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Sharon Collison, M.S., R.D., LDN, CSSD.  Explain physiologic anomalies and treatment recommendations for the female athlete triad  Discuss the high.

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Presentation on theme: "Sharon Collison, M.S., R.D., LDN, CSSD.  Explain physiologic anomalies and treatment recommendations for the female athlete triad  Discuss the high."— Presentation transcript:

1 Sharon Collison, M.S., R.D., LDN, CSSD

2  Explain physiologic anomalies and treatment recommendations for the female athlete triad  Discuss the high use and poor regulation of energy drinks/shots  Discuss new dietary guidelines for protein timing for muscle protein synthesis  Describe the role of tart cherry juice in reducing muscle soreness and inflammation  Apply recent guidelines for adequate hydration in athletes


4  Low Energy Availability  Energy availability = dietary energy intake minus the energy expended in exercise (EA=EI-EEE)  Functional Hypothalamic Amenorrhea (FHA)  Amenorrhea caused by low energy availability  Low Bone Mineral Density (BMD)  Z-score between - 1 and - 2 & secondary clinical risk factors for fracture


6  Energy availability < 30 kcal/kg FFM/day results in impaired bone formation and reproductive function (Loucks AB et al 2011)  Increased duration of missed menstrual cycles increases likelihood of decreased BMD (ACSM 2007)  Stress fracture risk 2-4 times greater in amenorrheic vs. eumenorrheic athletes or BMD below -1 (Bennell KG et al, 1999)

7  Increased risk of endothelial dysfunction due to FHA  hypo-estrogenic state results in poor vasodilation  predicts long-term atherosclerotic disease progression and CV events (Temme KE and Hoch AZ, 2013)  Implications for impaired athletic performance (Temme KE and Hock AZ 2013)  impaired vasodilation results in decreased blood flow to exercising muscle  decreased perfusion may limit maximal exercise tolerance

8  Improved energy availability of kcal/kg FFM should be a priority in management of amenorrheic athletes (ACSM 2007; Loucks et al 2011; Arends 2012) and associated endothelial dysfunction (Temme KE and Hock AZ, 2013)  Folic acid supplementation ( 10 mg/day) shows promise as a safe, effective treatment for endothelial dysfunction in young amenorrheic athletes (Temme KE and Hock AZ, 2013)



11 n, Jennifer L.; Williams, Nancy I.; De Souza, M

12  Calcium: mg/day (ACSM 2007)  Vitamin D: mg/day (ACSM 2007)  Vitamin K mcg/day (ACSM 2007)  Folic acid supplements: 10 mg/day ?? (Temme KE and Hock AZ, 2013; Hock AZ 2011; Hock AZ 2010)  Further research is needed to determine lowest optimal dose of folic acid at which significant vascular benefit occurs

13  Improved BMD is more closely associated with increased body weight than with OCP/HRT use (Nattiv et al 2007; Ducher G et al 2011; Arends 2012)  Restoration of menses with OCP will not normalize metabolic factors that impair bone formation, health and performance (Ducher G et al 2011; Arends et al 2012)  Use of OCP prevents determination of a healthy body weight as indicator of return of menses

14  EA = kcal/kg FFM/day for weight loss  EA = 45 kcal/kg FFM for weight maintenance  EA > 45 kcal/kg FFM/day for growth and carbohydrate loading  Strong association between increases in both BMD & body weight implies that increasing BMD may require EA > 45 kcal/kg FFM/day

15 600 energy drinks on the market $2.5 billion dollar industry in 2009 $9 billion dollar industry in 2011

16  Self-report surveys show use by 30%-50% of adolescents/young adults  Half of energy drink market consists of:  children ( <12 years old)  adolescents ( 12–18 years old)  young adults ( 19–25 years old)  Fastest growing US beverage market

17  “Energy drinks”  marketed to improve energy, weight loss, stamina, athletic performance, and concentration  contain caffeine (high & unregulated amounts), guarana, taurine, vitamins, herbs, sugar/sweeteners  “Energy shots”  low-volume ( 1–2 oz) beverages with > concentration of caffeine ▪ range 100–350 mg ▪ 90–171 mg per oz


19 8 ounces of tea (brewed): 47 mg 12 ounces Coca-Cola: 34 mg 12 ounces Sunkist: 41 mg 8 ounces Red Bull: 80 mg 8 ounces coffee: 108 mg 1.93 oz shot 5-hour energy: 242 mg 16 oz NOS energy: 260 mg

20  tachycardia  cardiac arrhythmias  increased blood pressure  sleep disturbances, including insomnia  diuresis  vomiting  seizures  mania  stroke  sudden death



23  FDA limits caffeine content in soft drinks  71 mg per 12 fl oz soda; categorized as food  No FDA regulation of energy drinks  classified as dietary supplements  Safety determinations of energy drinks are made solely by the manufacturers  No requirements for testing, warning labels, or restriction against sales or consumption by minors in the US

