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Amy Goodson, MS, RD, CSSD, LD
Ben Hogan Sports Medicine Sports DietitianTCU Sports Dietitian
Dallas Cowboys Sports Dietitian
Texas Rangers Sports Dietitian
FC Dallas Sports Dietitian
www.texashealth.org/benhogan
817.250.7512
The Ins and Outs of
Working with the
Female Athlete
Outline
� Macronutrient recommendations
� Carbohydrate, protein and fat needs for exercisers and
athletes
� Pre, during and post-exercise recommendations
� Easy, moderate and hard training days
� The Female Athlete Triad
� Three issues of concern with the female athlete
� Case studies
� High school, college and adult female athlete
2
Carbohydrate Needs of Athletes
� No real % recommendations for
carbohydrate intake for athletes
� General recommendation: 50-60% of total daily
energy should come from CHO for normal
people, but not for athletes
� Carbohydrate Recommendations
� 3-5 g CHO/kg BW for athletes in off-season &
attempting to lean out
� 5-7 g CHO/kg BW for general training needs
� 7-10 g CHO/kg BW for endurance athletes
� 11+ g CHO/kg BW for ultra-endurance athletes
Carbohydrate Goals
� Pre-Workout Goal:
� Provide long-lasting energy to start and sustain
beginning part of exercise
� Bagels, oatmeal, brown rice, pasta, whole grains
� During-Workout Goal:
� Maintain energy levels
� Provide carbohydrate to spare glycogen stores
� Energy bars, gus, energy chews, sports drinks
� Post-Workout Goal:
� Replenish glycogen stores
� Provide body with energy
� Quick digesting carbohydrate
� Sports drinks, fruit, milk, flavored milk, honey, etc.
3
Protein Needs� 0.8 gm/kg BW per day
� Sedentary individuals
� 1.0 gm/kg BW per day
� “Workout” people
� 1.2-1.4 gm/kg BW per day
� Endurance athletes, cycling
� 1.4-1.7 gm/kg BW per day
� Basketball, hockey, soccer, tennis, swimming, track
� 1.6-1.7 gm/kg BW per day
� Strength athletes
� Baseball, football
� 2.0 gm/kg BW per day
� Extreme exercise & heavy weight lifting
Protein: Best Choices
� Animal proteins are better absorbed
� Chicken, turkey, lean ham, lean red meat, fish, tuna, turkey bacon, turkey sausage, etc.
� Eggs and egg whites
� Low-fat dairy products
� Whey protein powders
� Good for smoothies/shakes
� Whey protein is a quick digesting protein
� Plant proteins are not absorbed as well so vegetarian/vegan athletes might need more protein than their exercise level
� Quinoa, oats, other whole grains
� Nuts, seeds, nut butters
� Beans and lentils
4
Fat Recommendations for Athletes
� 20-35% of total calories
� Anything less than 20% does not show
performance enhancement
� Essential Fatty Acids
� Consume at least 3-5% of dietary fat from food
sources such as fish and plant oils
� Consequences of low-fat diets in athletes
� Low-fat diets may not meet energy demands for
growth & development in young athletes
� Low-fat diets over time could cause deficiencies in
fat-soluble vitamins & essential fatty acids
� In females, low-fat diets can contribute to menstrual
dysfunction due to insufficient calories
Pre-Exercise Eating
� Pre-exercise meal
� 2-4 hours before a workout/game
� High carbohydrate
� Low in fat & fiber
� These slow down digestion
� Moderate protein
� Combine protein + carbohydrate
� Plenty of fluids (16-20 oz)
� Immediate Pre-exercise Snack
� 30 minutes before workout/game
� High carbohydrate, small amount of protein to
provide you with a boost of energy
� 5-10 oz water or sports drink
5
The Athlete’s Plates are a collaboration between the United States Olympic Committee Sport
Dietitians and the University of Colorado (UCCS) Sport Nutrition Graduate Program.
The Athlete’s Plates are a collaboration between the United States Olympic Committee Sport
Dietitians and the University of Colorado (UCCS) Sport Nutrition Graduate Program.
