-
This article is being published concur-rently on the Dietitians
of Canadawebsite (www.dietitians.ca/sports) andin Medicine &
Science in Sports andExercise�. The articles are identicalexcept
for minor stylistic and spellingdifferences in keeping with each
jour-nal’s style. Either citation can be usedwhen citing this
article.
2212-2672/Copyright ª 2016 by theAcademy of Nutrition and
Dietetics,American College of Sports Medicine, andDietitians of
Canada.http://dx.doi.org/10.1016/j.jand.2015.12.006
*Because credentialing practices varyinternationally, the term
“sports dieti-tian”will be used throughout this articleto encompass
all terms of accreditation,including registered dietitian
nutritionist(RDN), registered dietitian (RD), profes-sional
dietitian (PDt), or Board CertifiedSpecialist in Sports Dietetics
(CSSD).
ª 2016 by the Academy of Nutrition and Dietetics, American
College ofSports Medicine, and Dietitians of Canada. J
FROM THE ACADEMY
Position Paper
Position of the Academy of Nutrition andDietetics, Dietitians of
Canada, and theAmerican College of Sports Medicine: Nutritionand
Athletic Performance
ABSTRACTIt is the position of the Academy of Nutrition and
Dietetics (Academy), Dietitians ofCanada (DC), and the American
College of Sports Medicine (ACSM) that the performanceof, and
recovery from, sporting activities are enhanced by well-chosen
nutrition stra-tegies. These organizations provide guidelines for
the appropriate type, amount, andtiming of intake of food, fluids,
and supplements to promote optimal health and per-formance across
different scenarios of training and competitive sport. This
positionpaper was prepared for members of the Academy, DC, and
ACSM, other professionalassociations, government agencies,
industry, and the public. It outlines the Academy’s,DC’s, and
ACSM’s stance on nutrition factors that have been determined to
influenceathletic performance and emerging trends in the field of
sports nutrition. Athletesshould be referred to a registered
dietitian nutritionist for a personalized nutrition plan.In the
United States and in Canada, the Certified Specialist in Sports
Dietetics is aregistered dietitian nutritionist and a credentialed
sports nutrition expert.J Acad Nutr Diet. 2016;116:501-528.
POSITION STATEMENT
It is the position of the Academy of Nutritionand Dietetics,
Dietitians of Canada, and theAmerican College of Sports Medicine
that theperformance of, and recovery from, sportingactivities are
enhanced by well-chosen nutri-tion strategies. These organizations
provideguidelines for the appropriate type, amount,and timing of
intake of food, fluids, and di-etary supplements to promote optimal
healthand sport performance across different sce-narios of training
and competitive sport.
OURNAL OF THE AC
HIS ARTICLE OUTLINES THE to accommodate the unique issues of
This Academy position paper includes the
authors’ independent review of the litera-ture in addition to
systematic review con-ducted using the Academy’s EvidenceAnalysis
Process and information from theAcademy Evidence Analysis Library
(EAL).Topics from the EAL are clearly delineated.
Tcurrent energy, nutrient, andfluid recommendations foractive
adults and competitiveathletes. These general recommenda-tions can
be adjusted by sports dietitians*
The use of an evidence-based approachprovides important added
benefits toearlier review methods. The major advan-tage of the
approach is the more rigorousstandardization of review criteria,
whichminimizes the likelihood of reviewer biasand increases the
easewithwhichdisparatearticles may be compared. For a
detaileddescription of the methods used in the ev-idence analysis
process, access the Aca-demy’s Evidence Analysis Process
(http:www.andevidencelibrary.com/eaprocess).
Conclusion Statements are assigned agrade by an expert work
group based onthe systematic analysis and evaluation ofthe
supporting research evidence. GradeI¼Good; Grade II¼Fair; Grade
III¼Limited;Grade IV Expert Opinion Only; and GradeV¼Not Assignable
(because there is no ev-idence to support or refute the
conclusion).
See grade definitions at www.andevidencelibrary.com/.
Evidence-based information for this andother topics can be found
at https://www.andevidencelibrary.com and subscriptionsfor
nonmembers are purchasable at
https://www.andevidencelibrary.com/store.cfm.
individual athletes regarding health,nutrient needs, performance
goals,physique characteristics (ie, body size,shape, growth, and
composition), prac-tical challenges, and food preferences.
EVIDENCE-BASED ANALYSISThis article was developed using
theAcademy of Nutrition and Dietetics(Academy) Evidence Analysis
Library(EAL) andwill outline some key themesrelated to nutrition
and athletic per-formance. The EAL is a synthesis ofrelevant
nutrition research on impor-tant dietetics-related practice
ques-tions. The publication range for theevidence-based analysis
spannedMarch 2006 to November 2014. For thedetails on the
systematic review andmethodology go to www.andevidencelibrary.com.
Figure 1 presents the evi-dence analysis questions used in
thisposition paper.
NEW PERSPECTIVES IN SPORTSNUTRITIONThe past decade has seen an
increase inthe number and topics of publications
ADEMY OF NUTRITION AND DIETETICS 501
http://www.andevidencelibrary.comhttp://www.andevidencelibrary.comhttp://www.andevidencelibrary.com/eaprocesshttp://www.andevidencelibrary.com/eaprocesshttp://www.andevidencelibrary.com/http://www.andevidencelibrary.com/https://www.andevidencelibrary.comhttps://www.andevidencelibrary.comhttps://www.andevidencelibrary.com/store.cfmhttps://www.andevidencelibrary.com/store.cfmhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.jand.2015.12.006&domain=pdfhttp://www.dietitians.ca/sportshttp://dx.doi.org/10.1016/j.jand.2015.12.006
-
Evidence Analysis Library question Conclusion and evidence
grade
Energy balance and body composition
#1: In adult athletes, what effect doesnegative energy balance
have on exerciseperformance?
In three out of six studies of male and female athletes,
negative energybalance (losses of 0.02% to 5.8% body mass; over
five 30-day periods) wasnot associated with decreased performance.
In the remaining three studieswhere decrements in both anaerobic
and aerobic performance wereobserved, slow rates of weight loss
(0.7% reduction body mass) were morebeneficial to performance
compared to fast (1.4% reduction body mass)and one study showed
that self-selected energy restriction resulted indecreased hormone
levels.Grade II - Fair
#2: In adult athletes, what is the time, energy,and
macronutrient requirement to gain leanbody mass?
Over periods of 4-12 weeks, increasing protein intake during
hypocaloricconditions maintains lean body mass in male and female
resistance-trainedathletes. When adequate energy is provided or
weight loss is gradual, anincrease in lean body mass may be
observedGrade III - limited
Recovery
#3: In adult athletes, what is the effect ofconsuming
carbohydrate on carbohydrateand protein-specific metabolic
responses and/or exercise performance during recovery?
Based on the limited evidence available, there were no clear
effects ofcarbohydrate supplementation during and after endurance
exercise oncarbohydrate and protein-specific metabolic responses
during recovery.Grade III - Limited
#4: What is the effect of consumingcarbohydrate on exercise
performance duringrecovery?
Based on the limited evidence available, there were no clear
effects ofcarbohydrate supplementation during and after endurance
exercise onendurance performance in adult athletes during
recovery.Grade III - Limited
#5: In adult athletes, what is the effect ofconsuming
carbohydrate and proteintogether on carbohydrate- and
protein-specific metabolic responses during recovery?
� Compared to ingestion of carbohydrate alone, coingestion of
car-bohydrate plus protein together during the recovery period
resultedin no difference in the rate of muscle glycogen
synthesis.
� Coingestion of protein with carbohydrate during the recovery
periodresulted in improved net protein balance postexercise.
� The effect of coingestion of protein with carbohydrate on
creatinekinase levels is inconclusive and shows no impact on muscle
sore-ness postexercise.
� Grade I - Good#6: In adult athletes, what is the effect
ofconsuming carbohydrate and proteintogether on carbohydrate and
protein-specificmetabolic responses during recovery?
Coingestion of carbohydrate plus protein, together during the
recoveryperiod, resulted in no clear influence on subsequent
strength or sprintpower.Grade II - Fair
#7: In adult athletes, what is the effect ofconsuming
carbohydrate and proteintogether on exercise performance
duringrecovery?
Ingesting protein during the recovery period (postexercise) led
toaccelerated recovery of static force and dynamic power production
duringthe delayed onset muscle soreness period and more repetitions
performedsubsequent to intense resistance training.Grade II -
Fair
(continued on next page)
Figure 1. Evidence analysis questions included in the position
statement. Evidence grades: Grade I: Good, Grade II: Fair, Grade
III:Limited, Grade IV: Expert opinion only; and Grade V: Not
assignable. Refer to http://www.andevidencelibrary.com/ for a
complete listof evidence analysis citations.
