INTERPROFESSIONAL APPROACH TO SUPPORTING …€¦ · Most of these finishers were inexperienced runners 20% of Americans run regularly for fitness 30% of Americans may participate

JENNIFER STROMBERG, MD, CAQ SPORTS MEDICINEFRANCA B. ALPHIN, MPH, RDN, CSSD, CEDRD, LDN

INTERPROFESSIONAL APPROACH TO SUPPORTING COMPETITIVE RECREATIONAL ATHLETES:

MEDICAL AND NUTRITION

ABSTRACT

Many students coming to college seek out competitive sports opportunities to stay well, manage their weight and to seek a challenge. Students seeking to “up their game” in recreational and competitive sports may not always be aware of the importance of nutritional changes as they go through this progression. This session will help health care providers support this emerging class of student athletes, from both a nutritional and medical perspective.

CURRENT STATE

▪ Students set competitive recreational goals, mainly for purpose of weight loss and weight management, without consideration of possible overuse injuries, re-activing old injuries and inadequate nutritional support.

DESIRED STATE

▪ Students discuss with medical provider and registered dietitian, state of exercise engagement; recreational versus competitive, goals, and receive appropriate interdisciplinary guidance.

OBJECTIVES

▪ Discuss guidelines for appropriate training regimens and injury prevention strategies with students planning a race/competition

▪ Distance, intensity, periodization, recovery, nutrition, hydration

▪ Describe necessary dietary changes to support students in their transition to different levels of exercise; macro and micronutrients

▪ Carbohydrate and protein adjustments, increased vitamin and mineral needs, address misconceptions about competition and weight management

▪ Identify common injury patterns and warning signs of overtraining

▪ Overuse injuries, stress fracture recognition, amenorrhea, low energy availability

▪ Explain and describe the benefits of implementing dietary changes while in recovery from an injury.

▪ Weight and inflammation management, protein and healthy fat adjustments

WHAT ARE OUR STUDENTS TRAINING FOR?

▪ Varsity sports

▪ Club and intramural sports

▪ Recreational sports competitions

▪ Running (5k, 10k, marathon, etc)

▪ Triathlon

▪ Obstacle races

▪ Strength competitions

COMPETITIVE RECREATIONAL EVENTS

Becoming more popular 1

▪ A record 507,000 Americans completed a marathon in 2010

▪ Most of these finishers were inexperienced runners

▪ 20% of Americans run regularly for fitness

▪ 30% of Americans may participate at times in recreational races

WHY ARE THESE COMPETITIONS BECOMING MORE POPULAR?

▪ Physical health & weight loss

▪ Mental health & stress reduction

▪ Social interaction & community celebrations 1

▪ Improved sleep 2

▪ Charitable fundraising

▪ Memorial events

▪ Easily accessible 3

▪ Efficient way to achieve fitness 4

WHY SHOULD WE CARE?

▪ 26-92% of runners will experience a running-related injury in the course of a year

▪ 19-79% of runners will have lower extremity injuries

▪ 25% of runners are injured at any given time 5

▪ 6-18% of marathon runners present to aid stations during a race

▪ 3.6% of half marathon runners 3

WHEN SHOULD WE ASK OUR STUDENTS?

▪ Annual physicals

▪ GYN visits

▪ MSK injury visits

▪ Chronic fatigue

▪ Recurrent illness

▪ Depression/Anxiety

WHAT SHOULD WE ASK OUR STUDENTS?

▪ Are you training for a competition?

▪ What is your goal?

▪ Are you following a training program?

▪ Who are you training with?

▪ Our goal:

▪ Determine if students are at high risk for injury

▪ Provide interdisciplinary guidance to prevent injury

OBJECTIVE #1▪ Discuss guidelines for appropriate training regimens and injury prevention

strategies with students planning a race/competition

▪ Distance

▪ Intensity

▪ Periodization

▪ Recovery

▪ Nutrition

▪ Hydration

WHY DO RUNNERS THINK THEY ARE INJURED?