6
The Athlete’s Plates are a collaboration between the United States Olympic Committee Sport
Dietitians and the University of Colorado (UCCS) Sport Nutrition Graduate Program.
Morning Training
� Athletes that train early cannot always eat 2-4
hours prior workout
� Recommend quick carbohydrate snack
� Moderate to high GI goods
� Food or drink with ~25-50 gm carbohydrate
� Granola bar, banana, baggie of dry whole grain
cereal with a few nuts, slice of bread with smear of
peanut butter, etc.
� Bland, easy-to-digest carbohydrate likely best
� Some protein recommended for those clients
training harder, specifically strength training
� Protein bar, pack of peanut butter crackers, peanut
butter and jelly sandwich on wheat bread, etc.
7
During Workouts
� Carbohydrate-rich foods/drinks
� Carbohydrates digest the quickest & thus provide
energy faster!
� Avoid fat and fiber when exercise
� Slows digestion and increases time in which energy
is available to be used
� 100-300 calories of carbohydrates per hour,
after the first hour of exercise
� 30-60 grams of carbohydrate per hour
� 1 gram carbohydrate/kg body weight/per hour
� Fluid losses – match sweat losses
� Consume 5-10 oz fluid every 15-20 minutes
Mid-Practice/Workout Snacks
� Carbohydrates, some protein, little fat
� Energy bars and a fruit
� Granola bars and nuts
� Peanut butter and jelly sandwich
� Peanut butter crackers
� Dry cereal/trail mix with small amount of nuts
� Banana and beef jerky
� Sports drink with snack
� Athletes unintentionally losing weight
� Need to eat snack(s) during practice
� Constantly drink sports drink
8
Post-Exercise Nutrition
� The three R’s to post-workout recovery:
� Replenish carbohydrate burned during exercise
� Repbuild damage done to lean muscle mass
� Rehydrate the body to euhydration
Post-Exercise 2-Hour Window
� 2-Hour Window of Recovery
� Your body has a specific time period, post-exercise,
when you are able to more effectively take up nutrients
� Blood flow to muscles is greater
� Muscle cell is more likely to take up glucose
� Muscle cells more sensitive to the effects of insulin
during this time
� 0-45 minutes
� Best time to eat at least a snack…muscles more sensitive
to absorb nutrients!
� 45 minutes – 2 hours
� Try to get a nice-size meal or larger snack
� The window is the most important time to consume plenty
of carbohydrate, protein, & fluids to replenish & refuel
� Essential if participating in twice a day training
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Post-Exercise Fueling Goals
� Carbohydrate - Replenish
� Body NEEDS lots of carbohydrate post-exercise to
replace energy stores
� Simple carbs are best: milk, sports drink, fruit,
juice
� Protein - Rebuild
� Body needs some protein to start repairing tiny
muscle tears
� Ideally 20 gm protein immediately post-workout
� 10 gm seems to show benefit to athletes who need
less calories post-workout
� Whey protein is the highest in BCAAs, specifically
leucine which has been shown to re-synthesize
muscle the fastest after a workout
Whey Protein
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Protein
Source
BCAA
Content
Leucine
Content
Whey 26% 14%
Egg 20% 9%
Soy 18% 8%
Wheat 15% 7%
Join the Conversation: #BeyondLI
10
Post-Exercise Eating
� Carb-Protein Combo Food Examples
� If you have products available:
� Carb-Protein Replacement Shake
� Muscle Milk, Rockin’ Refuel or EAS
� Energy bar & Gatorade
� Smoothie made with 1-2 cups low-fat milk, fruit,
cold water, ice, and 1 scoop NSF Certified whey
protein powder
� If you are on a budget:
� 16-20 oz low-fat chocolate milk
� Granola bar and 12 oz low-fat milk
� Yoplait Greek 2x Protein Yogurt and a string cheese
Post-Exercise Eating
� Refuel with post-workout chocolate milk!