FROM THE ACADEMY
502 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS March 2016
Volume 116 Number 3
http://www.andevidencelibrary.com/
-
Evidence Analysis Library question Conclusion and evidence
grade
Energy balance and body composition
#8: In adult athletes, what is the effect ofconsuming protein on
carbohydrate- andprotein-specific metabolic responses
duringrecovery?
Ingesting protein (approximately 20 to 30 g total protein, or
approximately10 g essential amino acids) during exercise or the
recovery period(postexercise) led to increased whole body and
muscle protein synthesis aswell as improved nitrogen balance.Grade
I- Good
Training
#9: In adult athletes, what is the optimal blendof carbohydrates
for maximal carbohydrateoxidation during exercise?
Based on the limited evidence available, carbohydrate oxidation
wasgreater in carbohydrate conditions (glucose and
glucoseþfructose)compared with water placebo, but no differences
between the twocarbohydrate blends tested were observed in male
cyclists. Exogenouscarbohydrate oxidation was greater in the
glucoseþfructose condition vsglucose-only in a single study.Grade
III - Limited
#10: In adult athletes, what effect doestraining with limited
carbohydrate availabilityhave on metabolic adaptations that lead
toperformance improvements?
Training with limited carbohydrate availability may lead to some
metabolicadaptations during training, but did not lead to
performanceimprovements. Based on the evidence examined, whereas
there isinsufficient evidence supporting a clear performance
effect, training withlimited carbohydrate availability impaired
training intensity and duration.Grade II - Fair
#11: In adult athletes, what effect doesconsuming high or low
glycemic meals orfoods have on training-related metabolicresponses
and exercise performance?
In the majority of studies examined, neither glycemic index nor
glycemicload affected endurance performance nor metabolic responses
whenconditions were matched for carbohydrate and energy.Grade I -
Good
Figure 1. (continued) Evidence analysis questions included in
the position statement. Evidence grades: Grade I: Good, Grade II:
Fair,Grade III: Limited, Grade IV: Expert opinion only; and Grade
V: Not assignable. Refer to http://www.andevidencelibrary.com/ for
acomplete list of evidence analysis citations.
FROM THE ACADEMY
of original research and review,consensus statements from
sportingorganizations, and opportunities forqualification and
accreditation relatedto sports nutrition and dietetics. Thisbears
witness to sports nutrition as adynamic area of science and
practicethat continues to flourish in boththe scope of support it
offers to ath-letes and the strength of evidencethat underpins its
guidelines. Beforeembarking on a discussion of individ-ual topics,
it is valuable to identify arange of themes in contemporarysports
nutrition that corroborate andunify the recommendations in
thisarticle.
1. Nutrition goals and require-ments are not static.
Athletesundertake a periodized pro-gram in which preparation
forpeak performance in targetedevents is achieved by inte-grating
different types of
March 2016 Volume 116 Number 3
workouts in the various cyclesof the training calendar.
Nutri-tion support also needs to beperiodized, taking into
accountthe needs of daily training ses-sions (which can range
fromminor in the case of “easy”workouts to substantial in thecase
of high-quality sessions(eg, high-intensity, strenuous,or highly
skilled workouts) andoverall nutritional goals.
2. Nutrition plans need to bepersonalized to the
individualathlete to take into account thespecificity and
uniqueness ofthe event, performance goals,practical challenges,
food pref-erences, and responses tovarious strategies.
3. A key goal of training is toadapt the body to
developmetabolic efficiency and flexi-bility, whereas
competitionnutrition strategies focus on
JOURNAL OF THE ACADEM
providing adequate substratestores to meet the fuel de-mands of
the event and sup-port cognitive function.
4. Energy availability, which con-siders energy intake in
relationto the energy cost of exercise,sets an important
foundationfor health and the success ofsports nutrition
strategies.
5. The achievement of the bodycomposition associated withoptimal
performance is nowrecognized as an important butchallenging goal
that needs tobe individualized and perio-dized. Care should be
taken topreserve health and long-termperformance by avoiding
prac-tices that create unacceptablylow energy availability
andpsychological stress.
6. Training and nutrition have astrong interaction in
accli-mating the body to develop
Y OF NUTRITION AND DIETETICS 503
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FROM THE ACADEMY
50
functional and metabolic ad-aptations. Although
optimalperformance is underpinnedby the provision of
proactivenutrition support, training ad-aptations may be enhanced
inthe absence of such support.
7. Some nutrients (eg, energy,carbohydrate, and protein)should
be expressed usingguidelines per kilogram bodymass to allow
recommenda-tions to be scaled to the largerange in the body sizes
of ath-letes. Sports nutrition guide-lines should also consider
theimportance of the timing ofnutrient intake and
nutritionalsupport over the day and inrelation to sport rather
thangeneral daily targets.
8. Highly trained athletes walk atightrope between traininghard
enough to achieve amaximal training stimulus andavoiding the
illness and injuryrisk associated with an exces-sive training
volume.
9. Competition nutrition shouldtarget specific strategies
thatreduce or delay factors thatwould otherwise cause fatiguein an
event; these are specificto the event, the environ-ment/scenario in
which it isundertaken, and the individ-ual athlete.
10. New performance nutritionoptions have emerged in thelight of
developing but robustevidence that brain sensing ofthe presence of
carbohydrate,and potentially other nutri-tional components, in the
oralcavity can enhance perceptionsof well-being and increase
self-chosen work rates. Such find-ings present opportunities
forintake during shorter events, inwhich fluid or food intake
waspreviously not considered tooffer a metabolic advantage,
byenhancing performance via acentral effect.
11. A pragmatic approach to adviceregarding the use of
supple-ments and sports foods isneeded in the face of the
highprevalence of interest in, anduse by, athletes and the
evi-dence that some products canusefully contribute to a sports
4 JOURNAL OF THE ACADEMY OF NUTRIT
nutrition plan and/or directlyenhance performance.
Athletesshould be assisted to undertakea cost-to-benefit analysis
of theuse of such products and torecognize that they are of
thegreatest value when added to awell-chosen eating plan.
THEME 1: NUTRITION FORATHLETE PREPARATIONEnergy Requirements,
EnergyBalance, and Energy AvailabilityAn appropriate energy intake
is thecornerstone of the athlete’s diet becauseit supports optimal
body function, de-termines the capacity for intake ofmacronutrient
and micronutrients, andassists in manipulating body composi-tion.
An athlete’s energy intake fromfood, fluids, and supplements can
bederived from weighed/measured foodrecords (typically 3 to 7
days), a multi-pass 24-hour recall, or from foodfrequency
questionnaires.1 There areinherent limitations with all of
thesemethods, with a bias to the under-reportingof intakes.
Extensive educationregarding the purpose and protocols
ofdocumenting intakes may assist withcompliance and enhance the
accuracyandvalidityof self-reported information.Meanwhile, an
athlete’s energy re-
quirements depend on the periodizedtraining and competition
cycle, and willvary from day to day throughout theyearly training
plan relative to changesin training volume and intensity.
Factorsthat increase energy needs abovenormal baseline levels
include exposureto cold or heat, fear, stress, high
altitudeexposure, some physical injuries, spe-cific drugs or
medications (eg, caffeineand nicotine), increases in fat-free
mass(FFM), and possibly the luteal phase ofthe menstrual cycle.2
Aside from re-ductions in training, energy re-quirements are
lowered by aging,decreases in FFM, and possibly thefollicular phase
of the menstrual cycle.3
Energy balance occurs when totalenergy intake (EI) equals total
energyexpenditure (TEE), which in turn con-sists of the summation
of basal meta-bolic rate (BMR), the thermic effect offood (TEF),
and the thermic effect ofactivity (TEA).TEE[BMRDTEFDTEATEA[Planned
Exercise Expendi-
tureDSpontaneous Physical ActivityDNonexercise Activity
Thermogenesis
ION AND DIETETICS
Techniques used to measure or esti-mate components of TEE in
sedentaryand moderately active populations canalso be applied to
athletes, but there aresome limitations to this
approach,particularly in highly competitive ath-letes. Because the
measurement of BMRrequires subjects to remainexclusivelyatrest, it
is more practical to measurerestingmetabolic rate (RMR),whichmaybe
10% higher. Although population-specific regression equations
areencouraged, a reasonable estimate ofBMR can be obtained using
either theCunningham4 or the Harris-Benedict5
equations, with an appropriate activityfactor being applied to
estimate TEE.Whereas RMR represents 60% to 80% ofTEE for sedentary
individuals, it may beas little as 38% to 47% of TEE for
eliteendurance athletes whomay have a TEAas high as 50% of
TEE.2
TEA includes planned exerciseexpenditure, spontaneous physical
ac-tivity (eg, fidgeting), and nonexerciseactivity thermogenesis.