24  OTC caffeine stimulants (No-Doz with 100 mg caffeine/tablet) must list  minimum age for purchase ( 12 years)  adverse effects and cautionary notes  recommended dose  max daily recommended dose  Yet, an energy drink with 500 mg caffeine can be marketed with no warnings & no information on caffeine content

25  Healthy adults (Cannon et al, 2001)  ≤ 400 mg/day is considered safe  acute clinical toxicity begins at 1 g  lethal dose > 5g (42 cups coffee )  Adolescent (Heatherly et al 2006; Seifert SM et al 2011)  ≤ 100 mg per day  Child (Heatherly et al 2006; Seifert SM et al 2011)  ≤ 2.5 mg/kg per day

26  Guarana  Contains 40 to 80 mg caffeine per gram & has a potentially longer half-life because of interactions with other plant compounds (Seifert et al 2011)  contains stimulants theobromine & theophylline  Taurine  addition of taurine does not improve physical and cognitive performance better than caffeine alone (Evidence Category B) (McLellen and Leiberman, 2012)  B vitamins  addition of multivitamins do not improve physical and cognitive performance better than caffeine alone (Evidence Category C) (Mclellen and Leiberman, 2012)

27  On Jan 2, 2013, Canada passed a law that limits allowable caffeine in food products.  Single serving beverages limited to 180 mg caffeine  re-sealable bottles capped at 400 mg per liter  Energy drinks (including Monster, Rockstar, 5 -hr energy and Red Bull)  reclassified as food products  forced to reformulate to comply with new rules

28  Labeling of energy drinks  Food ▪ Red bull  Dietary Supplement ▪ Monster ▪ 5-hr energy  These criss-crossing definitions impede action in the US for regulation

29  3-6 mg caffeine/kg can significantly enhance endurance and high-intensity performance in trained athletes (Campbell et al 2013)  IOC mandates a limit of 12 μg/ml of urine  corresponds to 9-13 mg caffeine/kg  NCAA mandates a limit of 15 μg/ml  WADA  does not deem caffeine to be a banned substance  part of monitoring program which serves to establish patterns of misuse in athletic competition

30  Ergogenic value of energy drinks is due to caffeine and carbohydrate (Campbell B et al 2013)  3-6 mg/kg caffeine is effective and safe (Goldstein et al 2010; Campbell 2013)  Safety and efficacy of other ingredients has not been proven (McLellen and Leiberman, 2012)  Athletes need to consider that energy drinks are not regulated and can be potentially harmful  Education regarding risk/benefit of energy drinks in athletes is warranted


32  Endurance athletes ▪ g/kg body weight ▪ Accounts for use of protein as fuel for energy  Strength athletes ▪ g/kg body weight ▪ Supports muscle growth, especially during early training phase

33  Protein supplementation pre- and post-workout increases lean body mass, muscle hypertrophy, and strength and recovery  Immediate intake is recommended since exercise- mediated increases in muscle protein synthesis rate (MPS) are greatest immediately after exercise  Essential amino acids (EAAs) stimulate increased rates of MPS

34  g whey protein isolate considered to be superior to other proteins in stimulating MPS (Poortmans JR et al 2012; Tipton et al 2011; Moore DR et al 2012; Beelen M et al 2010; Hulmi et al 2010; Stark 2012; Churchward- Venne TA et al 2012)  readily digestible immediately after exercise training  rapidly absorbed by the intestinal tract  contains 8–10 g EAAs  contains a high BCAA content, primarily leucine  unique role in initiating protein translation  leucine content of protein source impacts protein synthesis and affects muscle hypertrophy ( 3 g)

35  Dairy-soy blend (whey + casein + soy) has also been found to be an effective post-exercise supplement (Reidy PT et al 2013)  Sufficient EAA content  Several digestion rates  Prolonged aminoacidemia  Fat-free milk post-workout also effective in promoting increases in lean body mass, strength, muscle hypertrophy and decreases in body fat (Stark et al 2012).


37  20 year old offensive lineman  Height = 6’4”  Weight = 321 #  Breakfast: 2 poptarts, 16 oz gatorade  Lunch: 2 pb/j sandwiches, 16 oz apple juice  Dinner: 12 oz chicken, 1 cup mashed potatoes, 1 roll, 2 cups 2 % milk  Snack: 1 slice pizza


39  Breakfast: 2 poptarts, 16 oz gatorade  Add 2 eggs, 2 slices turkey bacon, whole grain English muffin and 1 orange  Lunch: 2 pb/j sandwiches, 16 oz apple juice  Change to 4 oz turkey sandwich with 1 oz sun chips and 1 apple  Preworkout:Add protein/carb bar  Postworkout: Add whey protein shake with 20 grams protein plus peanut butter and jelly sandwich  Dinner: 12 oz chicken, 1 cup mashed potatoes, 1 roll, 2 cups 2% milk  Reduce to 5 oz chicken and 1 cup milk; add 1 cup broccoli  Before bed: 1 slice pizza  Change to 2 packets oatmeal made with milk plus ¼ cup nuts