▪ “Not respecting the body’s limitations” 2

▪ Biomechanics/technique

▪ Wearing the wrong shoe

▪ Training errors

▪ Not stretching

▪ Not warming up

▪ Excessive training

▪ Lack of strength

RISK FACTORS FOR INJURY▪ History of prior injury is the strongest risk factor for injury 6

▪ May be due to:

▪ Incomplete healing

▪ Altered biomechanics

▪ Consider PT referral to assess for any residual deficits

RISK FACTORS FOR INJURY- FOOTWEAR▪ Hot topic

▪ Systematic review found improvements in running economy with:

▪ Stiff midsoles

▪ Comfort

▪ Cushioning (>10mm)

▪ Lower mass (light/minimalist and barefoot)

▪ There is some evidence to indicate shock-absorbing insoles may help prevent stress fractures 7

RISK FACTORS FOR INJURY- FOOTWEAR

▪ Patients transitioning to minimalist/barefoot shoes need to progress gradually to avoid injury

▪ Metatarsal stress fractures

▪ Achilles tendinopathy

▪ Plantar fasciitis 8

TRAINING RISK FACTORS FOR INJURY-STRETCHING/WARM-UP▪ No studies have demonstrated a proven benefit of stretching either before or after

planned workout session

▪ Athletes who completed a 5 minute warm-up prior to start of training did see a reduction in injury rates 2

TRAINING RISK FACTORS FOR INJURY-DISTANCE/INTENSITY▪ Longer races

▪ Longer training sessions

▪ Speed training

▪ Interval training was actually a protective factor

▪ This is likely because periods of high intensity were followed by periods of low intensity resulting in a cumulative lower intensity 9

TRAINING RISK FACTORS FOR INJURY- FREQUENCY▪ Changes in routine

▪ 1/3 of runners described a change in routine just prior to injury 5

▪ Drastic increase in distance, frequency, intensity

▪ Change in footwear or surface

▪ Running the whole year through

▪ Lack of cross-training8

GUIDELINES FOR TRAINING▪ 10% rule

▪ Commonly used guideline

▪ Distance/intensity should be increased only by 10% per week

▪ 30% rule?

▪ A cohort study found an increased rate of distance-related injuries for runners who increased distance by more than 30% over a 2 week period

▪ Increases of <10% and 10-30% not associated with increased injury risk 5

▪ Running > 6 x/week is associated with higher risk for injury

▪ 1-3 running sessions per week is protective

▪ Distance per week

▪ Distance > 40 miles per week increases injury risk 2=1

▪ Distance <15 miles per week can increase risk of exercise-related leg pain 8

GUIDELINES FOR TRAINING- REST/RECOVERY▪ Should be built into training program

▪ Running more than once a day or 7 days a week does not permit adequate tissue recovery

▪ Less than 2 days a week of rest can increase risk of overuse injury by 5.2 fold 8

▪ One popular strategy is periodization in which rest/recovery weeks are included as part of training programs 2

▪ Consider exercise addiction in students unable to meet these guidelines

TRAINING RISK FACTORS FOR INJURY- STRENGTH▪ Poor core and functional strength 8

▪ Hip flexors/abductors

▪ Vastus medialis 4

▪ Consider a quick screening in office with a single-legged squat test 8

TRAINING RISK FACTORS FOR INJURY-NUTRITION/HYDRATION▪ Not mentioned by our athletes, but one of the first things I think about!

▪ Providers should ask about:

▪ Dietary changes/restrictions

▪ Calcium and vitamin D intake

▪ Iron/Ferritin

▪ Weight loss and goals

▪ History of irregular menstrual cycles

▪ I am very quick to get our nutrition team involved with these students

OBJECTIVE #2Describe necessary dietary changes to support students in their transition to a higher level of exercise; macro and micronutrients

▪ Carbohydrate and protein adjustments, increased vitamin and mineral needs, address misconceptions about competition and weight management

TRAINING AND WEIGHT LOSS

▪ Training does not guarantee weight loss.

▪ If the only reason someone is competing in an event is to lose weight, they may wish to rethink the event:

▪ What happens to weight once the training stops

▪ Hunger/Appetite can increase with increased workouts and body comp. changes = we eat more.

▪ Higher calorie demands to support body’s needs – may not result in weight loss.

