Chloride• Potassium

MICROMINERALSTrace Elements• Body requires <20 mg daily• Iron• Iodine• Selenium• Zinc• Copper• Chromium• Other minerals w/o established DRI

CALCIUMCalcium is the most abundant mineral in the body and serves various functions, including

mineralization of the bones and teeth, muscle contraction, blood clotting, blood-pressure control, immunity, and possibly colon-cancer prevention.

CALCIUM SUPPLEMENTATION• No more than 500 mg of calcium should be taken at a time because

this is the maximum amount the body can absorb at once. Calcium carbonate should be taken with food to help with absorption; calcium citrate can be taken with or without food

• High calcium intake can interfere with absorption of iron, zinc, manganese and can lead to constipation and nephrolithiasis

PHOSPHORUSAlong with calcium, phosphorus plays a key role in mineralization of bones and teeth. Phosphorus helps filter out waste in the kidneys and contributes to energy production in the body by participating in the breakdown of carbs, proteins, and fats. Phosphorus is needed for the growth, maintenance, and repair of all tissues and cells, and for the production of DNA and RNA. Phosphorus is also needed to balance and metabolize other vitamins and minerals including vitamin D, calcium, iodine, magnesium, and zinc. Too much phosphorus intake interferes with calcium absorption and may lead to decreased bone mass and density.

MAGNESIUM• Important for bone mineralization, protein production, muscle

contraction, nerve conduction, enzyme function, healthy teeth• Food sources: nuts, legumes, whole grains, dark leafy green

veggies, milk• High intakes of calcium, protein, vitamin D, and EtOH increase

body’s magnesium requirements• Depletion can occur as a result of aging, IDDM, hypermagnesuric

diuretics• Can contribute to many chronic illnesses and is assoc w/ heart

arrythmias and MI• Magnesium toxicity (very rare) may prevent bone calcification

SULFUR• Important component of many important body compounds• Cysteine and methionine• Thiamin, biotin, panothenic acid• Heparin

• Food sources: meat, poultry, fish, eggs, dried beans, broccoli, cauliflower

IRON• Regulates cell growth and differentiation• Production of hemoglobin and myoglobin• Fe stored in the body as ferritin for future use• Liver, spleen, bone marrow

• Fe released from breakdown of RBCs transferred to working cells via transferrin

IRON HOMEOSTASIS• Heme iron: from animal sources;

10 - 35% bioavailability• Nonheme elemental iron: from

plant sources; 2 - 10% bioavailability

• Increase Fe absorption via vitamin C

• Decrease Fe absorption via coffee/tea; excess Zn, Mg, Ca; high phytic acid (fiber)

SPORTS ANEMIA (PSEUDOANEMIA)• Athletes experience small amounts of exercise-induced blood loss• Urine, GI bleeding, high sweat rates, mechanical trauma• Leads to increased RBC destruction and loss of Fe

• Hg low; Fe normal• 2/2 increased plasma volume in response to physical training• Total Hg unchanged• Hg concentration decreased• Total Hg divided by total volume

IODINE• Stored in thyroid gland• Essential for normal growth• Food sources: seafood and iodized salt

SELENIUM

• Antioxidant• Deficiency: heart dz, hypothyroidism, weakened immune

system• Excess: (selonosis) GI distress, alopecia, white blotchy

nails, garlic breath, fatigue, irritability, nerve damage

ZINC• Found in almost every cell; 2nd most abundant trace element after

iron• Stimulates activity of enzymes, supports a healthy immune system,

assists in wound healing, strengthens the senses (esp taste and smell), supports normal growth and development, and helps with DNA synthesis

• Food sources: meat, fish, poultry, dairy, seafood• Deficiency: delayed wound healing, immune dysfunction• Toxicity: decreased HDL, impaired copper absorption, altered Fe

function

CHROMIUM• Trace mineral that helps to increase the effectiveness of insulin and

aids in glucose metabolism• Food sources: corn oil, clams, whole-grain cereals, brewer’s yeast• Deficiency and toxicity are very rare

COPPER• Helps make RBCs• Keeps nerve cells and immune

system healthy• Helps in formation of collagen and

cellular energy production• Acts as an antioxidant by

eliminating free radicals• Helps in the absorption of Fe• Food sources: oysters, liver, organ

meats, dried legumes• Deficiency rare: anemia, low body

temp, bone fractures, osteoporosis

ELECTROLYTESFour Essential Roles1. Water balance and distribution2. Osmotic equilibrium3. Acid-base balance4. Intracellular/extracellular differentials

SodiumPotassiumChloride

MICRONUTRIENT DIGESTION, ABSORPTION, DISTRIBUTION

ATHLETES RISK LOSING…• B vitamins• Vitamin C• Vitamin E• Beta-carotene• Calcium• Vitamin D• Selenium• Iron• Zinc• Magnesium

B VITAMINS AND EXERCISETwo essential roles:• Supporting energy production

• Thiamin• Riboflavin• Niacin• Pyridoxine (B6)• Pantothenic acid• Biotin

• Supporting formation of RBCs• Folate• Cobalamin (B12)

DRINK MORE H2O

KEY POINTS1. The DRIs provide recommended intakes of the vitamins and minerals depending on gender and age. While athletes may have higher

micronutrient needs compared to the sedentary individual, there are no sep DRIs for athletes. This doesn’t pose a problem for most athletes, as athletes tend to consume more calories and thus have more opportunities to obtain high levels of vitamins and minerals.

2. Vitamins are classified as water-soluble and fat-soluble. Waterisoluble vitamins include all the B vitamins and vitamin C. Fat-soluble vitamins include vitamins A, D, E, and K. Water-soluble vitamins have limited capacity for storage in human body, with deficiency resulting from months to rarely years (in the case of B12) of inadequate intake. Due to this decreased storage capacity, water-soluble vitamins must be taken in very large amounts to cause toxicity, as the body typically excretes excess vitamins in urine. Fat-soluble vitamins require fat for absorption and are readily stored in fat tissue in the body, which is helpful fro individuals at risk of vitamin deficiency, but potentially harmful for individuals who consume very large amounts of the vitamin, as fat-soluble vitamins are not readily excreted.

3. Minerals are classified as macrominerals and microminerals. Macrominerals are needed in larger amounts and include calcium, phosphorous, magnesium, sulfur, sodium, chloride, and potassium. Microminerals are needed only in small amounts and include iron, iodine, selenium, zinc, chromium, and others.

4. The electrolytes sodium, potassium, and chloride are macrominerals that play an important role in maintaining normal cellular function. All 3 electrolytes play at least 4 essential roles in the body: water balance and distribution, osmotic pressure, acid-base balance, and intracellular/extracellular differentials. An imbalance of electrolytes can cause severe disability or death.

5. The majority of vitamin and mineral digestion and absorption occurs in the small intestine. While vitamins are well absorbed and utilized by the body, the bioavailability of minerals is much less. Minerals with high bioavailability (> 40%) include sodium, potassium, chloride, iodide, and fluoride. Minerals with low bioavailability (1% to 10% absorptions) include iron, zinc, chromium, and manganese. (Bioavailability is 20% to 30% for heme iron.) All other minerals, including calcium and magnesium, are of medium bioavailability (30% to 40% absorption). Many factors affect a mineral’s bioavailability, including the effects of mineral –mineral interactions.

6. Antioxidants include vitamin C, beta-carotene, vitamin E, and selenium. Antioxidants fxn to prevent or repair oxidative damage. In the past, antioxidants were considered potent dz fighters. Subsequent research suggests the agents may not protect against dz and in excess some of them may act to increase the risk of cancer, heart dz, and mortality in some individuals

KEY POINTS7. A diet high in fruits and veggies is assoc. w/ lower risk of developing chronic dz, such as heart dz, cancer, and

possibly Alzheimer’s dz. Their beneficial effects could be due to antioxidants, fiber, agents that stimulate the immune system, monounsaturated fatty acids, B vitamins, folic acids, etc.

8. While nearly ½ of the adult population takes and multivitamin, there is no evidence to suggest that taking a multivitamin leads to improved health outcomes. Notable exceptions include folic acid for pregnant women and MD-directed treatment of iron deficiency and osteoporosis. There is also emerging evidence that many ppl could benefit from vitamin D supplementations

9. Athletes are at highest risk for low levels of the B vitamins, vitamins C and E, beta-carotene, calcium and vitamin D, selenium, iron, zinc, and magnesium.

