My clients’ standard complaint

Nutrition —  Your Missing Link?

“Nutrition is my missing link. I’ve got my

training down, but my eating needs help…”

Nancy Clark MS RD CSSD FACSM Sports Nutrition Services, Boston MA www.nancyclarkrd.com

Nancy Clark, MS RD CSSD

Focus of this presentation

Nancy Clark, MS RD CSSD

MISSING LINK #1: Respect

for the power of food on performance (and health)

• Exercise and weight management •  Calories, carbs, protein, fat •  Fueling before, during, and after exercise

“You know, Nancy, too many athletes show up for training but

•  Caffeine, alcohol

don’t show up for meals. They might

•  Building a balanced sports diet, vitamin supplements

as well not show up for training.”

•  Hydration

BC Hockey Coach Next session on Engineered Sports Foods will cover: Protein supplements, energy drinks, sports foods and drinks, sodium Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

Even lean, fit athletes get heart disease…. • Brian Maxwell, founder of PowerBar and world class marathoner, died at age 51 of a heart attack • Andy Palmer, two-time Olympic marathon-trials qualifier died at age 48 of a heart attack

MISSING LINK #2:

Breakfast!

The best energy booster: BREAKFAST

• Improves quality of overall diet



• Prevents the need for sugar fixes



• Enhances performance

• Ed Sheehan, two-time Olympic marathon-trials qualifier died at age 47 of a heart attack Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

1

Breakfast: The most important meal of the day

Breakfast: Better than a quick-fix

PC

I don’t have time for breakfast. And any ways, I’m not hungry in the morning...

C

I might eat breakfast at 10 a.m. if food were available...

P

When I do make time to eat in the morning, I have better workouts that afternoon—and I don’t get as many headaches…

#1. Baseline: No fuel, only water

I generally eat breakfast. I just have to plan time...

#2. Sugar (180 cals glucose) + water



+10 %

I always eat breakfast!!! It boosts my energy, curbs evening overeating, and helps me control my weight.

#3. Candy bar (270 cals) + water



+10 %

#4. Breakfast 4 hrs before + Candy bar + water

+20 %

A M 

STUDY:

Athletes with low glycogen stores biked hard for 45 minutes, then sprinted for 15 minutes

Trial







Improvements during final sprint



---

---Snack five minutes pre-exercise---

(800 cals) Nancy Clark, MS RD CSSD

MISSING LINK #3:

Knowledge of calorie budget

The body needs fuel for–

Estimating calorie needs  Example: 140 pound female athlete 140 lbs x 10 cal/lb =

• Resting metabolic rate (Wt x 10 cals/lb) • Daily activities

(±50% RMR)

• Purposeful exercise

(400-800 cals/hr)

50% RMR =

Nancy Clark, MS RD CSSD

How to lose weight appropriately

Example: If an athlete maintains weight on 2,600 calories– 2,600 - 20% (~500 calories) = 2,100 calories/day



Breakfast



Lunch

11-12 noon

Second Lunch 3-4:00 PM

Dinner

7-8:00 PM

Nancy Clark, MS RD CSSD



1,400

Calories RMR

700

Daily activity

500

Purposeful exercise

2,600

To maintain weight

Nancy Clark, MS RD CSSD

• Subtract about 10 - 20% from total calorie needs • Divide calories evenly throughout the day



1 hour cardio = Total calories =

MISSING LINK #4:

Neufer, Costill J Appl Physiol 62(3): 983, 1987

Nancy Clark, MS RD CSSD

7-8:00 AM

500 calories

600

400

600

How to eat and be lean–– •  FUEL ADEQUATELY during the day –  Have energy to exercise –  Prevent ravenous hunger and food binges

•  EAT REASONABLY at night Where’s the snack…???

–  Eat appropriately but do not over-eat. –  To lose weight: “I’d rather be leaner than eat more...”

Nancy Clark, MS RD CSSD

2

Exercise ≠ weight loss

Exercise enhances weight loss if it

contributes to a calorie deficit.