� 90% water which helps replace fluids and
rehydrate the body
� Contains calcium, Vitamin D and phosphorus to
help promote, maintain and build strong bones
� Contains protein to reduce muscle breakdown
� Contains carbohydrate to fuel muscles during
exercise and help muscles recover after exercise
� Contains potassium which helps with fluid and
mineral balance and muscle contraction
� Contains B vitamins that help convert food to
energy to fuel working muscles
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Why chocolate milk works!
� Athletes love the taste
� It is inexpensive
� It is found everywhere
� School cafeterias
� Fast food restaurants
� Restaurants
� Convenience stores
� Grocery stores
Fueling Summary for
Female Athletes
� Sports Nutrition
� Pre-workout
� Meal of complex carbohydrate and protein 2-4 hours
before workout and carbohydrate snack 30 minutes prior
� 16-20 oz fluid with meal and 5-10 oz with snack
� During-workout
� Consume electrolyte-rich fluids consistently throughout
workout; 5-10 oz every 15-20 mins
� Carbohydrate foods like sports drinks, energy bars, gus,
fruit, etc. are needed during workouts over 1 hour long
� Post-workout
� Replenish with carbohydrate
� Rebuild with protein
� Rehydrate with fluid
12
Female Athlete Triad
� Syndrome that comprises 3 medical disorders:
� Disordered eating
� Amenorrhea
� Osteoporosis
ACSM’s Position Stand Paper
Female Athlete Triad
� Low energy availability – key piece of the
metabolic and health consequences
� Energy availability = Energy intake –
Energy expenditure/kg of fat-free mass
� Need to identify reason for low energy
availability
� Result of disordered eating OR because an
athlete does not meet exercise energy
requirements due to lack of nutrition
knowledge, time constraints, and/or food
availability issues
13
Disordered Eating
� General term used to describe the spectrum of
abnormal and harmful eating behaviors that are
used to lose weight or maintain a lower than
normal body weight
� Examples:
� Excessive dieting
� Excessive exercise
� Fat and sugar phobias
� Patterns of alternating starvation & overeating
� Excessive supplementation with vitamins,
minerals and/or herbs
� Inability to eat adequately in public
� Laxative abuse
Signs and Symptoms of
Disordered Eating
� Physical� Chronic fatigue
� Orthostatic hypotension
� Anemia
� Noticeable weight loss or
gain
� Alopecia (hair loss)
� Callused fingers
� Cold intolerance
� Frequent GI
problems/complaints (such
as excessive gas,
constipation, ulcers, or
abdominal bloating)
� Lanugo (fine hair on face
and body)
� Brittle nails
� Tooth erosion or excessive
dental caries
� Dry skin and hair
� Frequent or prolonged
illnesses
� Irregular or absent
menstrual cycles (in
women)
� Delayed or prolonged
wound or injury healing
� Cardiovascular
abnormalities (such as
palpitations, prolonged QT
intervals, or bradycardia)
� Frequent musculoskeletal
injuries (such as stress
fractures)
14
Signs and Symptoms of
Disordered Eating
� Behavioral� Depression
� Social withdrawal
� Bathroom visits after eating
� Excessive use of diuretics,
laxatives, or diet pills
� Secretly eating or stealing
food
� Excessive criticism of
one’s body weight or shape
� Compulsive, excessive
exercise
� Mood swings, irritability
� Preoccupation with the
dietary patterns and eating
behaviors of other people
� Avoiding food-related
social activities
� Preoccupation with food,
calories, or weight
� Excessive fear of being
overweight or becoming fat
that does not diminish as
weight loss continues
� Consumption of large
amounts of food
inconsistent with the
athlete’s weight
� Lack of concern for
excessive weight loss or
extremely low body weight
Amenorrhea
� Difference between Amenorrhea,
Oligomenorrhea, and Eumenorrhea
� Primary Amenorrhea
� Never had a menstrual cycle by age 15
� Secondary Amenorrhea
� Started menstrual cycle and has had menstrual
cycle cease for at least 3 months
� Oligomenorrhea – menstrual cycles at intervals
longer than 35 days
� Luteal deficiency and anovulation do not have
detectable symptoms
� Eumenorrhea – menstrual cycles at intervals near
the median interval for young adult women
15
Osteoporosis
� Osteoporosis – skeletal disorder
characterized by compromised bone
strength predisposing an individual to an
increased risk of fracture
� Bone strength and fracture risk are based on
� Internal structure of the bone mineral
� Density of the bone mineral
