Nutrition Support for Bone and Soft Tissues Injuries

Ashley Armstrong, MS., RD, CSSD ., IOC Dip. Sport. Nutr., ISAK Level 1Sport Dietitian | CSI Pacific aarmstrong@csipacific.ca

AArmstrong@rugby.ca

oProtection FirstoThe Injured AthleteoSpecific Nutrients to Promote

HealingoSupplementation OptionsoResources

FOCUS

• Optimizing Energy Availability• Monitor BMD - DEXA• Vitamin D:

– Optimize Vitamin D status– Supplementation dose based on individual blood values

• Calcium: – 800mg/day added to habitual intake of 1000mg/day

prevented BDM loss at femoral mid-shaft in healthy female runners

– Amenorrheic runners: 1000g/day maintained hip & spine BMD

Protection – Bone Health

Southmayd AE., Hellmers CA & De Souza MJ 2017Chen et al 2013; Owens et al 2018

• Suboptimal status may increase risk to overuse and inflammatory injuries

• NFL Combine: 59% of players <32ng/mL; 10% <20ng/mL– Athlete’s with +ve injury hx had sig lower serum

Vitamin D levels– 13 players reported missing at least 1 game d/t lower

extremity strain or core ms injury – 86% had inadequate vitamin D levels

Vitamin D

Payne, B.P., Verhagen A.E., & Mountjoy M. 2014; Rebolledo et al., 2017; Owens J.D., Allison, R., Close L.G. 2018

PREVENTION: RED-S

Mountjoy et al, 2014. The IOC consensus statement: beyond the Female Athlete Triad – Relative Energy Deficiency in Sport (RED-S). Br. J. Sports Med. 48:491-497; Melin et al 2014

Heikura, I. A., Uusitalo, A. L. T., Stellingwerff, T., Bergland, D., Mero, A. A., & Burke, L. M. (2017). Low Energy Availability is Difficult to Assess But Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes. International journal of sport nutrition and exercise metabolism, 1-30.

Low Energy Availability is Difficult to Assess But Outcomes Have Large Impact on Bone Injury Rates in

Elite Distance Athletes

Energy Availability (EA)

Energy Consumed (food/fluids) –Energy Expended (training) /

Fat free mass (FFM) EA

Low Energy Availability

Females: ~<30kcal/kg FFM/day

Males: ~<20-25kcal/kg FFM/day

LOW EA

30-45 kcal/kg FFM/day

Moderate EA

Fagerberg, 2017, Koehler et al 2016; Loucks, Kiens & Wright 2013

>45kcal/kg FFM/day

OPTIMAL EA

• Focus: Eating to Promote Optimal Healing and Recovery

• Eating Habits Affected– Change in schedule– Immobilization– Medication– Post-Op– Support Network– Adding anxiety &/or stress d/t injury

The Injured Athlete

• Manage any appetite changes, N/V• Optimal EA• Food First Approach:

– Periodize CHO– Optimize Protein– Healthy Fats– Nutrient Density

• Planned recovery around rehab• Limit ETOH, highly process and high refined

sugar foods

NUTRITION FOCUS: GENERAL

Healing Nutrition Snapshot

Energy• >30kcal/kg FFM/day

Macros

• CHO: Depends on rehab schedule. General guide of 2-5g/kg/day

• PRO: 1.6-2.5g/kg/day – leucine source• Healthy FAT: 0.5-2g/kg/day – Focus on sources of O3FA

Essential Micros

• Calcium: 800-2500mg/day: 3-5 servings of dairy/dairy alt/day• Vitamin D: 1000-4000IU/day • Iron, Zinc, Vitamin C, Vitamin A• Vitamin K2

• Reduced muscle protein synthesis• Limb immobilization: reduced MPS

response to protein intake• GOAL: 1.6-2.5g/kg/day• Broken into 20-40g servs. 4-6x a day

(~q3-4hrs)– High biological value protein sources– Rich in leucine: ~3g/meal– Rich in other EAA: ~10g/meal

PROTEIN

Wall T.B., Morton, P.J., van Loon, C.J.L (2014); Tipton 2015

NUTRITION FOCUS: SPECIFIC

• Leucine Recommendations

1cup = 0.8g 6oz = 1g

1cup = 3.5g

3oz = 2g

1 cup = 3.5g

Jager R., et al 2017; Thomas DT, Erdman KA, Burke LM (2016)

Omega 3 Fatty Acids• Inflammation (excessive/prolonged)• Potential role in amelioration of muscle loss in

immobilization but does not promote muscle hypertrophy• DRI: 1.6mg/day ALA• Food Sources: Salmon, Mackerel, Chia, Walnuts

SPECIFIC NUTRIENTS

Flock MR, Harris SW, & Kris-Etherton MP (2014)Tipton 2015

• Omega Quant: http://www.omegaquant.com/• Omega-3 fatty acid levels of adults, 2012 and 2013:

http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14245-eng.htm

Harris SW, 2010; von Schacky et al., 2014

OMEGA INDEX

8-11%

SPECIFIC NUTRIENTS

Calcium

Gender/Age RDA (IU/d)

