Five Hot Topics in Sports Nutrition:

Female Athlete TriadEnergy Drinks and ShotsProtein Timing Guidelines for AnabolismTart Cherry Juice in Reducing InflammationGuidelines for HydrationSharon Collison, M.S., R.D., LDN, CSSD

Objectives 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

Female Athlete Triad

Female Athlete Triad 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

Female Athlete Triad (ACSM position stand 2007)

Review of Effects of Amenorrhea on Bone Mineral Density (BMD)

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)

Endothelial dysfunction and triad – effect on CVD & athletic performance

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

Treatment for endothelial dysfunction 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)

Folic Acid supplementation improves vascular function in young professional dancers (Hoch 2011)

Folic Acid supplementation improves vascular function in amenorrheic runners (Hoch 2010)

Strategies for managing amenorrhea in female athletes (Ducher et al 2011)

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

Micronutrient Recommendations for Treatment of Female Athlete TriadCalcium: 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

Treatment of Female Athlete Triad with Oral Contraceptive Pills (OCP) (ACSM 2007; Arends et al 2012)

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

Dietary Recommendations (ACSM

2007; Loucks et al 2011)

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

Energy Drinks600 energy drinks on the

market$2.5 billion dollar industry in

2009$9 billion dollar industry in

2011

Use of energy drinks (Seifert et al 2011 )

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

Energy Drinks/Shots “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

Energy Strips

Caffeine comparison8 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/

Serious adverse effects of heavy caffeine consumption (Seiffert SM et al 2011; Cannon

ME et al 2001; Wolk BJ et al 2012)

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

Energy drink related ER visits (DAWN 2011)

ER visits by age group and sex 2007 vs 2011

Energy Drink “Regulation” (Seifert et al 2011)

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

“Regulation” of Energy Drinks (Seifert et al 2011)

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

Recommended limits for caffeine 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 dayChild (Heatherly et al 2006; Seifert SM et al 2011)

≤ 2.5 mg/kg per day

Additional Ingredients in Energy Drinks & Shots 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)

New regulation of energy drinks in Canada

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

US has Poor Regulation of Energy Drinks

Labeling of energy drinks Food

▪Red bull Dietary Supplement

▪Monster ▪5-hr energy

These criss-crossing definitions impede action in the US for regulation

IOC, NCAA & WADA caffeine limits (Goldstein et al 2010)

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 

Advice for use in Athletes

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

Protein timing guidelines for maximizing muscle protein synthesis

Protein Quantity Recommendations (ADA and ACSM position papers

2009; Tipton 2011)

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

Protein intake recommendations before/after workout

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

Post exercise protein recommendations for muscle protein synthesis (Poortmans JR et al 2012)

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)

Post exercise protein recommendations for muscle protein synthesis

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)

.

.

Protein ingestion before sleep improves postexercise overnight recovery (Res PT et al 2012)

Collegiate athlete typical diet20 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

Distribution of Protein (grams)

0

20

40

60

80

100

120

Dietary Recommendations 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

Optimal Distribution of Protein (grams)

breakfast lunch pre-workoutpost-workout dinner bed snack0

5

10

15

20

25

30

35

40

45

50

Summary of Protein Recommendations 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)

Role of tart cherry juice in reducing muscle damage and pain during strenuous exercise

Current treatment recommendations for soft tissue injury/inflammation (Kuehl

2013)

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)

Tart Cherry Juice and Inflammation 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)

Improved inflammatory markers in cherry juice vs. placebo in marathon runners (Howatson G et al 2009)

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

Influence of tart cherry juice on indices of recovery following marathon running

Scandinavian Journal of Medicine & Science in SportsVolume 20, Issue 6, pages 843-852, 21 OCT 2009 DOI: 10.1111/j.1600-0838.2009.01005.xhttp://onlinelibrary.wiley.com/doi/10.1111/j.1600-0838.2009.01005.x/full#f1

Subjective report of pain after eccentric exercise with cherry juice vs. placebo

Connolly D A J et al. Br J Sports Med 2006;40:679-683Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

Summary of studies on effectiveness of tart cherry juice on exercise recoveryReduced 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) 

Pro sports teams that are currently using tart cherry juice

NFLDALLAS COWBOYS KANSAS CITY CHIEFSNEW ENGLAND PATRIOTS NEW YORK GIANTSPITTSBURGH STEELERS SAN DIEGO CHARGERSSEATTLE SEAHAWKS ST LOUIS RAMS

MLBCOLORADO ROCKIES NEW YORK METSPHILADELPHIA PHILLIES SEATTLE MARINERS

NHLCHICAGO BLACKHAWKS EDMONTON OILERSFLORIDA PANTHERS NEW YORK RANGERS

NBAHOUSTON ROCKETS NEW YORK KNICKS

Summary of current recommendations on hydration for athletes (JADA 2009)

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

Recent developments on hydration status and sports performance (Maughan RJ 2012; Goulet ED 2012)

Recommendations to limit dehydration to </=2% body weight during exercise is based on results of studies that used exercise protocols where athletes exercise at fixed-work rates until exhaustion

Results derived from fixed-intensity exercise models cannot be assumed to apply to the more realistic setting of self-paced competition

Recent developments on hydration status and sports performance (Goulet ED 2012)

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

Dehydration and Performance: A new paradigm (Goulet ED 2012)

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)

Guideline 1: Make sure to be well-hydrated before exercise (Goulet ED 2012)

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

Measuring Hydration Status

USE URINE COLOR AS A GUIDE1 If your urine matches the colors 1, 2,

or 3, you are properlyhydrated. Continue to consume fluids

at the recommendedamounts.

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

Guideline 2: Drink according to your thirst sensation: no more, no less (Goulet ED 2012)

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

Guideline 3: Fluid intake should be limited during 1-hour high-intensity exercise (Goulet 2012)

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.

Further research needed

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