10. Clients on very-low calorie or restrictive diets need to be aware of macronutrient uptakes to avoid deficiency.

11. Water makes up 50% to 70% of body wt. Its balance is essential for optimal health and performance. Water has many important fxns, including regulating body temp, protecting vital organs, providing a driving force for nutrient absorption, serving as a medium for all biochemical rxns, and maintaining a high blood volume for optimal athletic performance.

12. Water volume can be influenced by a variety of factors, such as food and drink intake; sweat, urine, and feces excretion, metabolic production of small amounts of water; and respiratory losses. These factors play an esp important role during exercise when metabolism is increased. The generated body heat is released through sweat evaporation, also releasing a solution of water, sodium, and other electrolytes.

13. Athletes need to consume sufficient – but not too much – water before, during, and after exercise to maintain fluid balance.

DIETARY G

UIDELINES

G E N E R A L R E C O MM

E N D A T I O N S A N D F E D E R A L N U T R I T I O N P O L I C Y

DIETARY GUIDELINES• Published q5yrs by USDA and Department of Health and

Human Services• Includes 23 recs for gen pop and 6 addl recs for special groups• 4 categories

1. Balance calories to achieve and maintain a healthy weight2. Foods and food components to reduce3. Foods and nutrients to increase4. Building healthy eating patterns.

DASH (DIETARY APPROACHES TO STOP HYPERTENSION)

MEDITERRANEAN DIET

MYPLATE1. Balance calorie intake with calories expended through physical activity.2. Enjoy food, but make sure proportions are appropriate; eat slowly; minimize

distractions (i.e. television; smartphones)3. Avoid oversized portions; utilize smaller plates, smaller serving sizes, mindful eating4. Eat more vegetables, whole grains, fat-free or low-fat dairy products (or dairy-free

alternatives) for adequate potassium, calcium, vitamin D, and fiber5. Make half of your plate fruits and veggies; most Americans need 9 servings of fruits

and veggies daily (2013 average adult in U.S. eats fruit 1.1x/day and veggies 1.6x/day)6. Switch to fat-free or low-fat (1%) milk or dairy alternative like almond/coconut milk7. Make at least half of grains whole grains; ensures adequate fiber intake and decreased

intake of processed foods8. Eat fewer foods high in solid (saturated/trans) fats, added sugars, and salt9. Compare sodium in foods and choose lower sodium version10. Drink water instead of sugary drinks to cut sugar and unnecessary calories

DIETARY REFERENCE INTAKES• RDA is the sufficient average intake for most healthy individuals.

RDA values may vary based on age and gender.• Estimated average requirement (EAR) is an adequate intake (AI) in

50% of an age- and gender-specific group• Tolerable upper intake level (UL), the maximum intake of a nutrient

that is unlikely to pose risk of adverse health effects to almost all individuals in an age- and gender-specific group.

• AI is used when a RDA cannot be determined. AI is a recommended nutrient intake level that is based on research and is sufficient for healthy individuals

FOOD LABELSClients should minimize intake of the first three nutrients:• Fat (esp sat and trans): clients

on a 2,000 cal/day diet should aim for a total per day of < 65 g total fat or < 20g saturated fat

• Cholesterol: goal of < 300 mg• Sodium: goal of <2,300 mg

REDUCE EXPOSURE TO FOODBORNE ILLNESS• Check produce for bruises and punctures, either may allow for

contamination.• Look for sell-by date for breads and baked goods, a use-by date on

packaged foods, an expiration date on yeast and baking powder, and a pack date on canned and some packaged foods.

• Make sure packaged goods are not torn, and cans are not dented, cracked or bulging to prevent contamination or botulism.

• Separate fish and poultry from other purchases by wrapping them separately in plastic bags. Once home, prevent leakage and cross-contamination.

• When shopping, choose refrigerated and frozen foods last. Try to make sure all perishable foods are refrigerated within one hour of purchase.

FOOD SAFETY• Wash hands often with warm water and soap for at least 20 seconds• Clean hands, food contact surfaces, and fruits and veggies; to prevent cross-

contamination, meat and poultry should not be washed or rinsed.• Separate raw, cooked, and ready-to-eat foods while shopping, preparing, and

storing foods• Cook foods to safe temp to kill microorganisms; pregnant women and ppl over

age 65 should eat deli meats only if reheated to steaming hot to reduce risk of infxn

• Refrigerate perishable food within 1-2 hrs and defrost foods properly; eat refrigerated leftovers within 3-4 days; “When in doubt, throw it out”

• Avoid raw (unpasteurized) milk (products), raw or partially cooked eggs, raw/undercooked meat/poultry, raw fish, unpasteurized juice, and raw sprouts• Esp infants, young children, pregnant women, older adults,

immunocompromised individuals

JAMA NUTRITION POLICYPolicy strategies to help increase nutrition and PA habits on a population level, to hopefully reduce obesity rates and improve health• Taxation: imposing higher taxes on calorie-dense and nutrient-poor foods might lower consumption of unhealthy foods and

generate revenue to subsidize healthful foods.• Food prohibitions: removing harmful ingredients from the food supply eliminates their health risks• Regulation of food marketing to children and adolescents: restricting food advertising during children’s programs,

counter-advertising to promote good nutrition and physical activity, limiting use of cartoon characters, and other regulations may help protect children who are otherwise unable to critically evaluate advertisements

• School policies: many school districts already have removed vending machines, provided healthier menus, and offered more PA opportunities for school children. Much worked remains ahead

• The “built’ environment: zoning laws to limit the number of fast-food restaurants, expand recreational facilities, and encourage healthier lifestyles would increase the ability for people to live and play healthfully, esp in poor neighborhoods where access to parks and healthy foods is severely limited

• Disclosure: restaurants and manufacturers could be required to disclose nutritional content and health warnings so that consumers make more informed decisions

• Tort liability: lawsuits against companies such as fast-food giants for selling “unreasonably hazardous’ products might force companies to offer healthier alternatives and provide accurate information

• Surveillance: similar to how health departments monitor ID, states could monitor chronic diseases like diabetes• “Training” Communities:

• Consider individuals within the larger social, economic, and cultural context• Form partnerships• Influence larger political and policy debates

KEY POINTS1. The 2010 Dietary Guidelines for Americans emphasize balancing calories to maintain a healthy wt; decrease

intake of solid fats, cholesterol, sugar, and to consume alcohol in moderation; increase fruits and veggies, whole grains, low-fat dairy, lean protein and seafood; adopt an overall healthy eating plan; and help to create a healthier environment that supports optimal nutrition and physical activity.

2. Overall, MyPlate encourages Americans to balance caloric intake and control portion sizes; make half of their plate fruits and veggies; make the other half of their plate protein and grains; choose 1% or fat-free milk; choose foods low in salt and saturated and trans fat; and drink water instead of sugary drinks.

3. Recommended nutrient intake is based upon reference values called Dietary Reference Intakes. The most commonly used DRI is the RDA, which is the amt of nutrient known to be adequate to meet the nutritional needs of nearly all healthy persons.

4. The Nutrition Facts Panel provides consumers important info to help make healthy nutrition decisions. Understanding how to interpret and evaluate the food label is a critical skill that health professionals should not only master but also be able to teach to clients.

5. When evaluating a food label, remember that there are 4 cal/g of protein and carbs and 9 cal/g of fat. A food with a percent daily value greater than 20% for any given nutrient is considered to be an “excellent source” of that nutrient.

6. Vigilance in choosing, storing, and preparing foods in a safe manner is essential to help prevent foodborne illness. Try to refrigerate foods within 1 hour of purchase and store leftovers within 2 hrs of prep. Keep leftovers in fridge no longer than 4 days.

7. Consider the potential social, community, environmental, and political changes when considering ways in which to help facilitate increased nutrition habits and physical activity.

SECTION 2

O P T I MI Z

I NG S

P O R T S PE R F O R M A N C E

THE POTENTIAL FOR ACTI(O)N

ATP AND MUSCLE CONTRACTION

GLYCOGENOLYSIS AND GLYCOLYSIS

OXYGEN AND NUTRIENT DELIVERY• Oxygen-carrying capacity: the body’s ability to obtain oxygen from the air inhaled

into the lungs and transported to the bloodstream; affected by 2 main factors:1. The ability to adequately ventilate the alveoli in the lungs2. Hemoglobin concentration in the blood

• Oxygen delivery: the ability of the body to transport oxygen from the lungs to the mitochondria of the working cells; the amount delivered is a function of cardiac output

VO2 MAXa measure of maximal oxygen uptake; liters of O2 consumed per

kilogram of bodyweight per minute; generally considered the best indicator of a person’s cardiovascular fitness and aerobic endurance (the more O2 used during intense performance, the more ATP is produced)

To increase VO2 max, exercise at 65-85%

max HR for >20min/day, 3-5 days/wk

AEROBIC GLYCOLYSIS- TCA

2 ATP8 NADH2 FADH6 CO2

Electron Tra

nsport

Chain

AEROBIC GLYCOLYSIS- OXIDATIVE PHOSPHORYLATION

2 ATP8 NADH2 FADH6 CO2

LYPOLYSIS AND FATTY ACID OXIDATION

ENERGY

DEAMINATION AND PROTEIN AS ENERGY

FOOD TO FUEL

LIPOGENESIS

OXYGEN CONSUMPTION AND EXERCISE

Respirat

ory

Quotient

GLYCOGENESIS

KEY POINTS1. Glucose is the body’s preferred energy source. It is delivered to the working cells from either the breakdown in

the muscle or liver through glycogenolysis or production from protein through gluconeogenesis or from food. The exogenous sources must first pass through the GI system, be absorbed in the small intestine, pass through the portal circulation to the liver, and then pass into the systemic bloodstream and track to the working cells.