TRUTH:

TRUTH:

What are you doing with the other  non-exercise hours in your day?

The sedentary athlete syndrome….

30 minutes of exercise = 300 calories

3 minutes of “rewards”= 300+ calories

Be aware of compensatory changes in daily activity! Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

Marathon training ≠ Weight Loss!

Gender differences: Exercise for weight loss

Among 64 novice runners (55% women) in a 3-month marathontraining program:

Range of weight changes: -27.5 lbs to +12 lbs 11% lost weight (n=7) due to change in eating habits 11% gained weight (6 of the 7 were women)

• Men:



High level of physical activity

contributes to a lower % body fat.

• Women:



No relationship between physical activity and % body fat

78% stayed about the same weight (n=50) Kennedy, ACSM 2010 Nancy Clark, MS RD CSSD

Gender differences: exercise and appetite 18 Women did 350 cals of low or high intensity exercise

Their food intake was monitored for 3 days Conclusion: --Hard exercise does not suppress hunger the same way

for women as for men.

Exercise + obese women = weight loss Three trials (19 days each) 1. Sedentary (baseline): maintained energy balance 2. Light exercise: burned 10% more cals; ate -114 fewer cals 3. Moderate ex: burned 25% more cals; ate -370 fewer cals

--Hard exercise increases attractiveness of food for women Pomerleau, Am J Clin Nutr 2004; 80:1230-6 Nancy Clark, MS RD CSSD

Westerterp Int’l J Obesity 1997; 21(3):184

Nancy Clark, MS RD CSSD

No compensation in energy intake







Woo, Pi_Sunyer Am J Clin Nutr 1982; 36:470

Nancy Clark, MS RD CSSD

3

The E in Exercise is for Enjoyment

MISSING LINK #5:

Adequate carbohydrates

Common belief: “Carbs are fattening”

Exercise = to train, improve athletic performance = to feel good, relieve stress,

improve health, build muscles

A survey of 425 female collegiate athletes across the US reports—

• The athletes wanted to lose 5 pounds, on average • 43% felt terrified of becoming overweight Exercise ≠ punishment for having body fat ≠ motivated by the desire to burn calories Beals, Manore Int’l J Sports Nutr, 2002 Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

Carbohydrates = muscle glycogen 24

What kinds of carbs should I eat?

Carbohydrate Diet

Carb

20

16

GLYCOGEN 12 CONTENT (GM/KG MUSCLE)

8

Protein & Fat Pro Diet +

Fat

4

0 Rest/

5

hard exercise

15

25

35

45 hours

RECOVERY TIME Nancy Clark, MS RD CSSD

5 days

Bergstrom, 1967

Quick & slow carbs

Nancy Clark, MS RD CSSD

MISSING LINK #6:

Wrong amount of dietary fat

24

• Pre-endurance: Slowly digest carbs (Low GI)

In theory:

• Post-exercise: Quickly digested carbs (High GI)

Carbohydrate Diet

Carb

20

16

• The glycemic index of a food varies

In reality:

—depends on where grown, how processed, etc.

• Each person has unique glycemic response

—can vary 43% on any given day (Vega-Lopez, 2007)

• Athletes should choose well-tolerated carbs Nancy Clark, MS RD CSSD

Donaldson “Glycemic Index and Endurance Performance” Int’l J Sports Nutr 20(2)154-165, 2010

GLYCOGEN 12 CONTENT (GM/KG MUSCLE)

8

Protein & Fat Pro Diet +

Fat

4

0 Rest/ hard exercise

5

15

25

35

45 hours

RECOVERY TIME Nancy Clark, MS RD CSSD

5 days

Bergstrom, 1967

4

Too little dietary fat hurts performance

Fat: A valuable part of a sports diet Fat is needed to absorb vitamins A, D, E, K