UL (IU/d)

Males & Females: 9-70

600 4000

Vitamin D

• Bone matrix = structure & strength

• Inadequate calcium can affect bone healing

Gender/Age RDA (mg/d)

UL (mg/d)

Males: 9-18 13003000Females: 9-18 1300

Males: 19-70 10002500Females: 19-50

Females: 51-7010001200

• Calcium absorption and bone turnover

• Optimize blood 25[OH]D

SPECIFIC NUTRIENTSVitamin A

• Cell growth & development• FOOD SOURCES: sweet

potatoes, bell peppers, carrots, papaya

Vitamin C• Tissue repair, wound

healing, immunity• FOOD SOURCES: Citrus

fruits, kiwi, strawberries, bell peppers

Gender/Age RDA (IU/d)

UL (IU/d)

Males: 9-13 20005667Females: 9-13 2000

Males: 14-50 3000 9333-10000Females: 14-50 2333

Gender/Age RDA (mg/d)

UL (mg/d)

Males: 9-13Males: 14-18Males: 19-70

457590

1200180020001200180020000

Females: 9-13Females: 14-18Females: 19-70

456575

Iron• Oxygen delivery to cells• Wound healing• Monitor blood work & avoid

anemia• FOOD SOURCES: heme &

non-heme iron sources

Zinc• Wound healing & immunity• FOOD SOURCES:

Almonds, seeds, beef, seafood

Gender/Age RDA (mg/d)

UL (mg/d)

Males & Females: 9-13

8 40

Males 14-18Females 14-18

1115

45

Males: 19-70+ 845Females: 19-50

Females: 50-70+188

Gender/Age RDA (mg/d)

UL (mg/d)

Males & Females: 9-13

8 23

Males: 14-18Females: 14-18

119

34

Males: 19-70+ 11 40Females: 19-70+ 8

SPECIFIC NUTRIENTS

• Proper Calcium utilization:– Coenzyme during synthesis of osteocalcin– Combined with D3: helps inhibit osteoclasts, the cells

responsible for bone resorption• Research focused on fractures & osteoporosis in

elderly• JAPAN: High doses of vitamin K2 approved treatment

for osteoporosis & benefit in prevention of further decline in BMD

• Food sources: butter, organ meat (liver), egg yolks, high-fat dairy esp. from grass-fed animals, natto

• DRI: not yet determined

Vitamin K2

Vermeer C, Shearer MJ, Zittermann A, et al. 2004

To Eat or To Supplement? - ProteinGrilled Chicken (6-oz) Whey Protein Powder

(1 serving = 1 scoop)

6 oz = 40gms PRO 1 scoop (40g) protein = 35 g PRO

Total cost: $2.82/scoop

Total Cost: $2.19

To Eat or To Supplement? – LeucineGrilled Chicken (4-oz)

Amino Acid MG

Tryptophan 436Threonine 1553Isoleucine*BCAA

1698

Leucine*BCAA 2864Lysine 3327Methionine 900Cystine 363Phenylalanine 1397Tyrosine 1247Valine*BCAA 1792Arginine 2340Histidine 1290Alanine 2021Aspartic acid 3255Glutamic acid 5127Glycine 1532Proline 1099

Amino Acid Blend Supplement (1 serving = 3 capsules)

Amino Acid MG

Tryptophan 43Threonine 227Isoleucine*BCAA

194

Leucine*BCAA 347Lysine 302Methionine 73Cystine 64Phenylalanine 86Tyrosine 89Valine*BCAA 189Arginine 85Histidine 62Alanine 164Aspartic acid 361Glutamic acid 607Glycine 63Proline 219

Source: USDA National Nutrient Database; http://ndb.nal.usda.gov/ndb/search/list

Source: General Nutrition Center Website; www.gnc.com; “Amino Acid Top Sellers”

Slide Credit: LUlfers@drugfreesport.com

4 oz = 35 gmsprotein

1 svg < 2 gmsprotein

• Creatine:– Evidence for use to counter muscle loss or

improve strength during immobility is not clear– May decrease muscle atrophy– During rehab post immobility – may increase

rate of muscle growth & strength gains– Athlete dependent - consider age, history of

use, sport, kidney function

Potential Supplement Options

Wall T.B., Morton, P.J., van Loon, C.J.L (2014); Tipton 2015

Health Canada (2017). NATURAL HEALTH PRODUCT FISH OIL http://webprod.hc-sc.gc.ca/nhpid-bdipsn/atReq.do?atid=fish.oil.huile.poisson&lang=eng

• Omega 3– Supplementation may play a role in reducing

muscle mass loss with disuse but not enhance hypertrophy

– 8 weeks of supplementation increased the response of MPS in older and younger volunteers

Tipton DK 2015

Gelatin

Shaw et al 2017

Injury Prevention and Recovery: Collaborative Care Approach

SCOPE OF PRACTICE

Within Scope• Educate clients about the benefits of

protein, healthy fats, and other macronutrients

• Offer clients recipes or demonstrate food prep skills

• Share evidence-based nutritional supplements that might augment their healthy lifestyle