2. ATP is the body’s usable energy. It is stored in miniscule quantities in the body’s muscle cells and must otherwise be produced through the phosphagen system, anaerobic glycolysis, aerobic glycolysis, or fatty acid oxidation.

3. The phosphagen system fuels high-intensity activity lasting 5-10 secs. The energy comes from the breakdown of stored muscle creatine phosphate and ATP.

4. Anaerobic glycolysis relies on breakdown of glucose immediately available from the bloodstream or muscle glycogen. The byproduct pyruvate gets converted to lactic acid. This system, which occurs in the cell cytoplasm without the presence of oxygen, provides the predominant source of ATP for activities lasting 1 – 3 minutes.

5. Aerobic glycolysis relies on the complete breakdown of glucose. Pyruvate is further broken down into acetyl-coA, which enters the TCA cycle. Aerobic glycolysis serves as the primary energy system for activities lasting 3 – 20 minutes.

6. Fatty acid oxidation requires oxygen, but also produces large amounts of ATP. Fatty acids are oxidized to acetyl-coA, which enters the TCA cycle. Fatty acid oxidation is the primary energy source for activities lasting longer than 20 min. Importantly, for fatty acid oxidation to continue, glucose must be present. Thus, if muscle glycogen stores are depleted, athletic performance falters.

KEY POINTS7. Protein is an energy source of last resort. In times of starvation or when there is low glucose availability,

ketogenic AAs can be converted to acetyl-coA to enter the TCA cycle while glucogenic AAs can be used to produce glucose. Athletes should strive to avoid the situation when protein is used as fuel since the majority of AAs can come from muscle tissue. This reinforces the concept of ensuring there is adequate carb intake so carbs are main source of energy.

8. At onset of anaerobic exercise the body produces ATP. It takes the body about 2 – 4 minutes to supply adequate oxygen to meet the metabolic demands. This absence of oxygen at the onset of exercise (oxygen deficit) leads to increased respiration at the end of exercise (EPOC) as the body tries to make up for the oxygen that wasn’t initially available.

9. The point at which exercise intensity increases beyond the body’s capacity to use oxygen for energy is known as VO2 max. To increase VO2 max, an athlete needs to increase the capacity for oxidation, such as through increased oxygen delivery and extraction. Each of these changes occurs with continued aerobic exercise, esp exercise that pushes the limits of ventilatory capacity. This is the reason why it is important to integrate sprints and other high-intensity exercise into an endurance training program.

10. Any excess carbs, protein , or fat consumes beyond what the body can immediately use for energy, muscle-building, or glycogen storage will be converted into and stored as fat.

11. Understanding and application of sports nutrition enables an athlete to set the stage for optimal athletic performance and accomplishment of new personal bests.

NUTRITIO

N STRATEGIES

F O R OP T I M

A L AT H L E T I C

PE R F O R M A N C E

GLUCOSE- FOOD TO FUEL• 1-4 hrs for carbs to be digested, absorbed,

and stored as glycogen in liver or muscle• Carbs can be ingested at 3 gm/min before

causing GI upset• Portal circulation is rate-limiting step in carb

food to fuel time• Max rate of carb absorption is 1.2 – 1.7

gm/min• Glucose released from liver at max 1 gm/min• Glucose uptake by muscle at max 1 g/min• Glucose ATP at ~ 1 g/min

CARBOHYDRATE DIVERSITY• Consumption of carbs with 2-3 diff saccharides (ie glucose, fructose,

and sucrose) may increase carb absorption bc diff transport mechanisms from small intestine to bloodstream are used• Less competition for transporters• Enhanced athletic performance• Decrease GI upset during exercise

CARBOHYDRATE LOADINGEating pattern that consists of increasing the amount of

carbohydrates consumed in the days leading up to an athletic endurance event to maximize muscle and liver glycogen stores. Typically, activity levels are decreased during this time as well

• Increased muscle and liver glycogen storage• Improvement in athletic performance• 7-day, 6-day, and 1-day protocols in two stages:

1. Glycogen depletion stage: moderate-to-high intensity exercise to deplete glycogen stores, coupled with low-to-moderate carbohydrate intakes (<55% of total kcal)

2. Glycogen loading stage: tapered exercise (low-intensity, short-duration), coupled with high carbohydrate intakes (>70% of total kcal)

• Two methods: classical and modified

CLASSICAL CARB LOADING• Two sessions of intense exercise to exhaustion to deplete glycogen• Two days of less than 10% carbs to “starve” muscle• Three days of rest while taking in 90% or more carbs

Side Effects:IrritabilityDizzinessLess productive training

MODIFIED CARB LOADINGDays 1-3: Moderate carb diet (50% of calores)Days 4-6: High carb diet (80%) of calories); ~4.5 gms of carbs per lb

body wtDay 7: Competitive event; pre-event meal (dinner the night prior) with

carbs (>80% of calories from carbs)

Side Effects:Mental and physical fatigue

IrritabilityMood disturbances

Poor recoveryIncreased risk of injury

BloatingGI distressWeight gainLethargyFrustration w/ altered

schedules

SPORTS NUTRITION STRATEGIES

PRE-EXERCISE NUTRITIONTwo main goals:1. Optimize glucose availability and glycogen stores2. Provide fuel needed for exercise performance

Practical Applications:• If you work out in the afternoon, consume a carb-rich breakfast• If you work out in the morning, consume a carb-rich snack before

bed• Aim to eat a “carbie meal” 4-6 hrs before workout to:• Minimize GI distress and• Optimize performance

In general, pre-exercise meal should be:• Relatively high in carbs to

maximize blood glucose availability

• Relatively low in fat and fiber to minimize GI distress and facilitate gastric emptying

• Moderate in protein• Well-tolerated by the

individual

NUTRITION DURING EXERCISEThe Academy of Nutrition and Dietetics, the Dietitians of

Canada, and the ACSM recs:• 30 to 60 gms carbs/hr of training• i.e. athlete training for 3 hrs needs 90 to 180 gms carbs• Especially true if:• Exercising in extreme heat, cold, high altitude; prolonged

exercise• Inadequate food/beverage intake prior to training• No carb loading or restricted energy intake for wt loss

• Carb consumption should begin shortly after initiation of workout q15-20min

POST-EXERCISE REPLENISHMENTTwo main goals:1. Replenish glycogen stores2. Facilitate muscle repair

Refueling should begin 30 min after; followed by high-carb meal within 2 hrs

Academy of Nutrition and Dietetics recommends: • Carbohydrate intake of 1.5 g/kg body wt in first 30 min and then

q2hrs x 4-6hrs• Then athlete can resume his/her typical balanced diet

KEY POINTS1. Carbs are the body’s preferred energy source due to their rapid breakdown and thus quick availability of ATP,

the body’s usable energy. However, the body also can get energy from breakdown of FAs, and in less desirable situations, from the conversion of AAs to glucose through gluconeogenesis.

2. A consumed carb passes through the GI system, into the portal circulation to the liver, and into systemic circulation before it reaches the exercising muscle. In the exercising muscle, it undergoes glycolysis to produce ATP.

3. Absorption of glucose from the small intestine into portal circulation is the rate-limiting step in transforming glucose from food to fuel. The max rate glucose passes from small intestine into portal circulation is 1.2 – 1.7 g/min.

4. Very little glucose is stored in the body. At most, slightly more than a day’s worth of calories is available from blood glucose, liver glycogen, and muscle glycogen combines. At the lower end of muscle glycogen stores, the total calories from this stored glucose is little more than the number of calories needed to fuel a half-marathon.