Trained runners ate 16% or 31% fat diet for 1 month

• self-selected diets were supposed to be isocaloric but

the runners ate 19% more calories with moderate-fat diet

• body fatness did not change

Female runners with irregular menses

--restricted fat intake (~60 gms/day; 24% fat; 2,400 cals)

-- had sub-normal vitamin E levels compared to

• had 14% more endurance

Regularly menstruating runners

-- ate more fat and calories (98 gm/day, 30% fat, 2,900)

Conclusion: Runners can perform better with (healthful) dietary

fat—as long as they eat enough carbs and calories

Nancy Clark, MS RD CSSD

MISSING LINK #7:

--normal vitamin E levels

Horvath, J Am Coll Nutr 2000; 19 (1): 52-60

Nancy Clark, MS RD CSSD

Tomten. Serum vitamin E concentration and osmotic fragility in female long distance runners J Sports Sci 2009; 27(1):69-76

Too little protein

The right balance of protein Grams Protein/lb

Safe intake/lb

Vegetarian Gymnast, 100 lbs

Current RDA, sedentary adult

0.4

Athletic adult



0.5 - .75

2



0.7 - 1.0

6 oz Yogurt

Adult building muscle mass

0.7 - 1.0

1

Athlete restricting calories

0.8 - 1.0



Growing teenage athlete

Nancy Clark, MS RD CSSD



Egg whites

2 Tb Hummus

Luna Bar

1/4 cake Tofu





0.7 - 1.0





g Protein/day

70 - 100

7 g Protein

2

6

10

9 Total: 34 g

Nancy Clark, MS RD CSSD

Too little protein can lead to low iron intake Collegiate female varsity athletes screened for anemia

Iron-deficiency (without anemia) is prevalent! •  2% of men in the general population. •  21% of male cross country/distance runners (ages 18-22)

-Anemia (hemoglobin 300 gms / day (4 gms/kg)

• Protein intake from 7 day food records:

Body builders: 2.0 g Pro/kg

Other athletes: 1.4 g Pro/kg

Blood tests: Renal stress and damage

170 g Pro/day

100 g Pro/day

Prescribed diet: 0.8 gm Pro/kg (70 gm Pro), 4,000 cals

• Nitrogen balance achieved at 1.3 g Pro / kg.

16 oz. milk 4 oz. meats 800 cals grains

• No indication of renal impairment (even at 2.8 g Pro / kg)

Poortmans. Int’l J Sports Nutr 10(1):28, 2000

Nancy Clark, MS RD CSSD

MISSING LINK #8:

1000 cals juice

600 cals fruit







200 cals veggies

Liberal fats, sugar

Nancy Clark, MS RD CSSD

Recommended Fluid Intake

Too little fluid

Standard advice— • 12-13 y.o. soccer players at summer camp drank too little, despite encouragement, availability of fluids • Pro basketball players started & ended dehydrated during two-a-day practices • Skiers and winter athletes at high risk



Nancy Clark, MS RD CSSD



ACSM Position Stand—

• Weigh pre-post exercise; learn personal needs Int’l Marathon Medical Directors Assoc.—

• Drink to thirst Nancy Clark, MS RD CSSD



Med Sci Sports Exerc May 2004 #1236, 1239

Goal: To prevent dehydration

• During Training -Learn sweat rate



-Practice drinking

• During Events

Nancy Clark, MS RD CSSD

• Prevent dehydration; drink before thirsty!

What about caffeine… ? • 

…Does it enhance performance? …Is it dehydrating?

-Drink on a schedule

Urine Color Chart L. Armstrong PhD

Nancy Clark, MS RD CSSD

7

Caffeine and exercise

Caffeine—not dehydrating

Pro: May make exercise seem easier and enhance performance (for both regular caffeine consumers and non-consumers alike)

• No diuretic effect in caffeine-tolerant athletes in

moderate (250-300 mg) doses



• Does not increase heat stress • OK to drink caffeinated beverages in hot weather

Con: May cause nervousness, upset stomach. Each person responds differently. Know your body! Nancy Clark, MS RD CSSD

MISSING LINK #9:

• 59 coffee drinkers consumed 1.5 mg caf/lb (~12 oz mug) • Performed 86 vs 75 minutes in heat

Nancy Clark, MS RD CSSD

- One group took supplement immediately before and after

strength training mid-afternoon





Suggested fueling patterns

Fueling at the right time

Two groups of recreational body builders; trained 4/wk x 10 weeks

Roti, Armstrong Med Sci Sports Exerc 36(5):S18, 2004

Exercise time:

Suggestions to fuel-up and then re-fuel

Morning

Smoothie // bagel + yogurt

Noon

Half sandwich // rest of lunch



- One group took the supplement in morning and late evening

Afternoon

Energy bar + latte // choc milk

Immediate pre- post-exercise fueling resulted in—

Before dinner Bagel w PB // smaller dinner

- 5.5 lbs gain LBM vs 3.3 lbs



- 27 lb gain in bench press vs 20 lbs

Eat on a time-line, not in a crescendo!

Cribb P. Med Sci Sports Exerc 38(11):1918-1925, 2006

Nancy Clark, MS RD CSSD

Pre-exercise calorie targets

Benefits of fueling before morning workouts After an overnight fast, 8 athletes biked hard (80% VO2max) for 50 minutes + 10 minutes sprint to exhaustion

Recommended intake: Time pre-exercise

1 hour

4 hours

Gm. Carbs / lb

0.5

2.0

Gm carb / 150 lb person 75

300

Calorie targets

300

1,200 ____________________________________ Sample 300 calorie options: PowerBar + Gatorade





Banana + Vanilla Yogurt





Oatmeal + raisins

Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

Work generated in the last 10 minutes:

+ 6% better with adequate water vs minimal water

+ 6% better with carbs vs no carbs (and minimal water)

+12% better with carbs + water (sports drink)

$2

$1 $0.50 - $0.80

If eat a pre-exercise snack, sports drink during exercise does not boost performance during short-term exercise. Nancy Clark, MS RD CSSD

8

Pre-exercise fuel: costs and benefits

Fueling just 5 minutes pre-exercise has benefits STUDY:

Athletes with low glycogen stores biked hard for 45 minutes, then sprinted for 15 minutes

Trial





Improvements during final sprint

#1. Baseline: No fuel, only water







---

Benefits:

--Restores liver glycogen after overnight fast



--Tops off sub-optimal muscle glycogen stores



--Offers fuel for exercise >60-90 minutes

Costs:

---Snack five minutes pre-exercise---

Intestinal concerns–

Upper GI:

#2. Sugar (180 cals glucose) + water



+10 %

#3. Candy bar (270 cals) + water



+10 %

#4. Breakfast 4 hrs before + Candy bar + water

+20 %







Lower GI: Cramps, gas, urge to defecate, diarrhea

(800 cals) Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

MISSING LINK #10: 

Train your intestinal tract! 

Too little fuel during prolonged exercise

(20-50% of runners have GI problems) Risk factors for gastrointestinal problems • high intensity exercise • dehydration • being female

Burping, reflux, heartburn, bloating, cramps,

stomach ache, nausea, vomiting

Exercise duration



• running sports that jostle the intestines

2.5 hours

60 - 90

240-360 calories plan a variety of foods to

Nancy Clark, MS RD CSSD

When swallowing won’t work…try swishing! • Runners “swished and spit” ~1 ounce sports drink every 15 min during a one-hour time trial. • They ran faster/longer (by 211 meters) compared to the placebo

Why does swishing result in self-selecting to run faster?

–Has no impact on blood glucose

–Does it trigger reward centers in the brain?

–Does it suppress fatigue signals?

Influence of Mouth Rinsing a Carbohydrate Solution on 1-h Running Performance. Rollo I, Williams, C et al. Med Sci Sports Exerc 43(4):798-804, 2010

Nancy Clark, MS RD CSSD

prevent flavor fatigue

Nancy Clark, MS RD CSSD

MISSING LINK #11:

Alcohol education

On a Friday night, Southern Methodist University students were asked about alcohol use on the previous night:

• Did you drink last night?