41  Quantity: g/kg body weight/day  Quality: whey, cow’s milk or protein blend are best  Timing: grams at each meal plus after workout/snacks to meet needs  Additional protein (milk or casein) 30 minutes before bed (Res et al 2012)  Addition of carbohydrate prior to and following exercise ( g/kg) (Kerksick C et al 2008)  Kcal intake of kcal/kg body weight (Stark M et al 2012: JADA 2000)


43  RICE  NSAIDs  NSAIDs are most used and prescribed medication in US (Kuehl 2013)  Adverse side effects ▪ gastric ulceration ▪ MI and stroke are also possible ▪ efficacy for their use in alleviating inflammatory symptoms remains questionable ▪ attenuates adaptive processes in exercise training and therefore should not be used long term (Glyn H and van Someren KA 2008)

44  Anti-inflammatory foods can mediate inflammatory process with fewer side effects  Tart cherry juice contains high levels of antioxidant/anti-inflammatory compounds (Wang H et al 1999; Connolly DA et al 2006; Bowtell JL et al 2011)  Cyclo-oxygenase inhibitory flavonoids  Anthocynanins  Tart cherry consumption appears to be effective in treating acute inflammation & injury pain among athletes (Kuehl 2013)

45  Interleuken-6 (IL-6) 49 % lower in tart cherry juice group  C-reactive protein (CRP) 34 % lower in tart cherry juice group  Uric acid levels were unchanged in tart cherry juice group but elevated in the placebo group  Results have important practical significance for distance runners since the inflammatory response to prolonged endurance exercise (particularly IL-6) has been linked to delayed recovery

46 Scandinavian Journal of Medicine & Science in Sports Volume 20, Issue 6, pages , 21 OCT 2009 DOI: /j x Volume 20, Issue 6,

47 Subjective report of pain after eccentric exercise with cherry juice vs. placebo Connolly D A J et al. Br J Sports Med 2006;40: Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

48  Reduced muscle damage (Bowtell et al 2011; Connolly et al 2006)  Reduced pain perception (Kuehl et al 2010)  Recovery of strength (Howatson et al 2009; Connolly et al 2006)  Reduced inflammation (Howatson et al 2009)  Reduced oxidative stress (Bowtell et al 2011; Howatson G et al 2009; Traustadottir R et al 2009)


50  Before exercise: > 4 hrs before exercise, drink 5-7 ml/kg body weight of water or sport beverage  During exercise: drink to avert a water deficit in excess of 2 % body weight  Amount and rate is dependent on an individual athletes sweat rate, exercise duration and opportunities to drink  Individualized hydration protocols are indicated  After exercise: drink at least oz of fluid per pound of body weight lost during exercise  Consuming rehydration beverages and salty foods at meals/snacks will help replace fluid/electrolyte losses

51  Recommendations to limit dehydration to

52  Field research shows that athletes can achieve outstanding endurance performance while dehydrated  2 % body weight loss rule does not apply to real- world exercise events  Only under exercise conditions comprising fixed- power output work does exercise induced dehydration impair endurance performance

53  Exercise-induced dehydration up to 4 % BW does not impair endurance performance during real- world exercise conditions  Endurance athletes are encouraged to follow thirst cues during exercise  Individualized, realistic, and evidence-based fluid replacement recommendations are needed based on each athlete (Lopez RM et al 2011)

54  Pay attention to thirst sensation by drinking fluids ad libitum  2 hr before exercise, ensure euhydration by drinking enough fluid  about 5–10 ml/kg body weight  produce 2 micturitions that are very pale yellow to pale yellow in color  Indicates body weight is within 1 % of well- hydrated baseline body weight

55  USE URINE COLOR AS A GUIDE 1 If your urine matches the colors 1, 2, or 3, you are properly hydrated. Continue to consume fluids at the recommended amounts If your urine color is below the BLUE line, you are DEHYDRATED and at risk for cramping / a heat illness! YOU NEED TO DRINK MORE WATER / SPORTS DRINK!

56  Endurance performance is maximized when plasma osmolality is regulated during exercise rather than body weight  Drinking to satisfy thirst during exercise should preserve extracellular fluid homeostasis and maximize endurance performance

57  Fluid intake is not important for maximization of endurance performance < 1 hour  Trying to fully replace fluid losses during high- intensity exercise may lead to gastrointestinal problems, which may impede performance  To optimize performance, mouth-rinse approximately every 8–10 min for 5–10 s with approximately 20–25 ml of a 6 % sports drink solution.

58  Research field is limited and much remains to be learned before reliable recommendations can be confidently made to competitive endurance athletes seeking the best performance (Goulet ED 2012)  Need for future studies looking at the relationship between endurance performance and dehydration  Include control group drinking to thirst  use research designs simulating out-of-doors exercise conditions as best as possible


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