5. Endurance athletes can increased the amount of glucose available to fuel exercise by carb-loading, which acts to help increase muscle glycogen stores. Carb loading is not without risks, though, esp. the classical method. However, the current modified methods can avert some of the negative effects of carb loading. A carb loading regimen for endurance athletes who are training for an event may best be developed with the assistance of a sports dietitian. Recommending a carb loading regimen is outside the scope of practice of most health professionals.

6. Glycemic index of carbs has been explored as a possible variable in improving athletic performance, but to date the research is mixed and inconclusive.

KEY POINTS7. The two main goals of a pre-exercise snack are to (1) optimize glucose availability and glycogen

stores, and (2) provide the fuel needed for exercise performance. For peak performance, the athlete should consume a high carb diet (>60% of total cam from carbs) in the week prior to event and aim to eat a meal about 4 – 6 hrs prior to workout.

8. Eating a small carb- and protein-containing snack 30 – 60 min before exercise helps increase glucose availability near end of workout and decrease exercise –induced protein catabolism.

9. As a general rule, athletes should try out any snacks or drinks with practice sessions prior to relying on them to help optimize athletic performance on race day.

10. The goal of fueling during exercise is to provide the body with the essential nutrients needed by muscle cells (sodium, potassium) and maintain optimal BG levels.

11. To maintain a ready energy supply during prolonged exercise sessions (>60 min), athletes should consume 30 – 60 gm of carb/hr of training.

12. Carbs consumed during exercise are most effective if the 30 – 60 gms/hr are consumed in small amts in 15- to 20-min intervals rather than as a large bolus.

13. Refueling should begin within 30 min after exercise and should be followed be a high-carb meal within 2 hrs. Depending on duration and intensity of exercise, for optimal glycogen replenishment athletes should consume up to 1.5 gm/kg of body wt in 1st 30 min after exercise and then q2hrs x 4-6 hrs.

THERMOREGULATION

Also ↑ aldosterone ↑ kidney’s reabsorption of Na+ and ↓ amount of Na+ lost in sweat

ACCLIMATIZATION AND HEAT-RELATED ILLNESS

OSMOREG

ULATION

T H E NO T - S O - D E L I C

A T E BA L A N C E

DETERMINING INDIVIDUAL FLUID NEEDS

DEHYDRATION• Euhydration: normal state of body water content; absence of

absolute or relative hydration or dehydration• Exertional hyponatremia: abnormally low blood sodium level that

results from excessive intake of low-sodium fluids during prolonged endurance activities

• Dehydration: a state of decreased total body fluid• Mild dehydration (1% to 2% body wt loss) during exercise is

normal • N/V• Dizziness• Disorientation• Weakness• Irritability• HA• Muscle cramps• Chills• Decreased

performance

SYMPTOMS

HYDRATIONPre-exercise Hydration• Begin 4 hours prior to activity

• 5-7 mL per 1 kg/2.2 lbs body wt• If after 2 hours, little to no urine addl 3-5 mL/kg body wt 2 hrs before

Hydration during exercise• Aim for 1:1 fluid replacement to fluid loss ratio• Avoid wt loss > 2%• ACSM rec: 0.4 – 0.8 L/hr (8 – 16 oz/h)• Drink fluids with sodium for prolonged sessions

• IOM recs: 20 – 30 mEq/L (450 – 700 mg/L) sodium; 2 – 5 mEq/L (80 – 200 mg/L) potassium• Drink carb-containing sports drinks to reduce fatigue

• 30 – 60 gms of rapidly-absorbed carb for every hour of training• As slong as carb conc is < 6% - 8%, it will have little effect on gastric emptying

Post-exercise Hydration• 0.75 L/lb of body wt

• Water to restore hydration, carbs to replenish glycogen, electrolytes for rehydration

KEY POINTS1. Women have lower sweat rates and decreased electrolyte losses compared to men. They are at lower risk of

dehydration compared with men and at a higher risk of hyponatremia.

2. Children are as adept as adults at regulating body temperature as long as they are well hydrated. Attention to maintaining adequate hydration , esp in hot and humid conditions, is paramount.

3. Use particular caution when monitoring the fluid status of older adults (>65yrs), as they are at increased risk of both dehydration and hyponatremia.

4. Caffeine intake has little effect on hydration status with exercise, while high amounts of alcohol can delay rehydration.

5. Sweat rate is highly variable and depends on many factors. Fluid replacement should be tailored to individual needs as much as possible.

6. Check for euhydration with the first morning void specific gravity and body wt. Aim for SG < 1.020 and minimal change in body wt. Urine color can provide a rough estimate of hydration status.

7. Athletes at highest risk of hyponatremia have a low body mass index, high fluid consumption during exercise with lower sweat rate (leading to wt gain), slower pace, and prolonged duration of activity. They are most likely to be female.

8. Athletes at highest risk of dehydration exercise at high intensity in hot and humid conditions with heavy clothing and inadequate fluid intake.

9. Dehydration with less than 2% body wt loss during exercise is normal and not of great concern. Larger losses in body wt can lead to heat illness or heat stroke and can negatively affect aerobic athletic performance.

KEY POINTS10. Symptoms of hyponatremia and dehydration are very similar. Symptoms of hyponatremia include N/V, extreme

fatigue, respiratory distress, dizziness, confusion, disorientation, coma, seizures. Symptoms of dehydration include N/V, dizziness, disorientation, weakness, irritability, HA, muscle cramps, chills, and decreased performance.

11. Prevent fluid disturbances by using thirst to approximate fluid needs, measuring fluid intake, and paying particular attention to environmental conditions. For optimal fluid balance, calculate a client's individual needs using the USATF Self-Testing Program for Optimal Hydration.

12. Most ppl begin exercise euhydrated. Those at risk for dehydration prior to an exercise session include weight-class sports athletes who purposely dehydrate themselves and those with less than 8- to 12- hr recovery period btw strenuous training sessions. These athletes should prehydrate with 5 to 7 ml of fluid per 1 kg/2.2 lbs of body wt 4 hrs prior to exercise. If they do not produce urine, or if it is dark and concentrated, then they should consume another 3 to 5 ml of fluid per 1 kg/2.2 lbs of body wt 2 hrs before exercise session. A salty snack will help to retain fluid and stimulate thirst.

13. During exercise, athletes should aim to consume an amount of fluid equal to that lost in sweat. The USATF STPOH can help to determine sweat rate. If this is not feasible, athletes should aim for 0.4 to 0.8 L/hr (8-16 oz/h) fluid replenishment.

14. Athletes exercising for prolonged periods in hot environments should consume sports drinks that contain 20 to 30 mEq/L (450 to 700 mg/L) of sodium and 2 to 5 mEq/L (80 to 200 mg/L) of potassium. Electrolytes may also be obtain from food sources.

15. For exercise lasting longer than 1 hour, athletes should consume drinks and snacks that contain about 30 to 60 g of rapidly absorbed carbs for every hour of training. Choose drinks and snacks with less than about 6% to 8% carb concentration to reduce gastric distress.

16. After exercise, rehydrate with water, carbs, electrolytes. Most athletes can rehydrate sufficiently with usual meal, snacks, and fluids. If rehydration needs to occur within 12 hrs or less, athletes should aim to drink about 1.5 L for each 1 kg/2.2 lbs lost.

COMMON ATHLETE NUTRITIONAL MISTAKES1. Focusing on weight alone instead of lean and fat mass

Energy intake sufficient to spare protein and support muscle mass can improve athletic performance, appearance, and bone health

2. Eating infrequently Increasing meal frequency and decreasing meal size improves within-day energy

balance and body composition3. Unnecessary micronutrient supplementation

In most cases, athletes should consume a diet that provides sufficient vitamins and minerals from food.

4. Failure to maintain adequate hydration status To maintain adequate hydration status and blood glucose levels, consume a few

sips of a sports drink q15min with engaging in high-intensity physical activity5. Excessive energy restriction

Consume sufficient energy to support physical activity, spare protein, and preserve lean tissue

TIPS TO MEET CALORIC NEEDS WHILE TRAINING…

FEMALE ATHLETE TRIAD

OPTIMIZING SPORTS PERFORMANCE

NUTRITION GOALS FOR ATHLETES• Energy

• Ensure adequate total energy intake to support physical activity• Maintain appropriate body weight

• Carbohydrate• 6 – 10 g/kg/day

• Protein• Endurance: 1.2 – 1.4 g/kg/day• Resistance: 1.6 – 1.7 g/kg/day

KEY POINTS1. Compared to the general population, athletes have special nutritional needs including increased caloric

requirements, greater amounts of protein, and more carbs.