PERIODIZATION▪ Where you are in your training matters; just

starting, midway through or close to race/event time.

▪ Caloric intake is dependent on exertion – more training, more intensity, more food.

▪ Injured athlete will require more protein and fewer carbohydrates, and generally fewer calories

▪ If just starting, your athlete may need fewer carbs – than later, i.e. fewer calories although protein intake may stay the same

▪ High intensity exercise will require more carbohydrates

▪ Midway in training is likely to be the highest caloric intake due to results from training and often there is some tapering before event.

▪ Very few athletes adjust their caloric intake/dietary needs based on where they are in training – which is detrimental to their performance and recovery.

ENERGY FOODS - CARBOHYDRATES

CARBOHYDRATES PER GRAM/KG/BODY WEIGHT

▪ 140 lbs = 63 kgs X 5 = 318 gms X 4 = 1273 Kcal.


▪ 170 lbs = 77 kgs X 5 = 385 gms

▪ 200 lbs = 91 kgs X 5 = 455 gms

Vs

▪ 140 lbs = 63 kgs X 7 = 441 gms x 4 = 1764 kcal.



▪ 200 lbs = 91 kgs X 7 = 637 gms

▪ 1 piece large fruit = 30 gms

▪ 1 Bruegger’s Bagel = 45 gms

▪ 2 cups pasta = 60 gms

▪ 1 slice of pizza = 30 gms

▪ 1 cup veggies.(raw) = 5 gms

.

ATHLETE’S PLATE

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.

For educational use only. Print and use front and back as 1 handout.

PROTEIN

▪ Essential for muscle development and repair but has many, many other functions in the body. Of the three macronutrients, it is the most important.

▪ There has been concern regarding increased calcium excretion with higher protein intake and so important to ensure adequate calcium intake as well, especially in healing bone.

▪ Protein has the highest “fullness/satiety” factor of the nutrients – high protein diet could limit caloric intake, which in recovery is not necessarily concerning, as along as intake is adequate.

PROTEIN REQUIREMENTS

Recreational

Competitive

Endurance

Ultra-endurance

Intermittent sports (soccer basketball)

Strength training – maintain

Strength training – build

Recovering athlete*

g/kg g/pound

1.1 - 1.6 0.5 - 0.7

1.3 - 1.8 0.59 - 0.80

1.2 - 1.8 0.55 - 0.8

1.4+ 0.64+

1.4 -1.8 0.64 - 0.80

1.2 - 1.3 0.55 - 0.59

1.5 - 2 0.68 - 0.9

1.4+ 0.64+

PROTEIN REQUIREMENTS

▪ 150 lbs = 68 kgs X 1.7 = 115 grams/day







PROTEIN

▪ ½ of a chicken breast 20 grams

▪ 1 can of tuna 14 grams

▪ 5 ounce filet 30 grams

▪ 1 12 ounce glass of milk 12 grams

▪ 1 egg 7 grams

▪ 2 TBSP peanut butter 8 grams

▪ 1 ounce cheese 7 grams

▪ Protein shakes 25-42 grams

TIMING* AND MEAL BALANCE▪ Eating throughout the day is optimal for weight management, energy, recovery

and performance. Small meals never make you feel to full, which also allows for more appetite.

▪ Sticking only to three larger meals can make you feel overly full and uncomfortable and may make it very challenging to get all the nutrients you need.

▪ Recent research continues to show the benefit of having protein with all meals (20-30 gms) and snacks, and ideally not having the bulk at the end of the day.

* Importance is often underestimated

FAT▪ Essential part of the diet and rich in fat soluble vitamins.

▪ Estimate about .45 gm/pound/body weight

▪ Healthy fats: Monounsaturated such as olive oil and canola oil, (omega 3’s)the oil you find in nuts ( also provide antioxidants) and seeds ▪ Fish oils: salmon and oilier fish (omega 3’s, flax seed)

▪ Polyunsaturated fat (omega 6)– corn, safflower, sunflower – can be inflammatory so should be limited.

▪ Saturated fat – least healthy, but also part of a healthy diet.

