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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

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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

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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 30-45 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)

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

12  Calcium: 1000-1300 mg/day (ACSM 2007)  Vitamin D: 400-800 mg/day (ACSM 2007)  Vitamin K 60-90 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 = 30 - 45 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

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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 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2735818/table/T1/

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

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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

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32  Endurance athletes ▪ 1.2-1.4 g/kg body weight ▪ Accounts for use of protein as fuel for energy  Strength athletes ▪ 1.2-1.7 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  20-25 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).

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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

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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

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41  Quantity: 1.4 - 2 g/kg body weight/day  Quality: whey, cow’s milk or protein blend are best  Timing: 20-30 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 ( 1.2-1.5 g/kg) (Kerksick C et al 2008)  Kcal intake of 44-50 kcal/kg body weight (Stark M et al 2012: JADA 2000)

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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 843-852, 21 OCT 2009 DOI: 10.1111/j.1600-0838.2009.01005.x http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0838.2009.01005.x/full#f1 Volume 20, Issue 6, http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0838.2009.01005.x/full#f1

47 Subjective report of pain after eccentric exercise with cherry juice vs. placebo Connolly D A J et al. Br J Sports Med 2006;40:679-683 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)

49  NFL DALLAS COWBOYSKANSAS CITY CHIEFS NEW ENGLAND PATRIOTSNEW YORK GIANTS PITTSBURGH STEELERSSAN DIEGO CHARGERS SEATTLE SEAHAWKSST LOUIS RAMS  MLB COLORADO ROCKIESNEW YORK METS PHILADELPHIA PHILLIESSEATTLE MARINERS  NHL CHICAGO BLACKHAWKSEDMONTON OILERS FLORIDA PANTHERSNEW YORK RANGERS  NBA HOUSTON ROCKETSNEW YORK KNICKS

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 16-24 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 { "@context": "http://schema.org", "@type": "ImageObject", "contentUrl": "http://images.slideplayer.com/14/4333861/slides/slide_51.jpg", "name": " 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. 2 3 4 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! 5 6 7 8

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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