2. The aerobic energy systems predominate during endurance exercise. These systems have a nearly unlimited capacity to generate ATP; however, the speed at which ATP Is generated (aerobic power) is slower than for the anaerobic systems.

3. Fatigue during endurance exercise typically results from depletion of muscle glycogen and reduced blood glucose concentrations. To avoid extreme fatigue and optimize performance, the major nutritional principles for endurance athletes aim to optimize muscle and liver glycogen stores and enhance the efficiency in which glucose and fatty acids are converted to fuel.

4. The increase in muscle glycogen stores resulting from the practice of carb loading contributes to a 2% to 3% improved performance in events lasting longer than 90 min; however, it does not seem to provide any benefit for shorter duration.

5. Strength sports require production of maximal force for optimal performance. These sports include weight lifting, throwing events, and bodybuilding.

6. Nutrition plays an important role in primarily three domains for strength athletes: (1) fueling sport and resistance training; (2) optimizing recovery from training; and (3) promoting muscular hypertrophy.

7. The protein needs for strength athletes are higher than for endurance athletes as the body relies on AAs (esp BCAAs) to support muscle growth.

KEY POINTS8. Nutritional factors important for attaining muscle hypertrophy include: protein source, protein quantity,

timing of intake, carb intake, and supplementation, if any and when appropriate

9. At the onset of intense exercise, the muscles rely on immediate energy from the phosphagen and anaerobic systems. After the first few minutes of intense exercise, the aerobic system predominates. As exercise becomes more intense and the aerobic system reaches max capacity for O2 consumption, the muscles rely on the anaerobic system to drive further increases in exercise intensity.

10. A periodized nutrition program, in which calorie and micronutrient intakes vary based on the training regimen , ensures optimal fuel availability to support the athlete’s specific training and competition demands. Energy and nutrient needs are highest during peak training, somewhat decreased during taper and competition, and much lower during the transition and rest phase.

11. Insufficient carb intake, and subsequently lower concentration of muscle glycogen stores, is assoc. w/ decreased immune fxn, increased rates of burnout, and decreased performance. For this reason, power athletes are advised to consume about 6 to 12 g/kg of carbs/day and at least 30 to 60 gm of carbs per hour during intensive training.

12. The major goals of nutritional recovery for power athletes include glycogen and creatine resynthesis and protein repair and synthesis

NUTRITIO

NAL

SUPPL

EMENTS

A N D ER G O G E N I C

AC I D

S

ERGOGENIC ACIDS

CAUTIO

N

EVALUATING SUPPLEMENTS• Understand the claim• Assess the credibility• Assess the relevance• Evaluate the safety• Evaluate the risks vs. benefits• Consider possible drug, supplement, and nutrient interactions• Make an informed decision• Continuously evaluate the need (or lack of need) for

supplementation

THE BOTTO

M LINE

…no matter how harmless a supplement seems, health professionals who are not

registered dietitians or physicians should never

recommend supplements to clients. Not only is it outside

the scope of practice, but recommending supplements without a full medical history

and physical exam is dangerous

While hea

lth prof

essio

nals play

an im

portant r

ole in

helping cl

ients

to unders

tand th

e risk

s and pote

ntial

benefi

ts of

supplem

ents…

KEY POINTS1. Supplements are not closely regulated by the federal government and should be used with extreme caution.

2. The existing legislation, including the Dietary Supplement and Health Education Act (DSHEA) and the Current Good Manufacturing Practices (CGMPs), dictate the government’s approach to supplements. The DHEA outlines supplement production, marketing, and safety guidelines. CGMPs assure that dietary supplements are consistently produced and of acceptable quality.

3. Many people use supplements with claims of weight loss. The safety and efficacy of these supplements are poorly understood. Health professionals should be aware of the commonly used weight loss supplements, their claims, efficacy, and safety.

4. Whole foods provide the majority of vitamins and minerals needed for optimal health. Most supplements that aim to improve health do not provide benefit beyond a wholesome, balanced eating plan. However, many people do not consume adequate amounts of nutrients such as vitamin D and DHA/omega-3 FAs and folic acid in pregnant women, suggesting that in some cases, supplementation may be beneficial.

5. Herbal supplements are plant-derived substances used for medicinal purposes. Like other supplements, they are not closely regulated and safety and purity are not certain.

6. Many of the most profitable supplements include those that boast enhanced athletic performance for strength/power athletes, endurance athletes, or both. Despite the large revenue they generate, only a select few supplements have strong evidence to support their efficacy.

KEY POINTS7. Many supplements that have proven effective are also toxic, dangerous, and banned. Other banned substances

do not provide rapid muscle gains. An alarming number of athletes use the illegal substances to gain a competitive edge. This is referred to as doping.

8. In addition to steroids, some athletes also use illegal hormones, diuretics, and stimulants to improve performance.

9. Caffeine is an allowed stimulant that is proven effective in improving athletic performance. It can be toxic in high levels.

10. Some protein supplements such as whey protein powder may facilitate increased athletic performance and improved muscle mass. However, others, such as individual AAs supplements, probably do not provide much additional benefit beyond a balanced protein-sufficient eating plan.

11. Creatine supplementation when combined with intense exercise training improves muscle mass. It is general considered to be safe, though clients should not begin creatine supplementation without first discussing with a physician.

12. Consumers and health professionals should develop a systematic approach to evaluating supplements. Be sure to understand the claim, assess the credibility and relevance, evaluate the safety and risks versus benefits, consider possible interactions, make an informed decision, and continuously evaluate the need (or lack of need) to use a supplement.

13. Health professionals should be keenly aware of their scope of practice when discussing sports nutrition with clients, especially in the case of discussing supplements. Health professionals who are not physicians or RDs should not recommend that a client begin a supplements. Rather, the client should first discuss this with the appropriate licensed, qualified professional.

EVALUATI

ON OF NUTR

ITIONAL

STATU

S

N U T R I T I O N A N D B O D Y C O MP O S I T I O N C O A C H I N G A N D A S S E S S M

E N T

THE INITIAL INTERVIEW• Warm welcome• Active listening techniques (building rapport)

• Open-ended questions• Reflections• Affirmations• Summarizing• Empathic statements

• Health History Questionnaire• Identification of health risks• Body composition• Nutrition assessment• Goal setting• Health education

MAKING REFERRALS

BODY COMPOSITION

• Fat mass• Essential fat: the fat required for normal body

functioning including that of the brain, nerves, heart, lungs, and liver; typically 3% to 5% in men and 10% to 15% in women

• Nonessential fat: triglycerides and other fatty tissue stored in muscle, around vital organs, and within subcutaneous tissue

A person’s proportion of fat, lean tissue (bone, muscle, connective tissue), and water

SOMATOTYPES AND SPORTS PERFORMANCE

Mesomorphs• Challenges: medium structure and height limits performance in sports that require very

large or tall build• Strengths: agility and speed; gain muscle easily; easy to lose or gain weight• Ideal: power sports like sprinting, mid-distance swimming, most team sports;

gravitational sports emphasizing high strength-to-weight ratio such as distance running, cycling, triathlon, weightlifting

Ectomorphs• Challenges: limited ability to gain mass restricts performance in power or strength sports• Strengths: lean and thin enhances performance in gravitational sports• Ideal: distance running, ultra-endurance events, aesthetic sports

Endomorphs• Challenges: agility and speed, sustained weight-bearing cardiovascular activities such as

running; lose conditioning quickly once training/activity ceases• Strengths: strong, large lung capacity• Ideal: power lifting, football lineman, wrestling

ASSESSMENT METH

ODS

I N T

H E FI E

L D , LA B O R A T O R Y , O

R RE F E R E N C E S

FIELD METHODS• Height and weight tables

• Rarely used; replaced by BMI• Body Mass Index (BMI)

• Weight in kilograms divided by height in meters squared; a proxy for measurement of composition

• Girth Measurements• Waist-to-hip ratio: waist circumference divided by hip circumference; a

number greater than or equal to 1.0 confers increased health risk; a ratio of 0.9 or less in men and 0.8 or less in women is considered safe

• Body density: calculated by dividing body weight by body volume; an intermediary to convert circumference measurements into body fat %

• Gynoid obesity: excess weight distributed mostly in the abdomen; “apple shape”

• Android obesity: excess weight distributed mostly in the hips and thighs; “pear shape”

• Skinfold Measurements• Approximate body fat percentage by measuring the amount of subcutaneo

• Bioelectrical Impedance Analysis• An indirect measure of body composition that measures the conduction of

current through muscle and fat, and inserts data into a predictive equation to estimate fat mass and lean mass

• Accuracy similar to skinfold technique at ~3.5%

“Techniques health professionals commonly use to measure body

composition”