Energy expen-diture from exercise can be estimatedin several ways
from activity logs(1 to 7 days’ duration) with subjectiveestimates
of exercise intensity usingactivity codes and metabolic
equiva-lents,6,7 US Dietary Guidelines, 2015,8
and the Dietary Reference Intakes(DRIs).9 The latter two
typically un-derestimate the requirements of ath-letes because they
fail to cover therange in body size or activity levels
ofcompetitive populations. Energy avail-ability (EA) is a concept
of recent cur-rency in sports nutrition, whichequates energy intake
with re-quirements for optimal health andfunction rather than
energy balance.EA, defined as dietary intake minusexercise energy
expenditure normal-ized to FFM, is the amount of energyavailable to
the body to perform allother functions after the cost of exer-cise
is subtracted.10 The concept wasfirst studied in women, where an EA
of45 kcal/kg FFM/day was found to beassociated with energy balance
andoptimal health; meanwhile, a chronicreduction in EA,
(particularly below 30kcal/kg FFM/day) was associated
withimpairments of a variety of bodyfunctions.10 Low EA may occur
frominsufficient EI, high TEE, or a combi-nation of the two. It may
be associatedwith disordered eating, a misguided orexcessively
rapid program for loss ofbody mass, or inadvertent failure to
March 2016 Volume 116 Number 3
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FROM THE ACADEMY
meet energy requirements during aperiod of high-volume training
orcompetition.10
Example Calculation of EA60 kg body weight (BW), 20% body
fat, 80% FFM (¼48.0 kg FFM), EI¼2,400kcal/day, additional energy
expendi-ture from exercise¼500
kcal/dayEA¼(EIeEEE)/FFM¼(2,400e500)
kcal$d/48.0 kg¼39.6 kcal/kg FFM/dayThe concept of EA emerged
from the
study of the female athlete triad (Triad),which started as a
recognition of theinterrelatedness of clinical issues
withdisordered eating, menstrual dysfunc-tion, and low bone mineral
density infemale athletes and then evolved into abroader
understanding of the concernsassociated with any movement alongthe
spectra away from optimal energyavailability, menstrual status, and
bonehealth.11 Although not embedded in theTriad spectrum, it is
recognized thatother physiological consequences mayresult from one
of the components ofthe Triad in female athletes, such asendocrine,
gastrointestinal, renal,neuropsychiatric, musculoskeletal,
andcardiovascular dysfunction.11 Indeed, anextension of the Triad
has been pro-posed—the Relative Energy Deficiencyin Sport
(RED-S)—as an inclusivedescription of the entire cluster
ofphysiologic complications observed inmale and female athletes who
consumeenergy intakes that are insufficient inmeeting the needs for
optimal bodyfunction once the energy cost of exercisehas been
removed.12 Specifically, healthconsequences of RED-S may
negativelyaffect menstrual function; bone health;and endocrine,
metabolic, hematologi-cal, growth and development, psycho-logical,
cardiovascular, gastrointestinal,and immunological systems.
Potentialperformance effects of RED-S mayinclude decreased
endurance, increasedinjury risk, decreased training
response,impaired judgment, decreased coordi-nation, decreased
concentration, irrita-bility, depression, decreased glycogenstores,
and decreased muscle strength.12
It is now also recognized that impair-ments of health and
function occuracross the continuum of reductions inEA, rather than
occurring uniformly atan EA threshold, and require
furtherresearch.12 It should be appreciated thatlow EA is not
synonymous with negativeenergy balance or weight loss; indeed, ifa
reduction in EA is associated with areduction in RMR, it may
produce a new
March 2016 Volume 116 Number 3
steady-state of energy balance or weightstability at a lowered
energy intake thatis insufficient to provide for healthybody
function.Regardless of the terminology, it is
apparent that low EA in male and fe-male athletes may
compromiseathletic performance in the short andlong-term. Screening
and treatmentguidelines have been established formanagement of low
EA11,12 and shouldinclude assessment with the EatingDisorder
Inventory-3 resource13 or theDiagnostic and Statistical Manual
ofMental Disorders, fifth edition, whichincludes changes in eating
disordercriteria.14 There is evidence that in-terventions to
increase EA are suc-cessful in reversing at least someimpaired body
functions; for example,in a 6-month trial with female
athletesexperiencing menstrual dysfunction,dietary treatment to
increase EA tow40 kcal/kg FFM/day resulted inresumption of menses
in all subjects ina mean of 2.6 months.6
Body Composition and SportsPerformanceVarious attributes of
physique (bodysize, shape, and composition) areconsidered to
contribute to success invarious sports. Of these, body
mass(“weight”) and body composition areoften focal points for
athletes becausethey are most able to be manipulated.Although it is
clear that the assessmentand manipulation of body compositionmay
assist in the progression of anathletic career, athletes, coaches,
andtrainers should be reminded that ath-letic performance cannot be
accuratelypredicted solely based on BW andcomposition. A single and
rigid optimalbody composition should not be rec-ommended for any
event or group ofathletes.15 Nevertheless, there are re-lationships
between body compositionand sports performance that areimportant to
consider within an ath-lete’s preparation.In sports involving
strength and po-
wer, athletes strive to gain FFM via aprogram of muscle
hypertrophy atspecified times of the annual macro-cycle. Whereas
some athletes aim togain absolute size and strength per se,in other
sports, in which the athletemust move their own body mass orcompete
within weight divisions, it isimportant to optimize power to
weightratios rather than absolute power.16
JOURNAL OF THE ACAD
Thus, some power athletes also desireto achieve low body fat
levels. Insports involving weight divisions (eg,combat sports,
lightweight rowing, andweightlifting), competitors typicallytarget
the lowest achievable BW cate-gory while maximizing their leanmass
within this target.
Other athletes strive to maintain alow body mass and/or body fat
level forseparate advantages.17 Distance run-ners and cyclists
benefit from a lowenergy cost of movement and a favor-able ratio of
weight to surface area forheat dissipation. Team athletes can
in-crease their speed and agility by beinglean, whereas athletes in
acrobaticsports (eg, diving, gymnastics, anddance) gain
biomechanical advantagesin being able to move their bodieswithin a
smaller space. In some ofthese sports and others (eg,
bodybuilding), there is an element of aes-thetics in determining
performanceoutcomes. Although there are demon-strated advantages to
achieving acertain body composition, athletes mayfeel pressure to
strive to achieve unre-alistically low targets of weight/bodyfat or
to reach them in an unrealistictime frame.15 Such athletes may
besusceptible to practicing extremeweight control behaviors or
continuousdieting, exposing themselves tochronic periods of low EA
and poornutrient support in an effort to repeatprevious success at
a lower weight orleaner body composition.15,18 Extrememethods of
weight control can bedetrimental to health and perfor-mance, and
disordered eating patternshave also been observed in these
sportscenarios.15,18
Nevertheless, there are scenarios inwhich an athlete will
enhance his orher health and performance byreducing BW or body fat
as part of aperiodized strategy. Ideally, this occurswithin a
program that gradually ach-ieves an individualized optimal
bodycomposition over the athlete’s athleticcareer, and allows
weight and body fatto track within a suitable range withinthe
annual training cycle.18 The pro-gram should also include avoiding
sit-uations in which athletes inadvertentlygain excessive amounts
of body fat as aresult of a sudden energy mismatchwhen energy
expenditure is abruptlyreduced (eg, the off-season or injury).In
addition, athletes are warned againstthe sudden or excessive gain
in body
EMY OF NUTRITION AND DIETETICS 505
-
FROM THE ACADEMY
fat that is part of the culture of somesports where a high body
mass isdeemed useful for performance.Although body mass index is
notappropriate as a body compositionsurrogate in athletes, a
chronic interestin gaining weight may put some ath-letes at risk
for an obese body massindex, which may increase the risk ofmeeting
the criteria for metabolicsyndrome.19 Sports dietitians should
beaware of sports that promote theattainment of a large body mass
andscreen for metabolic risk factors.19
Methodologies for Body Composi-tion Assessment. Techniques used
toassess athlete body compositioninclude dual energy x-ray
absorptiom-etry (DXA), hydrodensitometry, airdisplacement
plethysmography, skin-fold measurements, and single
andmultifrequency bioelectrical imped-ance analysis. Although DXA
is quickand noninvasive, issues around cost,accessibility, and
exposure to a smallradiation dose limit its utility, par-ticularly
for certain populations.20
When undertaken according to stan-dardized protocols, DXA has
the loweststandard error of estimate, whereasskinfold measures have
the highest; airdisplacement plethysmography (Bod-Pod, Life
Measurement, Inc) providesan alternative method that is quick
andreliable, but may underestimate bodyfat by 2% to 3%.20 Skinfold
measure-ment and other anthropometric dataserve as an excellent
surrogate mea-sure of adiposity and muscularity whenprofiling
composition changes inresponse to training interventions.20
However, it should be noted that thestandardization of skinfold
sites, mea-surement techniques, and calipers varyaround the world.