� Quality of bone protein
� Cause is not always a result of increased bone
mineral loss in adulthood, but may also be
related to not obtaining an ideal bone mineral
density during childhood and adolescence
Osteoporosis:
Bone Mineral Density
� Athletes participating in weight-bearing
sports typically show a 5-15% higher BMD
compared to nonathletes
� ACSM’s definition of low BMD includes:
� History of nutritional deficiencies
� Hypoestrogenism
� Stress fractures
� Other secondary clinical factors for fracture
� Along with a BMD Z-score between -1.0 and -2.0
� ACSM’s definition of osteoporosis includes:
� Secondary clinical risk factors for fracture with
BMD Z-scores ≤ -2.0
16
Female Athlete Triad
� Source of problem is two-fold:
� Burdened by sociocultural demands placed
on women to be thin
� Expected to meet weight standards and/or
body size expectations for sports
� Without a normal menstrual cycle female
athletes might experience declines in bone
mineral density
Warning Signs
� Excessive dieting for weight loss, large
fluctuations in body weight, or too much
weight loss
� Irregular or absent menstrual periods
� Stress fractures, especially recurrent stress
fractures
� Self-esteem and mood that appear to be
dictated by body weight and shape
� Compulsive over-exercising
17
Sports Putting Females at Risk
� Sports emphasizing leanness:
� Sports having subjective performance
scoring (i.e. dance, skating, diving, and
gymnastics)
� Endurance sports
� Sports that require an athlete to wear body-
contouring or body-revealing clothing
� Sports that require weigh-ins or specific
weights
� Sports that emphasize a preadolescent body
build for success
Effects on Health
� Macronutrient
deficiencies
� Micronutrient
deficiencies
� Anemia
� Chronic fatigue
� Increased risk of
injury, infections,
and illnesses
� Reduced basal
metabolic rate
� Cardiovascular and
GI disorders
� Depression
� BMD decreases
� Menstrual
dysfunction in
females
� Potential decreases
in testosterone for
males
18
Effects on Performance
� Chronic/severe energy restriction can be
detrimental to performance, and is due to
one or more of the following:
� Frequent infection, illness, and/or injuries
� Anemia
� Fatigue
� Nutrient deficiencies
� Decreased cardiovascular function
Female Athlete Triad Treatment
� First goal is to increase energy availability
� Through an increase in energy intake or a
reduction in energy expenditure
� Discuss that increases in body weight might
be needed to increase BMD
� Treatment for eating disorders and
disordered eating includes:
� Nutritional counseling
� Individual psychotherapy
� Cognitive-behavioral, group, family, and
behavioral therapy may also be utilized
19
Treatment for Eating Disorders
� Multidisciplinary approach:
� Sports medicine team
� Nutritionist/Dietitian
� Exercise physiologist
� Psychologist
� Coach
� Trainer
� Parents
� Friends
Eating Disorder Prevention
� Focus on the environmental risk factors
� Sociocultural emphasis on thinness
� Unrealistic body weight ideals
� Unhealthful eating and weight control practices
� For the younger athlete – education should
also focus on the parents
� Focus on dispelling myths and
misconceptions related to nutrition, body
weight and composition, weight loss, and
the affect of these factors on the individual’s
athletic performance
20
Issues of Concern with
Female Athletes
� Micronutrients of concern
� Calcium and Vitamin D
� Iron
� Fads with females
� Communicating with female athletes
Issues of Concern with
Female Athletes� Micronutrients of concern
� Calcium and Vitamin D
� Essential to bone health; bone is fully developed by about
age 25 in females with 90% by age 17
� Inadequate intake of calcium coupled with heavy intense
training can have detrimental effect on bone health in
maturing children
� Recommendation: 1000-1300 mg/day of calcium
� Best choice is low-fat dairy: milk, cheese and yogurt
� Ideally 3 servings per day
� Iron
� Puberty increases the requirements for iron due to
increase in hemoglobin mass, tissue deposition, growth
spurts and onset on menstruation in females
� Best choices: lean red meat, whole eggs, green leafy
vegetables, nuts and peanut butter
21
Issues of Concern with
Female Athletes
� Fads with female athletes
� Lack of understanding how many calories and
carbohydrates they actually need to train
� Cutting out entire food groups like dairy, grains,
processed foods, etc.