SKINFOLD MEASUREMENTS• Skinfold measurements approximate body fat by measuring the

amount of subcutaneous fat in various locations throughout the body utilizing skin calipers

• The U.S. Olympics Committee advocates measurement of 7 skinfold sites:1. Abdomen2. Biceps3. Anterior thigh4. Medial calf5. Subscapular6. Supraspinale7. Triceps*Chest

SKINFOLD SITES

ESTIMATING BODY COMPOSITION FROM SKINFOLD MEASUREMENTSFrom skinfolds to body density to % body fat

LAB METHODS• Hydrostatic Weighing

• Also known as underwater weighing and hydrodensitometry; measures body composition by comparing the weight of a person in water and on land

• Air Displacement Plethysmography (ADP; BodPod)• A device that uses the displacement of air to measure body volume and

density• Dual-Energy X-Ray Absorptiometry (DXA)

• A method of body composition assessment that maps the bone density, fat mass, and fat-free tissue mass using two low-dose x-rays from different sources that measure bone and soft tissue mass simultaneously

• Near-Infrared Interactance• Estimates body composition using the optical densities of skin, fat, and lean

tissue as an infrared light probe is reflected off bone and back to the probe• 3D Photonic Scanning

• Uses a low-power laser light and digital cameras to rapidly produce a 3D digital model of the human body, which is used to approximate lean and fat mass

• Ultrasound• An indirect measure of body composition that measures the conduction of

current through muscle and fat, and inserts data into a predictive equation to estimate fat mass and lean mass

“Techniques with lower rates of error used mostly in research studies in large

medical facilities”

REFERENCE METHODS“The most accurate, but least practical , methods used to measure body

composition.”

• Multi-Component Models• A reference method of assessing body composition

that bases an estimate of fat and lean mass on measurements from several methods.

• Margin of Error: 1-2%• Four Component Method• Body Volume• Total Body Water• Bone Mineral• Body Mass

• MRI and CT Scan• Limited practicality for widespread use

Click icon to add pictureCALCULAT

ING IDEAL B

ODY

WEIGHT

Based

on Body C

omposition

NUTRITIO

N ASSESSMENT

A BR I E

F I NT R O D U C T I O

N TO R

. D.

T E R R I TO R Y

ESTIMATING CALORIC NEEDS• Resting Energy

Expenditure:• The number of calories

expended at rest to maintain normal vital function. Also referred to as resting metabolic rate (RMR)

24-Hour Recall

Food Frequency Questionnaire

Food Record

When to Refer to RD: Specific, individualized meal

plans which fall outside recs of Dietary Guidelines for Americans or MyPlate

Chronic health problems or taking medications, dietary supplements, or OTC meds

Post-op nutrition Unexpected or

unexplainable weight loss/gain

Nutrition related situation outside level of training or expertise

ATTAINING A DIET HISTORY

BODY COMPO

SITION

A N D NU T R I T

I ON C

O A C H I NG

READINESS TO CHANGEStages of Change

PROCESSES OF CHANGE

GOAL SETTING

KEY POINTS1. Health professionals with the knowledge of nutrition and nutrition coaching provide a valuable asset to athletes and

active adults who would like nutrition information but do not have access to or resources to afford individualized consultations with an RD. With this said, health professionals must practice within their scope practice an initiate referrals to other health professionals when appropriate. Being able to identify when referral is necessary and who would be most helpful to meet the client’s needs is an important skill of a health professional.

2. The initial interview with a client includes time devoted to building rapport as well as time spent reviewing a client’s health history and potential indications for referral. The initial interview is also a good time to discuss body composition and nutrition assessment tools and decide whether the use of a specific tool will be beneficial to the client.

3. Body composition refers to a person’s proportion of fat; lean tissue such as bone, muscle, and connective tissue ; and water. Fat mass includes essential fat (3% to 5% for men; 12% to 14% for women) and nonessential fat. Body composition is determined by modifiable factors such as PA and nutrition, and non-modifiable factors such as age, gender, ethnicity, and somatype. Athletes can train to maximize their potential through strategic athletic training and nutrition.

4. Body composition plays an important role in athletic performance, especially for athletes who engage in gravitational, weight-based, and aesthetic sports. The body composition assessment can help to develop goals for target weight, evaluate effects of training and nutrition intake, develop a baseline from which to monitor progress of a nutrition and fitness program, and identify athletes who may be at increased health risk either due to too much body fat of not enough body fat,

5. Many methods are used in practice to monitor body composition. The most commonly used field methods include BMI, circumference, skinfold measurements, and BIA. Hydrostatic weighing and DXA scans are the most commonly used lab methods. Manufacturers are currently developing products to bridge from the lab standards to methods that may be more feasible in practice/. Two of these products include air displacement plethysmography (BodPod) and ultrasound techniques.

KEY POINTS6. Body composition assessment is prone to error. Health professionals should be careful to follow protocols,

undergo training, and interpret results cautiously. All results should be shared with the client as a range based on the method’s margin of error rather than a precise number.

7. Indirect calorimetry is the most accurate method used to estimate resting energy expenditure. Due to cost and convenience factors, it is rarely used in practice.

8. Attaining a diet history is an important step to help athletes achieve nutrition and performance goals. The health professional and client can use the information obtained from a diet history to better understand the types of foods eaten and the factors that influence intake, assess the quality of a client’s nutritional habits, and evaluate how well the client's typical eating habits compare with an ideal diet. In some cases the health professional may initiate the process of assessing diet history and recognize that , to best meet the client’s needs, referral to an RD is necessary.

9. Several tools are available to collect nutrition information, including 24-hr recall, food frequency questionnaire, and food logs. The USDA offers the SuperTracker online to track, analyze, and evaluate nutrition and PA.

10. After completing the initial assessment and comparing estimated body composition and dietary habits with ideals, the health professional can adopt the role of coach to help the athlete set and achieve goals. This includes assessing their athlete’s readiness to change, goal setting (w/ action plan), gaining proficiency in motivational interviewing, and ongoing health education and follow-up.

WEIGHT MANAGEMENT

A N D EN E R G Y B

A L A N C E

NUTRITION STRATEGIES TO MANAGE WEIGHT

1. Strong evidence supports that portion size is directly related to weight status. Smaller portion size contributes to wt loss, so clients should pay careful attention to this variable.

2. Decrease visits to fast food and quick-service restaurants. Strong evidence supports that people who eat at these establishments one or more times/week are at high risk of wt gain, overweight, and obesity.

3. Aim for a calorie deficit of 500+ cal/day, either through increased PA or decreased caloric intake or combo of both.

4. Increase intake of whole grains, veggies, and fruits. Moderate evidence suggests that adults who consume more high-fiber whole-grains, fruits, and veggies have lower body wt than their peers who eat fewer servings of these types of foods.

5. Decrease intake of sugar-sweetened beverages.

6. Eat breakfast. Eating breakfast is associated with wt loss and improved nutrient intake; while skipping breakfast is associated with excess weight, especially in children and adolescents.

WEIGHT MANAGEMENT• Prevention of weight gain• Improvement in physical and emotional health• Weight loss attained through changes in nutrition habits and

physical activity• Overall improvement in nutrition, exercise, and other behaviors.

Energy Balance: the relationship of calories consumed with calories expended

Negative Energy Balance: when fewer calories are consumed than expended; leads to weight loss

Positive Energy Balance: when more calories are consumed than expended; leads to weight gain

NeutralEnergy Balance: when the number of calories consumed is equal to the number of calories expended

ENERGY BALANCE

HHS PHYSICAL ACTIVITY GUIDELINES RECS Children and adolescents should perform 60 minutes (1 hour) or more of PA daily.

These activities should be fun, age-appropriate, and varied. Adults should avoid inactivity. Some PA is better than none, and adults who

engage in any amount of PA gain some health benefits. For substantial health benefits, adults should engage in at least 150 minutes (2

hours and 30 minutes) a week of moderate-intensity aerobic PA, or an equivalent combination of moderate- and vigorous-intensity activity. Aerobic activity should be performed in episodes of at least 10 minutes, and preferably, spread throughout the week.

For additional and more extensive health benefits, adults should increase their aerobic PA to 300 minutes (5 hours) a week of moderate intensity, or 150 minutes a week of vigorous intensity aerobic workouts, or an equivalent combo of moderate- and vigorous-intensity activity. Additional health benefits are gained by engaging in PA beyond this amount.

Adults should also do muscle-strengthening activities that are moderate or high intensity and involve all major muscle groups on 2+ days/week.

PHYSIOLOGY OF OBESITY

EATING HORMONES, OR NAH?