Despite some limi-tations, this technique remains a pop-ular method
of choice due toconvenience and cost, with informa-tion being
provided in absolute mea-sures and compared with sequentialdata
from the individual athlete or, in ageneral way, with normative
datacollected in the same way from athletepopulations.20,21
All body composition assessmenttechniques should be scrutinized
toensure accuracy and reliability. Testingshould be conducted with
the samecalibrated equipment, with a stan-dardized protocol, and by
technicians
506 JOURNAL OF THE ACADEMY OF NUTRIT
with known testeretest reliability.Where population-specific
predictionequations are used, they should becross-validated and
reliable. Athletesshould be educated on the limitationsassociated
with body compositionassessment and should strictly
followpreassessment protocols. These in-structions, which include
maintaininga consistent training volume, fastingstatus, and
hydration from test totest20 should be enforced to
avoidcompromising the accuracy and reli-ability of body composition
measures.Body composition should be deter-
mined within a sports program ac-cording to a schedule that
isappropriate to the performance of theevent, the practicality of
undertakingassessments, and the sensitivity of theathlete. There
are technical errorsassociated with all body compositiontechniques
that limit the usefulness ofmeasurement for athlete selection
andperformance prediction. In lieu ofsetting absolute body
compositiongoals or applying absolute criteria tocategorize groups
of athletes, it ispreferred that normative data are pro-vided in
terms of ranges.21 Becausebody fat content for an individualathlete
will vary over the season andover the athlete’s career, goals for
bodycomposition should be set in terms ofranges that can be
appropriatelytracked at critical times. When con-ducting such
monitoring programs, it isimportant that the communication
ofresults with coaches, training staff, andathletes is undertaken
with sensitivity,that limitations in measurement tech-nique are
recognized, and that care istaken to avoid promoting an
unhealthyobsession with body composition.17,18
Sports dietitians have important op-portunities to work with
these athletesto help promote a healthy bodycomposition, and to
minimize theirreliance on rapid-weight loss tech-niques and other
hazardous practicesthat may result in performance decre-ments, loss
of FFM, and chronic healthrisks. Many themes should beaddressed and
include the creation of aculture and environment that valuessafe
and long-term approaches tomanagement of body
composition;modification of rules or practicesaround selection and
qualification forweight classes;16,19,22 and programsthat identify
disordered eating
ION AND DIETETICS
practices at an early stage for inter-vention, and where
necessary, removalfrom play.18
Principles of Altering Body Com-position and Weight. Athletes
oftenneed assistance in setting appropriateshort-term and long-term
goals, un-derstanding nutrition practices thatcan safely and
effectively increasemuscle mass or reduce body fat/weight, and
integrating these strategiesinto an eating plan that achieves
otherperformance nutrition goals. Frequentfollow up with these
athletes may havelong-term benefits, including shep-herding the
athlete through short-termgoals and reducing reliance on
extremetechniques and fad diets/behaviors.
There is ample evidence in weightsensitive and weight-making
sportsthat athletes frequently undertakerapid weight loss
strategies to gain acompetitive advantage.20,23,24 Howev-er, the
resultant hypohydration (bodywater deficit), loss of glycogen
storesand lean mass, and other outcomes ofpathologic behaviors (eg,
purging,excessive training, or starving) canimpair health and
performance.18
Nevertheless, responsible use of short-term, rapid weight-loss
techniques,when indicated, is preferred overextreme and extended
energy restric-tion and suboptimal nutrition sup-port.17 When
actual loss of BW isrequired, it should be programmed tooccur in
the base phase of training orwell out from competition to
minimizeloss of performance,25 and should beachieved with
techniques that maxi-mize loss of body fat while preservingmuscle
mass and other health goals.Such strategies include achieving
aslight energy deficit to achieve a slowrather than rapid rate of
loss andincreasing dietary protein intake. Inthis regard, the
provision of a higherprotein intake (2.3 vs 1 g/kg/day) in
ashorter-term (2 week), energy-restricted diet in athletes was
foundto retain muscle mass while losingweight and body fat.26
Furthermore,FFM and performance may be betterpreserved in athletes
who minimizeweekly weight loss to
-
FROM THE ACADEMY
Nevertheless, for most athletes, thepractical approach of
decreasing en-ergy intake by w250 to 500 kcal/dayfrom their
periodized energy needs,while either maintaining or
slightlyincreasing energy expenditure, canachieve progress toward
short-termbody composition goals over approxi-mately 3 to 6 weeks.
In some situa-tions, additional moderate aerobictraining and close
monitoring can beuseful.27 These strategies can beimplemented to
help augment thediet-induced energy deficits withoutnegatively
impacting recovery fromsport-specific training. Arranging thetiming
and content of meals to sup-port training nutrition goals and
re-covery may reduce fatigue duringfrequent training sessions and
mayhelp optimize body composition overtime.18 Overall barriers to
bodycomposition management includelimited access to healthy food
options,limited skills or opportunity for foodpreparation, lack of
daily routine, andexposure to catering featuring unlim-ited portion
sizes and energy-densefoods. Such factors, particularly foundin
association with the travel andcommunal living experiences in
theathlete lifestyle, can promote poordietary quality that thwarts
progressand may lead to the pursuit of quickfixes, acute dieting,
and extremeweight loss practices.EAL Question #1 (Figure 1)
exam-
ined the effect of negative energy bal-ance on sport
performance, findingonly fair support for an impairment ofphysical
capacity due to a hypo-energetic diet in the currently exam-ined
scenarios. However, few studieshave investigated the overlay of
factorscommonly seen in practice, includingthe interaction of poor
dietary quality,low carbohydrate availability, exces-sive training,
and acute dehydration onchronic energy restriction. The chal-lenge
of detecting small but importantchanges in sports performance
isnoted in all areas of sports nutrition.28
EAL Question #2 summarizes theliterature on optimal timing,
energy,and macronutrient characteristics of aprogram supporting a
gain in FFMwhen in energy deficit (Figure 1).Again the literature
is limited inquantity and range to allow definitiverecommendations
to be made,although there is support for the ben-efits of increased
protein intake.
March 2016 Volume 116 Number 3
Nutrient Requirements for SportEnergy Pathways and
TrainingAdaptations. Guidelines for thetiming and amount of intake
of mac-ronutrients in an athlete’s diet shouldbe underpinned by a
fundamental un-derstanding of how training-nutrientinteractions
affect energy systems,substrate availability, and training
ad-aptations. Exercise is fueled by an in-tegrated series of energy
systems thatinclude nonoxidative (phosphagen andglycolytic) and
aerobic (fat and carbo-hydrate oxidation) pathways, usingsubstrates
that are both endogenousand exogenous in origin. ATP
andphosphocreatine (phosphagen system)provide a rapidly available
energysource for muscular contraction, butnot at sufficient levels
to provide acontinuous supply of energy for longerthan w10 seconds.
The anaerobicglycolytic pathway rapidly metabolizesglucose and
muscle glycogen throughthe glycolytic cascade and is the pri-mary
pathway supporting high-intensity exercise lasting 10 to
180seconds. Because neither the phospha-gen nor the glycolytic
pathway cansustain energy demands to allow mus-cles to contract at
a very high rate forlonger lasting events, oxidative path-ways
provide the primary fuels forevents lasting longer than w2
minutes.The major substrates include muscleand liver glycogen,
intramuscular lipid,adipose tissue triglycerides, andamino acids
from muscle, blood, liver,and the gut. As oxygen becomes
moreavailable to the working muscle, thebody uses more of the
aerobic (oxida-tive) pathways and less of the anaer-obic
(phosphagen and glycolytic)pathways. The greater dependenceupon
aerobic pathways does notoccur abruptly, nor is one pathway
everrelied on exclusively. The intensity,duration, frequency, type
of training,sex, and training level of the individual,as well as
prior nutrient intake andsubstrate availability, determine
therelative contribution of energy path-ways and when crossover
betweenpathways occurs. For a more completeunderstanding of fuel
systems forexercise, the reader is directed to spe-cific
texts.29
An athlete’s skeletal muscle has aremarkable plasticity to
respondquickly to mechanical loading andnutrient availability
resulting in
JOURNAL OF THE ACAD
condition-specific metabolic and func-tional adaptations.30
These adaptationsinfluence performance nutrition rec-ommendations
with the overarchinggoals that energy systems should betrained to
provide the most economicalsupport for the fuel demands of anevent
while other strategies shouldachieve appropriate substrate
avail-ability during the event itself. Adapta-tions that enhance
metabolic flexibilityinclude increases in transport mole-cules that
carry nutrients acrossmembranes or to the site of their usewithin
the muscle cell, increases inenzymes that activate or
regulatemetabolic pathways, enhancement ofthe ability to tolerate
the side-productsof metabolism, and an increase in thesize of
muscle fuel stores.3 Althoughsome muscle substrates (eg, body
fat)are present in relatively large quanti-ties, others may need to
be manipu-lated according to specific needs (eg,carbohydrate
supplementation toreplace muscle glycogen stores).