▪ Commercially produced trans fats – not necessary

SATURATED FAT

▪ May worsen outcome (as well as sugar - inflammatory) and so adding more fat to the diet is important but ensuring that it’s not excessive amounts of saturated fat.

▪ Butter

▪ Lard

▪ Dairy

▪ Meat

▪ Fried foods

▪ Sweets – often use butter or saturated fats

FLUIDS – HOW MUCH AND WHAT KIND

▪ Water

▪ Sports drink vs lower calorie sports drink? Not necessary in recovery

▪ Fitness/vitamin waters

▪ Carbonated beverages

▪ Energy drinks ( guarana, herbs, mate, kola nut) Not necessary in recovery

▪ Fruit juices High calorie beverage in recovery

▪ Milk Nice way to add protein, calcium, whey, casseine and leucine to the diet

▪ Alcohol Can worsen depressive symptoms, dehydrates and SLOWS recovery

▪ Smoothies If appetite is lacking, good way to get nutrients

VITAMIN D THE SUNSHINE VITAMIN

▪ Surprisingly high prevalence of vitamin D insufficiency and deficiency has recently been reported worldwide, although still controversial as to whether we need to supplement or not.

▪ Necessary for optimal bone health but also for immune health and inflammation.

▪ Compromised Vit. D. status can affect overall health and ability to train (by affecting bone health, innate immunity, and exercise-related immunity and inflammation).

IRON DEPLETION

Female and adolescent athletes have the highest rate of iron depletion.

National average of IDA – 3-5%

NHANES II - Adolescent girls – 9-10%, boys 1%

Suggested that 20-50% of female athletes and 4 to 50% of male athletes have depleted stores.

Highest frequency is seen in athletes participating in running, triathlon, swimming, rowing, soccer and basketball.

Ferritin should be above 35 ug/L for W and above 40 ug/L for male athletes.

Educate on dietary iron content and absorption considerations

Blockers: tea, coffee, calcium, antacids (ex. Tums), H2 blockers

(ex. Zantac), Proton Pump Inhibitors (ex. Prilosec)

Enhancers: 100mg vit C/~30mg elemental iron, pots

Food combinations: animal and vegetable sources

Supplement if necessary: Consider alternate days*

Monitor Side Effects: Constipation, nausea, upset stomach

Reassess Status

IRON DEFICIENCY AND ANEMIA

NUTRITION RESOURCES▪ Academy of Nutrition and Dietetics: www.eatright.org

▪ SCAN: http://www.scandpg.org/

▪ NSF: http://nsfsport.com/

▪ Gatorade Sports Science Institute: http://www.gssiweb.org/en

▪ International Journal of Sports Nutrition: http://www.jissn.com/

▪ AegisShield: App for supplements.

http://www.eatright.org/

http://www.scandpg.org/

http://nsfsport.com/

http://www.gssiweb.org/en

http://www.jissn.com/

OBJECTIVE #3

▪ Identify common injury patterns and warning signs of overtraining

▪ Overuse injuries

▪ Stress fracture recognition

▪ Amenorrhea

▪ Low energy availability

ASKING ABOUT INJURIES▪ Location

▪ Duration

▪ Onset (During training? Beginning middle or end of a session?)

▪ Course

▪ Quality

▪ Intensity

▪ Exacerbating Factors

▪ Alleviating Factors (Is it present at rest?)

ASKING ABOUT INJURIES▪ Who have you seen for this? (ATC, PT, chiropractor, massage therapist, PCP)

▪ What diagnosis have you been given?

▪ What treatments have you tried? (Massage, bracing, NSAIDs, warm up, stretching, gait changes, shoe changes) Have they helped?

▪ Have you rested? How long? Did you continue to cross-train? Did symptoms recur or resolve?