� Jumping on fad diets they see celebrities or their
friends go on and thinking that can fuel their body
adequately
� Orthorexia: Obsession with healthy eating
� Filling up on nutrient-rich, low-calorie foods
� Thinking that amenorrhea is a good thing and a
sign of adequate training
� Lack of concern with health issues
Issues of Concern with
Female Athletes
� How to communicate with female athletes
� Most don’t want to hear they need to eat more, gain
weight, eat higher calorie foods, etc.
� Don’t use the term disordered eating, eating
disorder, etc. as many will become defensive
� Educate about nutrition needs under the umbrella
of energy versus calories and fueling versus eating
� When talking about the Female Athlete Triad,
communicate about energy availability
� Understand that you likely will have to build them
up to the macronutrients and calories they need
� Most will not increase calories by large amounts
over night and be okay with it
22
Case Study:
High School Athlete
� Age: 16 – Height: 5’11” – Weight: 175 lbs
� Goal: Weight loss
� Lost 30 lbs but gained most of it back
� Weight went up upon upon switching schools and a
medication change
� Training
� Cross country: 5 miles a morning daily
� Lifts weights 3x/week
� Switches to soccer in cross country off-season
� Plays golf
� Amenorrhea for 1 year and 2 months
� Calorie needs: 2600-2800 for weight
maintenance with current exercise
Case Study:
High School Athlete
� Currently eating 800-1000 calories
� 7:00 am: Run
� 8:00 am: Breakfast of 2 egg whites, 1 cup
melons, 1 slice pita bread
� 8:30 am: 600 crunches, 600 heel touches, some
light dumbbell work, no cardio
� 12:15 pm: Lunch of bagel thin with little turkey,
lots of lettuce and mustard, 1 serving pretzels,
celery, 6 oz low-fat Greek yogurt OR ½
grapefruit and a rice cake with cottage cheese
� 6:00 pm: Dinner of grilled chicken, roasted
vegetables and quinoa
� Water to drink at all meals
23
Case Study:
High School Athlete
� First meal plan goal: 1600-1800 calories
� 8:00 am: Breakfast of ½ cup (measured dry) oats
with 1 Tbs. peanut butter, 6 oz low-fat Greek yogurt,
1 fruit
� 10:00 am: Snack of KIND Bar
� 12:15 pm: Lunch of 1 serving whole wheat crackers,
2 oz deli meat, 2% string cheese, ½ cup cottage
cheese and a fruit
� 4:00 pm: 8 oz low-fat chocolate milk post-run then 1
serving whole wheat pita chips and ¼ cup hummus
� 6:30 pm: Dinner of 3 oz lean meat, veggies, 1 cup
carbohydrate, 8 oz low-fat milk
� 9:00 pm: Snack of 1 apple with 1 Tbs. Justin’s cocoa
almond butter
Case Study:
High School Athlete
� Goal 1 month later
� Increase to 2000 calories
� Training had increased due to soccer and cross
country and workouts moved to afternoon
� Goal of adding another afternoon snack as she felt
hungry
24
Case Study:
College Athlete
� Age: 21 – Height: 5’4” – Weight: 98 lbs
� Goal: Weight gain; goal of 108
� 125# in high school; lost weight for running down to
110-115; then continued to lose
� Training
� Cross country: 40 miles a week
� Lifts weights 2x/week with core training
� Amenorrhea for 1 year; taking birth control
� RMR: 1095 calories
� RMR + daily activity: 1434 calories
� Maintenance calories with exercise: 2070 calories