Carbohydrate. Carbohydrate hasrightfully received a great deal
ofattention in sports nutrition due to anumber of special features
of its rolein the performance of, and adaptationto training. First,
the size of body car-bohydrate stores is relatively limitedand can
be acutely manipulated on adaily basis by dietary intake or even
asingle session of exercise.3 Second,carbohydrate provides a key
fuel forthe brain and central nervous systemand a versatile
substrate for muscularwork where it can support exerciseover a
large range of intensities due toits use by both anaerobic and
oxida-tive pathways. Even when working atthe highest intensities
that can besupported by oxidative phosphoryla-tion, carbohydrate
offers advantagesover fat as a substrate because it pro-vides a
greater yield of ATP per vol-ume of oxygen that can be deliveredto
the mitochondria,3 thus improvinggross exercise efficiency.31
Third, thereis significant evidence that the per-formance of
prolonged sustained orintermittent high-intensity exercise
isenhanced by strategies that maintainhigh carbohydrate
availability (ie,match glycogen stores and bloodglucose to the fuel
demands of exer-cise), whereas depletion of thesestores is
associated with fatigue in theform of reduced work rates,
impaired
EMY OF NUTRITION AND DIETETICS 507
-
Table. Summary of guidelines for carbohydrate intake by
athletes36
SituationCarbohydratetargets
Comments on type and timingof carbohydrate intake
Daily needs for fuel and recovery1. The following targets are
intended to provide high carbohydrate availability (ie, to meet the
carbohydrate needs of the
muscle and central nervous system) for different exercise loads
for scenarios where it is important to exercise with highquality
and/or at high intensity. These general recommendations should be
fine-tuned with individual consideration oftotal energy needs,
specific training needs, and feedback from training
performance.
2. On other occasions, when exercise quality or intensity is
less important, it may be less important to achieve
thesecarbohydrate targets or to arrange carbohydrate intake over
the day to optimize availability for specific sessions. In
thesecases, carbohydrate intake may be chosen to suit energy goals,
food preferences, or food availability.
3. In some scenarios, when the focus is on enhancing the
training stimulus or adaptive response, low
carbohydrateavailability may be deliberately achieved by reducing
total carbohydrate intake, or by manipulating carbohydrate
intakerelated to training sessions (eg, training in a fasted state
or undertaking a second session of exercise without
adequateopportunity for refuelling after the first session).
Light � Low intensity orskill-based activities
3-5 g/kg of athlete’sbody weight/d
� Timing of intake of carbohydrate over theday may be
manipulated to promote highcarbohydrate availability for a
specificsession by consuming carbohydratebefore or during the
session, or duringrecovery from a previous session
� Otherwise, as long as total fuel needs areprovided, the
pattern of intake may simplybe guided by convenience and individual
choice
� Athletes should choose nutrient-richcarbohydrate sources to
allow overallnutrient needs to be met
Moderate � Moderate exerciseprogram (eg, w1 h/d)
5-7 g/kg/d
High � Endurance program(eg, 1-3 h/d moderate tohigh-intensity
exercise)
6-10 g/kg/d
Very high � Extreme commitment(eg, >4-5 h/d moderateto
high-intensityexercise)
8-12 g/kg/d
Acute fueling strategies e These guidelines promote high
carbohydrate availability to promote optimal performance
duringcompetition or key training sessions
General fuelingup
� Preparation for events90 min of sustained/intermittent
exercise
36-48 h of 10-12 g/kgbody weight/24 h
Speedyrefueling
� 60 min 1-4 g/kg consumed1-4 h beforeexercise
� Timing, amount, and type of carbohydratefoods and drinks
should be chosen to suitthe practical needs of the event
andindividual preferences/experiences
� Choices high in fat/protein/fiber may needto be avoided to
reduce risk ofgastrointestinal issues during the event
� Low glycemic index choices may providea more sustained source
of fuel forsituations where carbohydrate cannot beconsumed during
exercise
(continued on next page)
FROM THE ACADEMY
508 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS March 2016
Volume 116 Number 3
-
Table. Summary of guidelines for carbohydrate intake by
athletes36 (continued)
SituationCarbohydratetargets
Comments on type and timingof carbohydrate intake
During briefexercise
� 2.5-3 h Up to 90 g/h � As above� Higher intakes of
carbohydrate are
associated with better performance� Products providing multiple
transportable
carbohydrates (Glucose:fructose mixtures)achieve high rates of
oxidation ofcarbohydrate consumed during exercise
FROM THE ACADEMY
skill and concentration, and increasedperception of effort.
These findingsunderpin the various performancenutrition strategies,
to be discussedsubsequently, that supply carbohy-drate before,
during, and in the re-covery between events to enhancecarbohydrate
availability.Finally, recent work has identified
that in addition to its role as a musclesubstrate, glycogen
plays importantdirect and indirect roles in regulatingthe muscle’s
adaptation to training.32
The amount and localization ofglycogen within muscle cells
alters thephysical, metabolic, and hormonalenvironment in which the
signaling re-sponses to exercise are exerted. Specif-ically,
starting a bout of endurance
March 2016 Volume 116 Number 3
exercise with low muscle glycogencontent (eg, by undertaking a
secondtraining session in the hours after theprior session has
depleted glycogenstores) produces a coordinated upregu-lation of
the transcriptional and post-translational responses to exercise.
Anumber of mechanisms underpin thisoutcome, including increasing
the ac-tivity of molecules that have a glycogenbinding domain,
increasing free fattyacid availability, changing osmoticpressure in
the muscle cell, andincreasing catecholamine concentra-tions.32
Strategies that restrict exoge-nous carbohydrate availability
(eg,exercising in a fasted state or withoutcarbohydrate intake
during the session)also promote an extended signaling
JOURNAL OF THE ACAD
response, albeit less robustly than is thecase for exercise with
low endogenouscarbohydrate stores.33 These strategiesenhance the
cellular outcomes ofendurance training such as increasedmaximal
mitochondrial enzyme activ-ities and/or mitochondrial content
andincreased rates of lipid oxidation, withthe augmentation of
responses likely tobe explained by enhanced activation ofkey cell
signaling kinases (eg, AMPK andp38MAPK), transcription factors
(eg,p53 and PPARd) and transcriptionalcoactivators (eg, PGC-1a).33
Deliberateintegration of such training-dietarystrategies (“train
low”) within the per-iodized training program is becoming
arecognized,34 although potentially mis-used,33 part of sports
nutrition practice.
EMY OF NUTRITION AND DIETETICS 509
-
FROM THE ACADEMY
Individualized recommendations fordaily intakes of carbohydrate
should bemade in consideration of the athlete’straining/competition
program and therelative importance of undertaking itwith high or
low carbohydrate accord-ing to the priority of promoting
theperformance of high quality exercise vsenhancing the training
stimulus oradaptation, respectively. Unfortunately,we lack
sophisticated information onthe specific substrate requirements
ofmany of the training sessions under-taken by athletes; therefore,
we mustrely on guesswork, supported by in-formation on work
requirements ofexercise from technologies such asconsumer-based
activity and heart ratemonitors,35 power meters, and
globalpositioning systems.General guidelines for the suggested
intake of carbohydrate to provide highcarbohydrate availability
for desig-nated training or competition sessionscan be provided
according to the ath-lete’s body size (a proxy for the size
ofmuscle stores) and the characteristicsof the session (see the
Table). Thetiming of carbohydrate intake over theday and in
relation to training can alsobe manipulated to promote or
reducecarbohydrate availability.36 Strategiesto enhance
carbohydrate availabilityare covered in more detail in relation
tocompetition eating strategies. Never-theless, these fueling
practices are alsoimportant for supporting the high-quality
workouts within the perio-dized training program. Furthermore, itis
intuitive that they add value in fine-tuning intended event eating
strate-gies, and for promoting adaptationssuch as gastrointestinal
tolerance andenhanced intestinal absorption37 thatallow competition
strategies to be fullyeffective. During other sessions of
thetraining program, it may be lessimportant to achieve high
carbohy-drate availability, or there may be somevalue in
deliberately exercising withlow carbohydrate availability toenhance
the training stimulus oradaptive response. Various tactics canbe
used to permit or promote low car-bohydrate availability,
includingreducing total carbohydrate intake ormanipulating the
timing of training inrelation to carbohydrate intake (eg,training
in a fasted state, undertakingtwo bouts of exercise in close
prox-imity without opportunity for refuelingbetween
sessions).38
510 JOURNAL OF THE ACADEMY OF NUTRIT
Specific questions examined via theevidence analysis on
carbohydrateneeds for training are summarized inthe Table and show
good evidence thatneither the glycemic load nor glycemicindex of
carbohydrate-rich meals affectsthe metabolic nor performance
out-comes of training once carbohydrateand energy content of the
diet havebeen taken into account (Question #11).Furthermore,
although there is soundtheory behind the metabolic advantagesof
exercising with low carbohydrateavailability on training
adaptations, thebenefits to performance outcomes arecurrently
unclear (Figure 1, Question#10). This possibly relates to the
limi-tations of the few available studies inwhich poor
periodization of this tacticwithin the training program has
meantthat any advantages to training adapta-tions have been
counteracted by thereduction in training intensity andquality
associated with low carbohy-drate variability. Therefore, a more
so-phisticated approach is needed tointegrate this
training/nutrient interac-tion into the larger training
program.33
Finally, although there is support forconsuming multiple forms
of carbohy-drate which facilitate more rapidabsorption, evidence to
support thechoice of special blends of carbohydrateto support
increased carbohydrateoxidation during training sessions
ispremature (Question #9).