• Educate them about the pillars of good nutrition and provide them with strategies to improve their eating habits

• Help them choose the right foods to eat before and after workouts;

• Suggest evidence-based way that will help clients stay hydrated

• Share resources from recognized nutrition organizations

Beyond Scope

• Treat• Prescribe• Diagnosis

• Know what to look for:– http://dieteticdirections.com/dietitian-vs-

nutritionist-vs-holistic-nutritionist/• Find a dietitian: www.dietitian.ca/find• https://sportmedbc.com/practitioners• https://www.scandpg.org/sports-dietitian-job-description/

Referral to Dietitian

Not all Dietitian’s are created equal

SPORT NUTRITION RESOURCEShttps://www.sportsdietitians.com.au/http://www.mysportscience.com/http://www.gssiweb.org/en https://www.ausport.gov.au/ais/nutritionhttps://home.mysportsd.com/www.mastersathlete.com.auhttp://www.nutrition411.com/http://www.powerbar.com/training

American Dietetic Association, Dietitians of Canada, & American College of Sports Medicine. (2016). Position of the American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and athletic performance. Journal of the American Dietetic Association, 116(3) Pages 501-528.

TEXT BOOKS & MORE

• Subscriptions:– Examine.com– ConsumerLabs

• Podcasts:– GuruPerformace– sigmanutrition.com

RESEARCH• Researchers:

– Louise Burke, Trent Stellingwerff, James Morton, Graeme Close, Anna Melin, Keith Baar, Stuart Philips, Dan Moore, Kevin Tipton, Lawrence Spriet, Dana Lis, Nanna Meyer, Nanci Guest

• Journals/Abstracts:– Medicine and

Science in Sports & Exercise

– International Journal of Sports Nutrition and Exercise Metabolism

– British Journal of Sport Medicine

– Applied Physiology Nutrition & Metabolism

• USCO: https://www.teamusa.org/About-the-USOC/Athlete-Development/Sport-Performance/Nutrition/Athlete-Factsheets-and-Resources

• https://home.mysportsd.com/• http://www.mysportscience.com/

Resources & References

Thank You!

• Heikura, I. A., Uusitalo, A. L. T., Stellingwerff, T., Bergland, D., Mero, A. A., & Burke, L. M. (2017). Low Energy Availability is Difficult to Assess But Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes. International journal of sport nutrition and exercise metabolism, 1-30.

• Mountjoy et al, 2014. The IOC consensus statement: beyond the Female Athlete Triad – Relative Energy Deficiency in Sport (RED-S). Br. J. Sports Med. 48:491-497

• Koehler, K., Hoerner, N. R., Gibbs, J. C., Zinner, C., Braun, H., De Souza, M. J., & Schaenzer, W. (2016). Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones. Journal of Sports Sciences, , 1-9. doi:10.1080/02640414.2016.1142109 [doi]

• Fagerberg, P. (2017). Negative Consequences of Low Energy Availability in Natural Male Bodybuilding: A Review. International Journal of Sport Nutrition and Exercise Metabolism, , 1-31. doi:10.1123/ijsnem.2016-0332 [doi]

• Wall T.B., Morton, P.J., van Loon, C.J.L (2014). Strategies to maintain skeletal muscle mass in the injured athlete: Nutritional considerations and exercise mimetics. European Journal of Sport Science, DOI:10.1080/17461391.2014.936326

• Tipton, D.T. (2016). Nutritional Support for Exercise-Induced Injuries. Sports Med. 45(Suppl 1):S93-104 doi: 10.1007/s40279-015-0398-4

• Flock RM., Harris SW & Kris-Etherton MP (2013). Long-chain omega-3 fatty acids: time to establish a dietary reference intake. Nutr. Rev. 71(10): 692-707.

• Katsanos SC., et al (2006). A high proportion of leucine is required for optimal stimulation of the rate of muscle protein synthesis by essential amino acids in the elderly. Am J Physiol Endocrinol Metabl 291:E381-E387

• Jager R., et al (2017). International Society of Sports Nutrition Position Stand: protein and exercise. Journal of the International Society of Sports Nutrition 14:20 DOI 10.1186/s12970-017-0177-8

• Thomas DT., Erdman KA., Kurke LM. (2016). Position of the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and Athletic Performance. J. Acad. Nutr. Diet. 116(3):501-528 doi: 10.1016/j.jand.2015.12.006.

• Phillips MS, Chevalier S., & Leidy JH. Protein “requirements” beyond the RDA: implications for optimizing health. Appl. Physiol. Nutr. Metab. 2016;41:565-572

• National Institutes of Health. Nutrient Recommendations: Dietary Reference Intakes (DRI). https://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx

• Government of Canada: Dietary Reference Intakes Tables (2010). https://www.canada.c.a/en/health-canada/services/food-nutrition/healthy-eating/dietary-reference-intakes/tables.html

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