� Weight gain calorie goal: 2500-2600 calories
Case Study:
College Athlete
� Currently eating 2300-2400 calories
� 8:30 am: ¾ cup oatmeal made w/ ¼ cup egg whites,
½ scoop protein powder, 1 Tbs. peanut butter and a
banana
� 1:00-1:30pm: Sandwich w/turkey, avocado and
veggies, laughing cow cheese with pretzels and an
apple
� Pre-workout: Protein bar or Greek yogurt w/ granola
� Post-workout: 1 scoop whey protein in water or
protein bar
� 7:30pm: Chicken, vegetables, large sweet potato with
1 Tbs. peanut butter
� 9:00pm: Greek yogurt with 1 scoop casein protein
powder and a Lara bar crumbled in
25
Case Study:
College Athlete
� Goals
� Add mid-morning snack around 11:00am
� Energy bar, fruit, string cheese
� ½ cup trail mix, 6 oz Greek yogurt, fruit
� 2 Kashi cookies with 8-12 oz low-fat milk
� Add 100-ish calories to each meal and snack
� 1 Tbs. peanut butter or 3 Tbs. nuts
� ½ avocado
� 1/3-1/2 cup hummus
� 2-3 Tbs. granola
� Eat a meal/dessert out with friends that she did
not prepare, look-up or subtract calories for
earlier in the day
Case Study:
Adult Exerciser
� Age: 53 – Height: 5’2” – Weight: 91 lbs
� Goal: Gain muscle
� Normally around 94-95 pounds
� Training
� 3 d/week run 3-4 miles and abs
� 3 d/week group resistance training for 1 hour
� Osteopenia
� Lactose intolerant and severe GI issues
� RMR: 971 calories
� RMR + daily activity: 1165 calories
� Maintenance calories with exercise: 1700 calories
� Weight gain calorie goal: 2200-2300 calories
26
Case Study:
Adult Exerciser
� Currently eating 1100-1200 calories
� 7:30 am: 2 egg whites, English muffin, 8-12 oz
Lactaid milk
� 10:00 am: Homemade protein bar 125 calories (15 c,
10 p, 3 f)
� 12:00-1:00 pm: Sandwich thin with lunch meat and
maybe nuts
� 3:30pm: 8-12 oz Lactaid and 1 Tbs. peanut butter
� 7:00pm: 4-5 oz lean protein, vegetables (used to eat
couscous)
Case Study:
Adult Exerciser
� Goal of 2000-2200 calories
� 7:30 am: ½ cup oats w/1 Tbs. peanut butter, 6 oz
low-fat Greek yogurt and 8-12 Lactaid milk
� 10:00 am: Homemade protein bar 125 calories (15 c,
10 p, 3 f) with 8-12 oz Lataid milk
� 12:00-1:00 pm: Whole wheat pita with 2 oz chicken,
¼ cup 2% cheese, veggies and 1/3 avocado, salad
with balsamic vinaigrette and banana
� 3:30pm: 1 Kashi cookie with 1 Tbs. peanut butter and
a 2% string cheese
� 7:00pm: 4-5 oz lean protein, vegetables, 1 cup Barilla
Pasta Plus and salad with balsamic vinaigrette
� 1 hard-boiled egg and a fruit
27
Case Study:
Adult Exerciser
� Follow-up
� Would barely eat 1500 calories
� When she would eat more in one place, she would
subtract it another place
� Frustrated and confused why she could not gain
weight
� Seemed unwilling to try to add more nutrient dense
foods
� Recommended adding Boost Plus or Ensure Plus a
few times a day to help get calories in
References
� American Dietetic Association, Dietitians
of Canada, and the American College of
Sports Medicine: Nutrition and Athletic
Performance Position Stand. Medicine &
Science in Sports & Exercise: March 2009;
Volume 41, Issue 3: 709-731.
� Dunford M and Coleman EJ. Sports
Nutrition: A Practice Manual for
Professionals, 5th ed.
28
Questions
Thank you to Dairy MAX
for sponsoring this
presentation