Protein. Dietary protein interactswith exercise, providing both
a triggerand a substrate for the synthesis ofcontractile and
metabolic proteins39,40
as well as enhancing structuralchanges in nonmuscle tissues such
astendons41 and bones.42 Adaptationsare thought to occur by
stimulation ofthe activity of the protein syntheticmachinery in
response to a rise inleucine concentrations and the provi-sion of
an exogenous source of aminoacids for incorporation into new
pro-teins.43 Studies of the response toresistance training show
upregulationof muscle protein synthesis (MPS)for at least 24 hours
in response toa single session of exercise, withincreased
sensitivity to the intakeof dietary protein over this period.44
This contributes to improvementsin skeletal muscle protein
accretionobserved in prospective studies thatincorporate multiple
protein feedingsafter exercise and throughout the
ION AND DIETETICS
day. Similar responses occur followingaerobic exercise or other
exercisetypes (eg, intermittent sprint activitiesand concurrent
exercise), albeit withpotential differences in the type ofproteins
that are synthesized. Recentrecommendations have underscoredthe
importance of well-timed proteinintake for all athletes even if
musclehypertrophy is not the primarytraining goal, and there is now
goodrationale for recommending dailyprotein intakes that are well
above theRecommended Dietary Allowance(RDA)39 to maximize metabolic
adap-tation to training.40
Although classical nitrogen balancework has been useful for
determiningprotein requirements to prevent defi-ciency in sedentary
humans in energybalance,45 athletes do not meet thisprofile and
achievingnitrogenbalance issecondary to an athlete with the
pri-mary goal of adaptation to training andperformance
improvement.40 Themodern view for establishing recom-mendations for
protein intake in ath-letes extends beyond theDRIs. Focus
hasclearly shifted to evaluating the benefitsof providing enough
protein at optimaltimes to support tissues with rapidturnover and
augment metabolic adap-tations initiated by training
stimulus.Future research will further refine rec-ommendations
directed at total dailyamounts, timing strategies, quality
ofprotein intake, and provide new rec-ommendations for protein
supplementsderived from various protein sources.
Protein needs. Current data suggestthat dietary protein intake
necessary tosupport metabolic adaptation, repair,remodeling, and
for protein turnovergenerally ranges from 1.2 to 2.0 g/kg/day.
Higher intakes may be indicated forshort periods during intensified
trainingor when reducing energy intake.26,39
Daily protein intake goals should bemet with a meal plan
providing a reg-ular spread of moderate amounts ofhigh-quality
protein across the day andfollowing strenuous training
sessions.These recommendations encompassmost training regimens and
allow forflexible adjustments with periodizedtraining and
experience.46,47 Althoughgeneral daily ranges are provided,
in-dividuals should no longer be solelycategorized as strength or
endur-ance athletes and provided with staticdaily protein intake
targets. Rather,
March 2016 Volume 116 Number 3
-
FROM THE ACADEMY
guidelines should be based aroundoptimal adaptation to specific
sessionsof training/competition within a perio-dized program,
underpinned by anappreciation of the larger context ofathletic
goals, nutrient needs, energyconsiderations, and food choices.
Re-quirements can fluctuate based on“trained” status (eg,
experienced ath-letes requiring less), training (eg, ses-sions
involving higher frequency andintensity, or a new training stimulus
athigher end of protein range), carbohy-drate availability, and
most importantly,energy availability.46,48 The consump-tion of
adequate energy, particularlyfrom carbohydrates, to match
energyexpenditure, is important so that aminoacids are spared for
protein synthesisand not oxidized.49 In cases of energyrestriction
or sudden inactivity as oc-curs as a result of injury, elevated
pro-tein intakes as high as 2.0 g/kg/dayor higher26,50 when spread
over theday may be advantageous in prevent-ing FFM loss.39 More
detailed reviewsof factors that influence changing pro-tein needs
and their relationship tochanges in protein metabolism andbody
composition goals can be foundelsewhere.51,52
Protein timing as a trigger formetabolic adaptation.
Laboratory-based studies show that MPS is opti-mized in response to
exercise by theconsumption of high biological valueprotein,
providing w10 g essentialamino acids in the early recoveryphase (0
to 2 hours after exercise).40,53
This translates to a recommendedprotein intake of 0.25 to 0.3
g/kg BWor 15 to 25 g protein across the typicalrange of athlete
body sizes, althoughthe guidelines may need to be fine-tuned for
athletes at extreme ends ofthe weight spectrum.54 Higher doses(ie,
>40 g dietary protein) have notyet been shown to further
augmentMPS and may only be prudent for thelargest athletes, or
during weightloss.54 The exercise-enhancement ofMPS, determined by
the timing andpattern of protein intake, responds tofurther intake
of protein within the24-hour period after exercise,55 andmay
ultimately translate into chronicmuscle protein accretion and
func-tional change. Whereas proteintiming affects MPS rates, the
magni-tude of mass and strength changes
March 2016 Volume 116 Number 3
over time are less clear.56 However,longitudinal training
studies currentlysuggest that increases in strengthand muscle mass
are greatest withimmediate postexercise provision ofprotein.57
Whereas traditional protein intakeguidelines focused on total
proteinintake over the day (grams per kilo-gram), newer
recommendations nowhighlight that the muscle adaptation totraining
can be maximized by ingestingthese targets as 0.3 g/kg BW after
keyexercise sessions and every 3 to 5hours over multiple
meals.47,54,58
Question #8 (Figure 1) summarizesthe weight of the current
literatureof consuming protein on protein-specific metabolic
responses duringrecovery.
Optimal protein sources. High-qual-ity dietary proteins are
effective for themaintenance, repair, and synthesis ofskeletal
muscle proteins.59 Chronictraining studies have shown that
theconsumption of milk-based protein af-ter resistance exercise is
effective inincreasing muscle strength and favor-able changes in
body composi-tion.57,60,61 In addition, there arereports of
increased MPS and proteinaccretion with whole milk, lean meat,and
dietary supplements, some ofwhich provide the isolated
proteinswhey, casein, soy, and egg. To date,dairy proteins seem to
be superior toother tested proteins, largely due toleucine content
and the digestion andabsorptive kinetics of branched-chainamino
acids in fluid-based dairyfoods.62 However, further studies
arewarranted to assess other intact high-quality protein sources
(eg, egg, beef,pork, and concentrated vegetable pro-tein) and mixed
meals on the stimula-tion of mammalian target of rapamycin(mTOR)
and MPS following variousmodes of exercise. When whole-foodprotein
sources are not convenient oravailable, then portable,
third-partytested dietary supplements with high-quality ingredients
may serve as apractical alternative to help athletesmeet their
protein needs. It is impor-tant to conduct a thorough assessmentof
the athlete’s specific nutrition goalswhen considering protein
supple-ments. Recommendations regardingprotein supplements should
be con-servative and primarily directed atoptimizing recovery and
adaptation to
JOURNAL OF THE ACAD
training while continuing to focus onstrategies to improve or
maintainoverall diet quality.