28%

• What % of SMU students do you think

drank last night?





Perception

>50%

• Did you get drunk last night?



8%



Perception

>33%



• What % of SMU students do you think

got drunk last night?





Nancy Clark, MS RD CSSD

9

Social Norms—alcohol

MISSING LINK #12:

• Of students who drank, most reported only a few drinks/week

—Believed most students consumed 10 to 15 drinks/wk • 35% reported abstaining from alcohol

—Very few believed many of their peers were non-drinkers.



(Appropriate) Post-exercise recovery food “You haven’t finished training until you’ve refueled!”

• The answers showed major misperceptions about alcohol norms. Social norm education can save lives! http://smu.edu/healthcenter/alcoholeducation/adp_socialnorms.asp

Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

The right balance of carbs, protein & fat

Lack of carbs hurts ice hockey performance • During a hockey game, muscle glycogen declines 38-88%.

Carbs

A motion analysis of elite ice hockey teams showed: • Players with high (60%) carb diet skated 30% more distance- and faster than the players who ate standard diet (40% carb).

(GM/KG MUSCLE)

In the final period: Pro + Fat

• The high carb group skated 11% more distance.

• The low carb group skated 14% less than in first period.

Rest/ hard exercise

5

15

25

35

45 hours

5 days

Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

Nancy Clark, MS, RN

Lack of carbs hurts ice hockey performance The researchers conclude: 1) low muscle glycogen can jeopardize performance at the end of the game

Optimal recovery choices:  Carbs + water + protein (3 or 4:1 ratio C:P) Fluid



Gm Carb/8 oz.

Gm Pro/8 oz

Beer



8



--

2) three days between games (with training on two of those days) + a low carb diet does not replace glycogen (players with high carb diet had 45% more glycogen)

Gatorade



14



--

Coke



26



--

Accelerade



15



4

3) the differences in performance between the groups

Chocolate milk

29



8

(Whey)

was most evident in the last period of the game.



Nancy Clark, MS RD CSSD



Akermark, Int'l J Sports Nutr 6:272-84, 1996

Nancy Clark, MS RD CSSD

10

Recovery foods



Recommended dose: ~0.5-0.75 g Carb/lb within 30 min. ~0.1-0.2 g Pro/lb Repeat every two hours x 4-6 hours





Wt (lb) Carbs (g) Pro Cals 100 75 20 ~400

150 115 200 150

30 40

~600 ~800

Carb (g) Pro (g)

Cals

Yogurt, flavored, 6 oz



26

8



160

Cheerios w/ milk



32

11



200

Pasta + meat sauce



80

20



Chocolate milk hastens recovery • 9 trained males performed glycogen-depleting trial, refueled during a 4-hour recovery period, and then cycled to exhaustion (70% VO2 max). • Consumed ~400 calories at 1 min post-ex and again at 2 hours of recovery Time to exhaustion

450

(~400 calories; 63 g C, 14 g P, 9 g F)

Endurox

21 min

(~400 calories; 73 g C, 19 g P, 2 g F)

23 min

(~110 cals; same volume as Endurox)

Gatorade

Does higher fat content help chocolate milk be a better recovery drink?

Be responsible and plan ahead! Nancy Clark, MS RD CSSD

Chocolate milk 32 min

Nancy Clark, MS RD CSSD

MISSING LINK #13:

Thomas K, Appl Physiol Nutr Metab 34:778-82, 2009

Rest days ≠ “Being lazy”

Rest days to provide time to refuel 2.5

• Rest is an important part of a training program

–Muscles need time to heal and refuel

–Mind needs time to rest and recharge

2.0

MUSCLE 1.5 GLYCOGEN (GM/100 GM TISSUE)

• On rest days, you won’t “get fat” or “lose fitness”

–Expect hunger; muscles need carbs to refuel

–Expect weight gain; glycogen holds water

1.0

0.5

10 miles DAY 1

10 miles DAY 2

10 miles DAY 3

Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

Nancy Clark, MS, RN

Double workouts…???