GREEDY WITH THE GHRELIN, LOSING LEPTIN

THE FOUR APPROACHES TO WEIGHT LOSS1. Lifestyle Changes

I. Eat LessII. Exercise More

2. Behavioral Modification3. Medications4. Surgery

LIFESTYLE CHANGES- NUTRITION• 1,200 – 1,500 kcal/day for women; 1,500 – 1,800 kcal/day for men• Eating plan incorporating 500-750 kcal/day energy deficit• Evidence-based eating plan restricting certain foods in order to

create deficit• i.e. no high-carbohydrate foods, low-fiber foods, and/or high-fat

foods• Weight management program w/ behavioral therapy

• At least 6 months duration• With weight maintenance intervention thereafter • Body weight monitoring• Physical activity• Reduced-calorie diet

POPULAR DIETS

MEDITERRANEAN DIET

Great

Pinkprint;

Adjust

Accordingly!

HOW MAY I HELP YOU?The health professional can guide the client considering a new

diet plan to critically evaluate whether or not a particular diet is a good choice. The client should be able to answer the following questions:• How does the diet cut calories?• What is the nutrient density of the diet?• Does the diet advocate exercise?• Does it make sense?• Where is the evidence?• Does it meet individual needs?• How much does it cost?• What kind of social support does the client have?• How easy is it to adhere to the diet?

BEHAVIORAL MANAGEMENT• Avoid tempting situations

• i.e. “stimulus control”• Self-monitor• Set SMART goals• Practice behavioral substitution• Retrain the brain- and the taste buds.

PHAT PHARMA RULES THE WORLD

SURGERY- LAP BAND

SURGERY- GASTRIC BYPASS

WEIGHT LOSS MAINTENANCE1. Control portions2. Be mindful3. Exercise4. Check the scale5. Eat breakfast6. Monitor intake7. Minimize screen time8. Do not cheat9. Strengthen social support networks10.Encourage optimism

UNDERWEIGHT? WHAT’S THE MATTER?1. Inadequate intake to meet caloric needs2. Excessive activity3. Ineffective food absorption and digestion4. A disease that increases metabolic rate and energy needs

• i.e. cancer or hyperthyroidism5. Psychological stress or depression

KEY POINTS1. Energy balance is the relationship of calories consumed and calories expended. A positive energy balance

occurs when more calories are consumed than expended. A negative energy balance occurs when more calories are expended then consumed. A neutral energy balance occurs when calories consumed equal calories expended.

2. Body Mass Index (BMI) is a measure of height and weight (weight in kg divided by height in meters squared), and provides an estimate of body fatness.

3. Any adult with a BMI greater than 25 is considered “overweight” and those with a BMI over 30 are considered “obese.”

4. Factors affecting a client’s ability to maintain his or her weight include a decline in metabolism, which often occurs with aging, and attention to nutrition and physical activity.

5. As metabolism decreases with aging, so do energy needs. Increasing energy expenditure through exercise and controlling caloric intake can help offset this decline in metabolism.

6. Strength training and muscle building are essential to maintain metabolically active muscle mass, and regular cardiovascular PA is essential to maintain a high level of energy expenditure and prevent increased fat mass.

7. Ghrelin, the ”hunger hormone,” signals hunger to the brain. Leptin, insulin, and peptide YY signal feelings of satiety and suppress appetite. Adiponectin is another hormone that plays a role in weight control. In obese individuals, leptin and insulin are elevated, and the cells of the body are no longer responsive to these hormones.

8. Obesity can lead to many serious health risk factors including heart disease, HTN, T2DM, respiratory dz, gallstones, osteoarthritis, and other musculoskeletal disorders, social marginalization, discrimination, depression and other mental health disorders, and early death.

KEY POINTS9. Certain obese individuals appear to have more metabolically healthy obesity, characterized by the lack of other

cardiovascular risk factors often associated with excess weight. Some research suggests this may be due to these individuals maintaining a high level of fitness.

10. Safe rates of weight gain have not been rigorously studied, but 1 – 2 lbs/week with 500 to 1,000 additional calories per day from quality food sources is probably an acceptable rate.

11. There are 4 approaches to weight loss: lifestyle changes, behavioral modification, medications, and surgery.

12. The following factors help clients choose the diet that is right for them: How does the diet cut calories? What is the nutrient density of the diet? Does the diet advocate exercise? Does it make sense? Where is the evidence? Does it meet individual needs? How much does it cost? What kind of social support does the client have? How easy is it to adhere to the diet?

13. The following are 10 insights for successful weight loss maintenance:

14. Competitive athletes may be under tremendous pressure to attain a particular weight. Those with specific weight management and performance goals may benefit from consultation with an RD who is a Certified Specialist in Sports Dietetics.

15. An underweight individual is defined as being 15% to 20% or more below accepted weight standards, or having a BMI less than 18.5.

i. Control portionsii. Be mindfuliii. Exerciseiv. Check the scalev. Eat breakfastvi. Monitor intakevii. Minimize screen timeviii. Do not cheatix. Strengthen support

networksx. Encourage optimism

CHILDREN/ADOLESCENTS NUTRITION RECS• Focus on whole grains; vs simple sugars• Ample nutrient-dense dark green and oranges veggies• A variety of whole fruits (as opposed to fruit juices)

• Limit juice to < 4 oz/day• Oils in moderation, with emphasis on mono or polyunsaturated fats• Low-fat or nonfat milk products (as opposed to whole milk products)• Lean meat and bean products

CHILDREN/ADOLESCENTS NUTRITION RECS

HELPING FAMILIES TEACH NUTRITION• Practice division of responsibility

• Parents purchase foods and decide when foods may be eaten• Children then choose among available food options

• Arrange for family meals.• Teach children about food and healthful nutrition via engagement• Be a source of quality nutrition information and actively counteract nutrition

misinformation in the media and via other sources• Discuss nutrition preferences and goals with other adults who provide food to

children• Serve as role models and lead by example• Promote and participate in regular daily physical activity

CALORIE NEEDS FOR A LIFETIME

Age Protein (gm/kg/day)

1-3 years 1.054-13 years 0.9514-18 years 0.85

Protein Needs of Children and Adolescents

NUTRITIO

N FOR PR

EGNANT

WOMEN

Good Nutri

tion Beg

ins at C

onceptio

n

NUTRITION FOR PREGNANCY• Appropriate physical activity

• At least 30+ min of moderate intensity PA daily• Consumption of a variety of foods and calories in accordance with the DGA• Appropriate and timely vitamin and mineral intake or supplementation• Avoidance of alcohol and tobacco• Safe food handling; Avoid:

• Soft cheeses not made with pasteurized milk• Deli meats, unless reheated to steaming hot• Raw or unpasteurized milk or milk products; raw eggs, raw/undercooked meat,

unpasteurized juice, raw sprouts, raw/undercooked fish• Cat litter boxes• Handling pets when preparing foods• Shark, swordfish, king mackerel, or tilefish• Limit fish to 12 oz or less weekly

• Limit albacore tuna to 6 oz or less

EXERCISE RECS DURING PREGNANCY

COMPARING NUTRIENT NEEDS

HEALTHY WEIGHT GAIN DURING PREGNANCY

PHYSICAL ACTIVITY AND OLDER ADULTS• At least 150 min/week of moderate-intensity (advance to 300

min/week), or 75 min/week of vigorous-intensity (advance to 150 min/week) physical activity

• Do muscle-strengthening exercises that are moderate or high–intensity and involve all major muscle groups on 2+ days/week

• Do exercises that help maintain or improve balance• Engage in activity with an appropriate level of effort to match level

of fitness

KEY POINTS1. Children have unique nutritional needs. One major consideration is that, unlike adults, children

undergo periods of rapid growth and development. To achieve their full growth potential , many environmental factors must be optimized, including appropriate nutrition, PA, maintenance of a healthy weight, and adequate sleep.

2. Allied health professionals, parents, and pediatricians can monitor a child’s growth through the use of growth charts.

3. Youth athletes who engage in intensive physical training more than 18 hrs/wk, restrict caloric intake, or participate in weight-conscious sports are at highest risk of impaired growth.

4. There is currently a worldwide epidemic of childhood obesity due primarily to decreases in physical activity and poor nutrition habits. Potential areas of treatment include increased physical activity and improved nutrition intake.

5. Youth athletes are not just “little adults.” Youth athletes require sufficient calories and protein to support growth and maturation as well as athletic performance. Children are also more susceptible than adults to heat illness in the face of dehydration.