Fat. Fat is a necessary component of ahealthy diet, providing
energy, essen-tial elements of cell membranes, andfacilitation of
the absorption of fat-soluble vitamins. The Dietary Guide-lines for
Americans8 and Eating Wellwith Canada’s Food Guide63 have
maderecommendations that the proportionof energy from saturated
fats be limitedto less than 10% and include sources ofessential
fatty acids to meet adequateintake recommendations. Intake of fatby
athletes should be in accordancewith public health guidelines
andshould be individualized based ontraining level and body
compositiongoals.46
Fat, in the form of plasma free fattyacids, intramuscular
triglycerides, andadipose tissue provides a fuel sub-strate that is
both relatively plentifuland increased in availability to themuscle
as a result of endurancetraining. However,
exercise-inducedadaptations do not appear to maxi-mize oxidation
rates because they canbe further enhanced by dietary stra-tegies
such as fasting; acute pre-exercise intake of fat; and
chronicexposure to high-fat, low-carbohy-drate diets.3 Although
there has beenhistorical64 and recently revived65
interest in chronic adaptation tohigh-fat, low-carbohydrate
diets, thepresent evidence suggests thatenhanced rates of fat
oxidation canonly match exercise capacity/perfor-mance achieved by
diets or strategiespromoting high carbohydrate availabil-ity at
moderate intensities,64 whereasthe performance of exercise at
thehigher intensities is impaired.64,66 Thisappears to occur as a
result of adown-regulation of carbohydratemetabolism even when
glycogen isavailable.67 Further research is war-ranted both in view
of the current dis-cussions65 and the failure of currentstudies to
include an adequate con-trol diet that includes
contemporaryperiodized dietary approaches.68
Although specific scenarios may existwhere high-fat diets may
offer somebenefits or at least the absence ofdisadvantages for
performance, in gen-eral they appear to reduce rather thanenhance
metabolic flexibility byreducing carbohydrate availability and
EMY OF NUTRITION AND DIETETICS 511
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FROM THE ACADEMY
capacity to use carbohydrate effectivelyas an exercise
substrate. Therefore,competitive athletes would be unwiseto
sacrifice their ability to undertakehigh-quality training or
high-intensityefforts during competition that coulddetermine the
outcome.68
Conversely, athletes may choose toexcessively restrict their fat
intake inan effort to lose BW or improve bodycomposition. Athletes
should bediscouraged from chronic imple-mentation of fat intakes
below 20% ofenergy intake since the reduction indietary variety
often associated withsuch restrictions is likely to reduce
theintake of a variety of nutrients such asfat-soluble vitamins and
essential fattyacids,9 especially n-3 fatty acids. If suchfocused
restrictiveness around fatintake is practiced, it should be
limitedto acute scenarios such as the pre-event diet or
carbohydrate-loadingwhere considerations of preferredmacronutrients
or gastrointestinalcomfort have priority.
Alcohol. Alcohol consumption may bepart of a well-chosen diet
and socialinteractions, but excessive alcoholconsistent with binge
drinking patternsis a concerning behavior observedamong some
athletes, particularly inteam sports.69 Misuse of alcohol
caninterfere with athletic goals in a varietyof ways related to the
negative effectsof acute intake of alcohol on the per-formance of,
or recovery from, exercise,or the chronic effects of binge
drinkingon health and management of bodycomposition.70 Besides the
calorie loadof alcohol (7 kcal/g), alcohol suppresseslipid
oxidation, increases unplannedfood consumption, and may compro-mise
the achievement of body compo-sition goals. Research in this area
isfraught with study design concernsthat limit direct translation
to athletes.Available evidence warns against
intake of significant amounts of alcoholduring the pre-exercise
period andduring training due to the direct nega-tive effects of
alcohol on exercisemetabolism, thermoregulation,
andskills/concentration.69 The effects ofalcohol on strength and
performancemay persist for several hours evenafter signs and
symptoms of into-xication or hangover are no longerpresent. In the
postexercise phase,where cultural patterns in sport oftenpromote
alcohol use, alcohol may
512 JOURNAL OF THE ACADEMY OF NUTRIT
interfere with recovery by impairingglycogen storage,71 slowing
rates ofrehydration via its suppressive effect onantidiuretic
hormone,72 and impairingthe MPS desired for adaptation
andrepair.69,73,74 In cold environments,alcohol consumption
increases periph-eral vasodilation resulting in core tem-perature
dysregulation75 and there arelikely to be other effects on body
func-tion such as disturbances in acid-basebalance and
cytokine-prostaglandinpathways, and compromised glucosemetabolism
and cardiovascular func-tion.76 Binge drinking may indirectlyaffect
recovery goals due to inattentiontoguidelines for recovery.
Bingedrinkingis also associated with high-risk behav-iors leading
to accidents and antisocialbehaviors that can be detrimental tothe
athlete. In conclusion, athletes areadvised to consider both public
healthguidelines and team rules regardinguse of alcohol and are
encouraged tominimize or avoid alcohol consumptionduring the
postexercise period whenissues of recovery and injury repair area
priority.
Micronutrients. Exercise stressesmany of the metabolic pathways
inwhich micronutrients are required, andtraining may result in
muscle bio-chemical adaptations that increase theneed for some
micronutrients. Athleteswho frequently restrict energy intake,rely
on extreme weight-loss practices,eliminate one or more food
groupsfrom their diet, or consume poorlychosen diets, may consume
suboptimalamounts of micronutrients and benefitfrom micronutrient
supplementa-tion.77 This occurs most frequently inthe case of
calcium, vitamin D, iron,and some antioxidants.78-80
Single-micronutrient supplements are gener-ally only appropriate
for correction ofa clinically defined medical reason(eg, iron
supplements for iron defi-ciency anemia [IDA]).
Micronutrients of key interest:Iron. Iron deficiency, with or
withoutanemia, can impair muscle functionand limit work
capacity78,81 leading tocompromised training adaptation andathletic
performance. Suboptimal ironstatus often results from limited
ironintake from heme food sources andinadequate energy intake
(approxi-mately 6 mg iron is consumed perw1,000 kcal).82 Periods of
rapid
ION AND DIETETICS
growth, training at high altitudes,menstrual blood loss,
foot-strike he-molysis, blood donation, or injury cannegatively
influence iron status.79,81
Some athletes in intense training mayalso have increased iron
losses insweat, urine, feces, and from intravas-cular
hemolysis.
Regardless of the etiology, acompromised iron status can
nega-tively influence health, physical andmental performance, and
warrantsprompt medical intervention andmonitoring.83 Iron
requirements for allfemale athletes may be increased by upto 70% of
the estimated averagerequirement.84 Athletes who are atgreatest
risk, such as distance runners,vegetarian athletes, or regular
blooddonors, should be screened regularlyand aim for an iron intake
greaterthan their RDA (ie, >18 mg for womenand >8 mg for
men).81,85
Athletes with IDA should seek clin-ical follow-up, with
therapies,including oral iron supplementation,86
improvements in diet, and a possiblereduction in activities that
influenceiron loss (eg, blood donation or areduction in
weight-bearing training tolessen erythrocyte hemolysis).87
Theintake of iron supplements in theperiod immediately after
strenuousexercise is contraindicated becausethere is the potential
for elevatedhepcidin levels to interfere with ironabsorption.88
Reversing IDA can require3 to 6 months; therefore, it is
advan-tageous to begin nutrition interventionbefore IDA
develops.78,81 Athletes whoare concerned about iron status or
haveiron deficiency without anemia (eg,low ferritin without IDA)
should adopteating strategies that promote anincreased intake of
food sources ofwell-absorbed iron (eg, heme iron andnonheme
ironþvitamin C foods) as thefirst line of defense. Although there
issome evidence that iron supplementscan achieve performance
improve-ments in athletes with iron depletionwho are not anemic,89
athletes shouldbe educated that routine, unmonitoredsupplementation
is not recommended,not considered ergogenic withoutclinical
evidence of iron depletion, andmay cause unwanted
gastrointestinaldistress.89
Some athletes may experience atransient decrease in hemoglobin
atthe initiation of training due to he-modilution, known as
dilutional or
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FROM THE ACADEMY
sports anemia, and may not respond tonutrition intervention.
These changesappear to be a beneficial adaptation toaerobic
training and do not negativelyinfluence performance.79 There is
noagreement on the serum ferritin levelthat corresponds to a
problematiclevel of iron depletion/deficiency, withvarious
suggestions ranging from
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FROM THE ACADEMY
deficiency78,79 and the literature tosupport micronutrient
supplementa-tion is often marred with equivocalfindings and weak
evidence. Despitethis, many athletes unnecessarilyconsume
micronutrient supplementseven when dietary intake
meetsmicronutrient needs. Rather than self-diagnosing the need for
micronutrientsupplementation, when relevant, ath-letes should seek
clinical assessment oftheir micronutrient status within alarger
assessment of their overall di-etary practices. Sports dietitians
canoffer several strategies for assessingmicronutrient status based
on collec-tion of a nutrient intake history alongwith observing
signs and symptomsassociated with micronutrient defi-ciency. This
is particularly importantfor iron, vitamin D, calcium, and
anti-oxidants. By encouraging athletes toconsume a well-chosen diet
focused onfood variety, sports dietitians can helpathletes avoid
micronutrient de-ficiencies and gain the benefits of manyother
performance-promoting eatingstrategies. Public health
guidelinessuch as the DRIs provide micronutrientintake
recommendations for sports di-etitians to help athletes avoid
bothdeficiency and safety concerns associ-ated with excessive
intake. Micro-nutrient intake from dietary sourcesand fortified
foods should be assessedalongside micronutrient intake from
allother dietary supplements.