Using vitamin supplements to

compensate for poor eating.

MISSING LINK #14:



Six-week study with two groups of swimmers

- Group 1 trained 1.5 hrs (afternoon)

- Group 2 trained 3 hours (morning + afternoon)

50 College Football Players -59% of calories from fat, sugar

Single-workout group:

Improved sprint speed

Double-workout group:

Decline in sprint speed

-poor intake fruit, veggies, dairy

Rest is an important part of a training program! Nancy Clark, MS RD CSSD

Costill Med Sci Sport Exerc 23:371-377, 1991

Nancy Clark, MS RD CSSD

11

For vitamins:  Eat healthful foods!

Do athletes need extra vitamins & minerals? A review of 90 studies examining vitamin and mineral status in athletes’ blood suggests–

• Athletes & non-athletes had similar vitamin status

The more you exercise–

• Exception: Athletes had lower serum ferritin

• the more food you can eat.

• Stronger vitamin status ≠ better performance (apart from anemia)

• the more vitamins you can get.

• CONCLUSION: Athletes generally eat extra vitamins!

Vitamins are re-used, not used up. Nancy Clark, MS RD CSSD

Fogelholm. I J Sports Nutr 5:267, 1995

Nancy Clark, MS RD CSSD

Vitamin D “The sunshine vitamin”

What about antioxidants like vitamins C and E? 

• Indoor athletes at risk for low D:

figure skaters, gymnasts, ballerinas, wrestlers • Low serum D in 40% (8 of 20) of distance runners in Louisiana

Too many anti-oxidants become pro-oxidants

• D’s potential benefits to athletes is reduced risk of—

x stress fractures

total body inflammation

infectious illness

impaired muscle function

• may hinder training adaptations Natural sources of antioxidants: Tart cherry juice, PomWonderful juice, grape juice, blueberries…

• Recommended intake (without sun exposure) 600-1,000+ IU D3 / day Nancy Clark, MS RD CSSD

Larson-Meyer. Curr Sports Med Rep 2010; 9(4):220-6



Breads, cereals, whole grains

DON’T JUST EAT; EAT RIGHT–

Foundation of every meal–for carbohydrates, fiber, B-vitamins

At each meal choose foods made from– Wheat Rice Oats Corn

Nancy Clark, MS RD CSSD

DON’T JUST EAT; EAT RIGHT–



Nancy Clark, MS RD CSSD

Fruits & vegetables

3 large or 6 small daily for fiber, carbs, phytochemicals, C, A

Best fruit choices include:

Oranges Grapefruit

Melon

Bananas

Strawberries Kiwi

Whole grains should be at least half your choices



Carrots



Best vegetable choices are colorful:

Broccoli



Tomato

Pepper

Spinach Squash

Nancy Clark, MS RD CSSD

12

 Calcium-rich foods

1 cup

1.5 oz.

2 cups

3 - 4 servings daily

Milk or Yogurt (lowfat)

Cheese

Cottage cheese



Protein-rich foods

DON’T JUST EAT; EAT RIGHT–

DON’T JUST EAT; EAT RIGHT—



Small amount at each meal for protein, iron, zinc



Chicken, turkey, fish Lean beef, pork, lamb Milk, yogurt, cheese* Eggs



Non-dairy sources

1 cup

8 oz.

3 cup

3-4 oz.

Calcium-enriched orange juice

Tofu, soy milk

Broccoli, kale, leafy green vegetable

Salmon or sardines with bones

Nancy Clark, MS RD CSSD

Nuts, peanut butter *Poor sources of iron and zinc

Lentils, beans, tofu Nancy Clark, MS RD CSSD

Fuel Responsibly! If you find time to train, you can find time to fuel for training

For more information–

www.nancyclarkrd.com Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

Nancy Clark, MS RD CSSD

13