ASKING ABOUT INJURIES▪ Goals and timeline

▪ Training regimen

▪ Weekly mileage

▪ Intensity

▪ Recent changes

▪ Surface

▪ Footwear (300-500 miles) 10

▪ Dietary habits and nutrition

▪ Menstrual history

▪ History of prior injury or stress fracture

COMMON INJURY PATTERNS-OVERUSE INJURIES▪ Usually of gradual onset and worse with increased training

▪ Knee pain most common in runners

▪ Anterior pain in runners is typically patellofemoral syndrome (“Runner’s knee”)

▪ Lateral pain in runners is typically iliotibial band syndrome

▪ Lower leg pain also common in runners

▪ “Shin splints” or medial tibial stress syndrome most common

▪ Shoulder pain common in swimmers, weightlifters

▪ Often rotator cuff tendinopathy or imbalance/impingement

▪ Relative rest while correcting biomechanics can help students overcome these injuries to reach their goals- this is a great place to get PT involved

▪ …but what if it’s a stress fracture?

COMMON INJURY PATTERNS-STRESS FRACTURES▪ 10% of running injuries

▪ Can occur in foot, tibia, fibula, femur, pelvis

▪ Low grade chronic pain

▪ May progress to:

▪ Pain earlier in the run

▪ Pain with rest

▪ An acute traumatic event (fracture) 11

COMMON INJURY PATTERNS-STRESS FRACTURES▪ Risk factors

▪ Female sex (particularly those with irregular menses)

▪ Caucasians

▪ Low bone mineral density

▪ Prior stress fracture 1

▪ Steroid use 10

▪ Smoking 11

▪ Shoes older than 6 months 11

COMMON INJURY PATTERNS-STRESS FRACTURES▪ Exam findings

▪ Focal point tenderness

▪ Percussion, tuning fork vibration, fulcrum testing and dynamic testing (hopping) can also help differentiate stress fractures from more benign etiologies of pain

▪ Swelling/warmth may also be present

▪ Imaging

▪ X-rays can be low yield for up to 3 weeks following injury

▪ Bone scans poor for monitoring recovery

▪ MRI now imaging of choice 11

COMMON INJURY PATTERNS-STRESS FRACTURES▪ Treatment

▪ Relative rest

▪ Cross-training

▪ High risk

▪ Femoral neck, tibia diaphysis, navicular, 5th metatarsal diaphysis

▪ Sports med consult, NWB x 6 weeks

▪ Address low bone density

▪ Gradual return to activity

COMMON INJURY PATTERNS-LOW ENERGY AVAILABILITY▪ “Female Athlete Triad”

▪ Disordered eating

▪ Amenorrhea

▪ Osteoporosis

▪ Now

▪ Low energy availability (with or without eating disorders) 12

▪ Menstrual irregularity

▪ Low BMD

LOW ENERGY AVAILABILITY

▪ Can result from:

▪ Increased total output

▪ Reduced total intake

▪ Combination

▪ Weight can be stable- body compensates

▪ Reduced metabolism

▪ Shut down of reproductive cycle

▪ Decreased cellular maintenance

▪ Student may hear that they have to “gain” weight in order to rectify this – that is not the case.

MENSTRUAL IRREGULARITY▪ Anovulatory eumenorrhea

▪ Primary amenorrhea

▪ Secondary amenorrhea (3 missed cycles)

▪ Multiple possible causes

▪ Physical and emotional stress

▪ % body fat

▪ Genetics

▪ LOW ENERGY AVAILABILITY

LOW BONE MINERAL DENSITY▪ Osteopenia: Z score of -1.0 to -1.9

▪ Osteoporosis: Z score < -2.0

▪ Risk factors

▪ Low energy availability

▪ Hypogonadism

▪ Glucocorticoid exposure

▪ Previous fracture

▪ Calcium and vitamin D deficiency

AN INTERDISCIPLINARY APPROACH TO RECOVERY

▪ Medical Team

▪ Primary Care

▪ Specialty Care (Sports Medicine, Orthopedist, Endocrinologist)

▪ Nutrition Team

▪ Physical Therapist

▪ Psychologist/Psychiatrist

OBJECTIVE #4

▪ Explain and describe the benefits of implementing dietary changes while in recovery from an injury.

▪ Weight and inflammation management

CHALLENGES OF EATING WHEN INJURED

▪ Depressed mood- the effect of this is sorely underestimated and often overlooked with an injured athlete.

▪ Pain or discomfort

▪ Lack of appetite- cold increases appetite, so athletes requiring ice baths may be hungrier afterwards than those that do not. Watch weight management for inactive athletes.