6. Sports drinks provide benefit to youth athletes engaging in prolonged activity or who participate in multiple practices or competitions in one day. However, sports drinks are not appropriate for routine hydration. Energy drinks are never safe or recommended for children.

7. The benefits of physical activity during pregnancy outweigh the risks for most women. Women already engaged in a vigorous exercise regimen prior to pregnancy often may continue throughout the pregnancy, depending on how they feel and the recommendation of their obstetrician.

KEY POINTS8. Optimal nutrition during pregnancy is essential to support the growth and development

of the mother and fetus as well as athletic performance. Needs for most nutrients increase during pregnancy. Caloric needs increase by about 300 calories per day.

9. Normal weight women are advised to gain 25 to 35 pounds throughout pregnancy, with the majority of weight gain in the late-second and third trimesters. Underweight women should gain 28 to 40 pounds, overweight women 15 to 20 pounds, and obese women 11 to 20 pounds. Dieting is not safe during pregnancy.

10. A healthy eating plan during pregnancy includes: small, frequent meals; avoiding fasting > 13hrs; daily breakfast; and an abundance of whole grains, fruits, veggies, and foods high in calcium and iron.

11. Increased nutritional needs extend beyond pregnancy for breastfeeding women. Calorie needs increase by about 500 calories/day beyond baseline.

12. Pregnant and lactating female athletes should avoid high intakes of caffeine beyond about 200 mg/day.

13. Physical activity and healthful nutrition play key roles in successful aging. While calorie needs decease 2/2 sarcopenia and decreased basal metabolic rate, nutrient needs increase or stay the same.

SPORTS

NUTRITIO

N FOR SPECIAL

POPU

LATIONS

Nutritio

n for A

thletes

with

Illnes

s or I

njury

ACUTE ILLNESS• Acute illness: sudden onset of a time-limited ailment• Exercise immunology: the study of the effects of exercise on the

immune response• Levels of B cells, T cells, and IgA decline in athletes engaged in

long periods of intensified training• Potentially increased susceptibility to acute infection• Maintain immune health by starting a program of low to

moderate intensity and volume and gradually increasing volume and load• Include cross training, ensure sufficient rest and recovery, watch for

overtraining

Open Window of Impaired Immunity:a period of time lasting 3 to 72 hours in which athletes who engage in intensive exercise are at particularly increased risk of infection

SIGNS OF OVERTRAINING• Irritability• Lack of concentration• Fatigue• Increased and poorly healing injuries• Frequent URIs• Poor sleep• Poor appetite• Increased resting HR• Menstrual irregularities

High risk periods:• Intensive training

weeks• Taper prior to

competition• During competition

IMMUNONUTRITIONAL SUPPORTThe use of nutrient intake or supplementation to attenuate

immune changes and inflammation following intensive exercise or injury

• Carbohydrates help to lessen the immune response to strenuous exercise by decreasing blood levels of stress hormones ad cytokines

• Quercetin: a flavonoid that may help protect from illness and enhance healing from injury• Flavonoid: antioxidant found naturally in fruits, veggies, and

some grains

PROMOTING HEALTH LITERACY1. Do not assume understanding. Pilot test health education materials with the target

audience prior to widespread dissemination.

2. Know your audience. Develop materials based on what you learn. A one-size-fits-all approach is not effective.

3. Engage the target audience in the development and implementation of health education materials. Ask for feedback on communication effectiveness and ease of understanding.

4. Evaluate whether or not your target audience has been able to effectively learn and apply the shared information.

5. Aim for simplicity. Limit teaching sessions or material to no more than three to four main messages. Give only the necessary information, unless clients ask for further details.

6. Provide a list of resources for further information.

7. Collaborate with other health professionals and community members who know and understand the target audience well.

8. Avoid jargon. Consider the client’s culture and language, and speak at the appropriate level.

9. Evaluate your environment. How comfortable and welcoming is the setting? How conducive is it to understanding clear health messages.

10. Make improved health literacy a personal and professional priority.

NUTRITIO

N FOR AT

HLETES WITH

CHRONIC

DISEASE

B A S I CA L LY , R

E F E R TO M

D OR R

D

Components of Optimal Heart Health:1. Has never been told by health

professional that s/he has hypertension

2. Has a self-reported BMI < 253. Has never been told by health

professional that s/he has hypercholesterolemia

4. Has not smoked > 100 cigs in lifetime; or reported smoking 100+ cigs in lifetime but currently a nonsmoker

5. Has never been told by health professional that s/he has diabetes

6. Participates in 150+ minutes/week of moderate physical activity or 75+ minutes of vigorous PA weekly

7. Consumes 5+ servings of fruits/veggies daily

CARDIOVASCULAR DISEASE

DIABETES AND EXERCISEExercise works through at least 2 pathways to decrease diabetes symptoms:1. Activates insulin-dependent glucose and increases insulin sensitivity in the insulin-

dependent GLUT4 transporters More glucose is passed from the bloodstream into the cells

2. Helps to decrease risk of cardiovascular disease by decreasing blood pressure, cholesterol levels, and body fat Loss of body fat helps improve insulin sensitivity

Pancreas is then prompted to secrete less insulin, leading to decreased appetite and further weight loss (#awesomeness)

Clients are advised to:1. Balance nutrition intake with exercise and insulin or other medications2. Consume five to six equally sized small meals3. Work with a Registered Dietitian or Certified Diabetes Educator

Oh, how the medical industrial complex creates professions from sick people

FIVE STEPS TO OPTIMAL BONE HEALTH1. Start with good nutrition. Get adequate amounts of calcium, vitamin D, vitamin K, and

vitamin C.2. Maintain an overall healthy lifestyle. Eating disorders, smoking, and depression contribute

to bone weakening and increased risk of osteoporosis.3. Engage in weight-bearing physical activity. Benefits include increased bone mass,

increased muscle mass and strength, improved function, delayed loss of independence, improved quality of life, and decreased fall risk.

4. Aim to prevent falls. Muscle strengthening, balance training, a regular Tai Chi program, removal of home hazards such as rugs and clutter, elimination of psych meds when possible, and use of a multidisciplinary program to assess risk factors for falls all contribute to substantial reduction in falls.

5. Encourage regular visits to the physician, especially if clients have risk factors for osteoporosis.

Female gender, increased age, estrogen deficiency, white race, low weight and BMI, family history, smoking, history of prior fracture

Dual-energy X-ray absorptiometry to diagnose or rule out Several meds are available to treat or prevent osteoporosis

KEY POINTS1. Athletes who engage in very high-intensity exercise are at increased risk of mild infections, while

athletes who engage in moderate-intensity exercise are afforded a protective effect against common illness. Periods of particularly increased risk of infection include intensive training weeks, the taper prior to competition, and during competition. Athletes can reduce risk of illness by gradually increasing program intensity and volume, including cross training in their training program, and allowing sufficient time for rest and recovery.

2. Research to date does not support supplementation to decrease risk of illness in athletes. However, attention to carb intake helps to reduce the immune response. There is limited evidence that quercetin supplementation may provide benefits.

3. Athletes should refrain from exercise when they have a fever due to increased risk of dehydration.4. Injured athletes have decrease calorie and protein needs compared with the needs during periods

of intense activity, but increased needs compared with baseline in order to promote healing. Muscle atrophy occurs with immobilization . There is growing interest in possible roles for creatine and omega-3 fatty acid supplementation in protecting against immobilization –induced atrophy and improving wound healing.

5. Gastrointestinal discomforts are the most common ailments experienced by athletes. While many of these symptoms are short-lived, some athletes suffer from chronic GI disease such as GERD, IBS, celiac disease, and IBD. Many of these illnesses can be managed at least in part with changes in nutritional habits.

KEY POINTS6. Cardiovascular disease is the leading killer of American men and women. A healthy

diet for optimal heart health includes at least 4.5 cups of fruits/veggies daily, at least two 3.5 oz servings of fish weekly, less than 1,500 mg daily of sodium, fewer than 450 kcal/week from sugary beverages, and at least 3 servings of whole grains daily.

7. Three major nutritional considerations when working with diabetic clients includei. Balancing nutrition intake with exercise and/or insulinii.Consuming several small meals throughout the day to maintain a relatively stable

blood sugar leveliii.Monitoring blood glucose before, after, and during exercise, being sure to have a

carb snack on hand if the case of hypoglycemia8. Athletes at highest risk for osteoporosis are

i. Females who are estrogen-deficient, have a FH of osteoporosis, low BMI, and/or history of prior fracture

ii.Advised to minimize risk factors and consume recommended amounts of vitamin D, calcium, vitamin K, and vitamin C

iii.Encouraged to engage in weight-bearing physical activities to reduce risk

Namaste