▪ Abuse of alcohol and other drugs

▪ Concern about weight gain; results in under eating and/or overdoing physical therapy

OXIDATIVE STRESS

OXIDATIVE STRESS AND INFLAMMATION

▪ High GL diet (but not high carbohydrate intake) associated with lipid peroxidation markers.

▪ High GI/GL increases cellular inflammation.

CHRONIC, NON-EXERCISE INDUCED, INFLAMMATION

VITAMIN C

▪ Ligament repair Vitamin C is particularly important.

▪ Deficiency may result in a wound with decreased tensile strength secondary to a prolonged substrate phase and a decrease in collagen synthesis.

GLYCEMIC LOAD

▪ Glycemic load = GI x carbohydrate (grams per serving) divided by 100

▪ Low 0-10 Medium 11-19 High >20

GI 80 GL 7.81 cup watermelon

GI 72 GL 25.6½ bagel

Dr. Weil’s Anti-inflammatory Pyramid

TAKE HOME POINTS▪ More and more of our students are training for competitive recreational athletic

competitions and are at risk for associated injuries

▪ We need to ask about what students are training for and what their training habits are to properly treat and prevent injuries

▪ Most recreational athletes do not consider poor nutrition to be a significant risk factor for injury, but it is an important part of treating the whole student athlete

▪ A multidisciplinary approach to caring for these students will best help them meet their goals in good health and in good spirits!

REFERENCES1. Fields KB. Running Injuries- Changing Trends and Demographics. Curr Sports Med Rep. 2011;10:299-

303.

2. Saragiotto BT, Yamato TP, Lopes AD. What Do Recreational Runners Think About Risk Factors for Running Injuries? A Descriptive Study of Their Beliefs and Opinions. J Ortho Sports PT. 2014;44:733-738.

3. Van Gent RN, Siem D, Van Middelkoop M, Van Os AG, Bierma-Zeinstra SMA, Koes BW. Incidence and Determinants of Lower Extremity Running Injuries in Long Distance Runners: A Systematic Review. Br J Sports Med. 2007;41:469-480.

4. Fields KB, Sykes JC, Walker KM, Jackson JC. Prevention of Running Injuries. Curr Sports Med Rep. 2010;9:176-182.

5. Nielsen RO, Parner ET, Nohr EA, Sorensen H, Lind M, Rasmussen S. Excessive Progression in Weekly Running Distance and Risk of Running-Related Injuries: An Association Which Varies According to Type of Injury. J Ortho Sports PT. 2014;44:739-748.

6. Van der Worp MP, Ten Haaf DSM, Van Cingel R, De Wijer A, Nijhuis-van der Sanden MWG, Staal JB. Injuries in Runners; A Systematic Review on Risk Factors and Sex Differences. PLoS ONE. 2015 10(2):e0114937.

REFERENCES7. Fuller JT, Bellenger CR, Thewlis D, Tsiros MD, Buckley JD. The Effect of Footwear on Running

Performance and Running Economy in Distance Runners. Sports Med. 2015;45:411-422.

8. Vincent HK, Herman DC, Lear-Barnes L, Barnes R, Chen C, Greenberg S, Vincent KR. Setting Standards for Medically-Based Running Analysis. Curr Sports Med Rep. 2014;13:275-283.

9. Hespanhol Jr LC, Costa LOP, Lopes AD. Previous Injuries and Some Training Characteristics Predict Running-Related Injuries in Recreational Runners: A Prospective Cohort Study. J Physiotherapy. 2013;59:263-269.

10. Meininger AK, Koh JL. Evaluation of the Injured Runner. Clin Sports Med. 2012;31:203-215.

11. McCormick F, Nwachukwu BU, Provencher MT. Stress Fractures in Runners. Clin Sports Med. 2012;31:291-306.

12. Lynch SL, Hoch AZ. The Female Runner: Gender Specifics. Clin Sports Med. 2010;29:477-498.

THANK YOU!

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INTERPROFESSIONAL APPROACH TO SUPPORTING …€¦ · Most of these finishers were inexperienced runners 20% of Americans run regularly for fitness 30% of Americans may participate