THEME 2: PERFORMANCENUTRITION: STRATEGIES TOOPTIMIZE PERFORMANCE
ANDRECOVERY FOR COMPETITIONAND KEY TRAINING SESSIONSPre-, During-,
and PosteventEatingStrategies implemented in the pre-,during-, and
postexercise periods mustaddress a number of goals. First
theyshould support or promote optimalperformance by addressing
variousfactors related to nutrition that cancause fatigue and
deterioration in theoutputs of performance (eg, power,strength,
agility, skill, and concentra-tion) throughout or toward the endof
the sporting event. These fac-tors include, but are not limited
to,dehydration, electrolyte imbalances,glycogen depletion,
hypoglycemia, gas-trointestinal discomfort/upset, and dis-turbances
to acid-base balance. Fluids
514 JOURNAL OF THE ACADEMY OF NUTRIT
or supplements consumed before, dur-ing, or in the recovery
betweensessions can reduce or delay the onsetof these factors.
Strategies includeincreasing or replacing key exercisefuels and
providing substrates to returnthe body to homeostasis or
furtheradapt to the stress incurred during aprevious exercise
session. In somecases, pre-event nutrition may need toredress the
effects of other activitiesundertaken by the athlete during
eventpreparation such as dehydration orrestrictive eating
associated with mak-ing weight in weight category sports.A
secondary goal is to achieve gutcomfort throughout the event,
avoid-ing feelings of hunger or discomfortand gastrointestinal
upsets that maydirectly reduce the enjoyment andperformance of
exercise and interferewith ongoing nutritional support. Afinal goal
is to continue to providenutritional support for health andfurther
adaptation to exercise, particu-larly in the case of competitive
eventsthat span days and weeks (eg, tourna-ments and stage
races).Nutrient needs and the practical
strategies for meeting them beforeduring, and after exercise
depend on avariety of factors, including the event(mode, intensity,
and duration of exer-cise), the environment, carryover ef-fects
from previous exercise, appetite,and individual responses and
prefer-ences. In competitive situations, rulesof the event and
access to nutritionalsupport may also govern the opportu-nities for
food intake. It is beyond thescope of this review to provide
furtherdiscussion other than to comment thatsolutions to feeding
challenges aroundexercise require experimentation andhabituation by
the athlete, and areoften an area in which the foodknowledge,
creativity, and practicalexperiences of the sports dietitianmake
valuable contributions to anathlete’s nutrition plan. Such
scenariosare also where the use of sports foodsand supplements are
often most valu-able, because well-formulated productscan often
provide a practical form ofnutritional support to meet
specializednutrient needs.
Hydration Guidelines: Fluid andElectrolyte BalanceBeing
appropriately hydrated contrib-utes to optimal health and
exercise
ION AND DIETETICS
performance. In addition to the usualdaily water losses from
respiration,gastrointestinal, renal, and sweatsources, athletes
need to replace sweatlosses. Sweating assists with the dissi-pation
of heat, generated as a byproductof muscular work but is often
exacer-bated by environment conditions, andthus helps maintain body
temperaturewithin acceptable ranges.104 Dehydra-tion refers to the
process of losingbody water and leads to hypohydra-tion. Although
it is common to inter-change these terms, there are
subtledifferences since they reflect processand outcome.
Through a cascade of events, themetabolic heat generated by
musclecontractions during exercise can even-tually lead to
hypovolemia (decreasedplasma/blood volume) and, thus,
car-diovascular strain, increased glycogenuse, altered metabolic
and central ner-vous system function, and a greaterrise in body
temperature.104-106 Al-though it is possible to be hypohy-drated
but not hyperthermic (definedas core body temperature exceeding40�C
[104�F]),107 in some scenarios theextra thermal strain associated
withhypohydration can contribute to anincreased risk of
life-threatening exer-tional heat illness (ie, heatstroke).
Inaddition to water, sweat contains sub-stantial but variable
amounts ofsodium, with lesser amounts of potas-sium, calcium, and
magnesium.104 Topreserve homeostasis, optimal bodyfunction,
performance, and perceptionof well-being, athletes should strive
toundertake strategies of fluid manage-ment before, during, and
after exercisethat maintain euhydration. Dependingon the athlete,
the type of exercise, andthe environment, there are situationswhen
this goal is more or lessimportant.
Although there is complexity and in-dividuality in the response
to dehydra-tion, fluid deficits of >2% BW cancompromise
cognitive function andaerobic exercise performances, particu-larly
in hot weather.104,105,108,109 Decre-ments in the performance of
anaerobicor high-intensity activities, sport-specific technical
skills, and aerobic ex-ercise in a cool environment are
morecommonly seen when 3% to 5% of BW islost due to
dehydration.104,105 Severehypohydration with water deficits of 6%to
10% BW has more pronounced effectson exercise tolerance, decreases
in
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cardiac output, sweat production, andskin and muscle blood
flow.107
Assuming an athlete is in energybalance, daily hydration status
may beestimated by tracking early morningBW (measured upon waking
and aftervoiding) because acute changes in BWgenerally reflect
shifts in body water.Urinary specific gravity and urineosmolality
can also be used to approxi-mate hydration status by measuring
theconcentration of the solutes in urine.When assessed from a
midstreamcollection of the first morning urinesample, a urinary
specific gravity of
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FROM THE ACADEMY
fluids, especially extracellular fluids,including plasma volume.
Therefore,athletes should not be advised torestrict sodium in their
postexercisenutrition particularly when large so-dium losses have
been incurred.Because sweat losses and obligatoryurine losses
continue during the post-exercise phase, effective
rehydrationrequires the intake of a greater volumeof fluid (eg,
125% to 150%) than the finalfluid deficit (eg, 1.25 to 1.5 L fluid
forevery 1 kg BW lost).104,106 Excessiveintake of alcohol in the
recovery periodis discouraged due to its diuretic ef-fects.
However, the previous warningsabout caffeine as a diuretic appear
tobe overstated when it is habituallyconsumed in moderate (eg, 90
minutes induration may benefit from higher
516 JOURNAL OF THE ACADEMY OF NUTRIT
glycogen stores,118 which can be ach-ieved by a technique known
as carbo-hydrate loading. This protocol ofachieving
supercompensation of muscleglycogen evolved from the
originalstudies of glycogen storage in the 1960sand, at least in
the case of trained ath-letes, can be achieved by extendingthe
period of a carbohydrate-rich dietand tapering training over 48
hours36
(Table).Carbohydrate consumed in meals
and/or snacks during the 1 to 4 hourspre-exercise may continue
to increasebody glycogen stores, particularly liverglycogen levels
that have beendepleted by the overnight fast.117 Itmay also provide
a source of gutglucose release during exercise.117 Car-bohydrate
intakes of 1 to 4 g/kg, withtiming, amount, and food choicessuited
to the individual, have beenshown to enhance endurance or
per-formance of prolonged exercise(Table).117,119 Generally, foods
with alow-fat, low-fiber, and low-moderateprotein content are the
preferredchoice for this pre-event menu becausethey are less prone
to cause gastroin-testinal problems and promote gastricemptying.120
Liquid meal supplementsare useful for athletes who
experiencepre-event nerves or an uncertain pre-event timetable and,
thus, prefer amore quickly digested option. Aboveall, the
individual athlete shouldchoose a strategy that suits their
situ-ation and their past experiences andcan be fine-tuned with
furtherexperimentation.The intake of carbohydrate before
exercise is not always straightforwardbecause the metabolic
effects of theresulting insulin response include areduction in fat
mobilization and useand concomitant increase in carbohy-drate
use.119 In some individuals, thiscan cause premature fatigue.121
Strate-gies to circumvent this problem includeensuring at least 1
g/kg carbohydrate inthe pre-event meal to compensate forthe
increased carbohydrate oxidation,including a protein source at
themeal, including some high-intensity ef-forts in the pre-exercise
warm up tostimulate hepatic gluconeogenesis, andconsuming
carbohydrate during theexercise.122 Another approach has
beensuggested in the form of choosing pre-exercise meals from
carbohydrate-richfoods with a low glycemic index,which might reduce
the metabolic
ION AND DIETETICS
changes associated with carbohydrateingestion as well as
providing a moresustained carbohydrate release duringexercise.
Although occasional studieshave shown that such a strategy
en-hances subsequent exercise capacity,123
as summarized by the EAL (Figure 1,Question #11) and others,119
pre-exercise intake of low glycemic indexcarbohydrate choices has
not beenfound to provide a universal benefit toperformance even
when the metabolicperturbations of pre-exercise carbohy-drate
intake are attenuated. Further-more, consumption of
carbohydrateduring exercise, as further advised inthe Table,
dampens any effects of pre-exercise carbohydrate intake on
meta-bolism and performance.124
Depending on characteristics,including the type of exercise,
theenvironment, and the athlete’s prepa-ration and carbohydrate
tolerance, theintake of carbohydrate during exerciseprovides a
number of benefits to exer-cise capacity and performance
viamechanisms such as glycogen sparing,provision of an exogenous
musclesubstrate, prevention of hypoglycemia,and activation of
reward centers in thecentral nervous system.116 Robustliterature on
exercise carbohydratefeeding has led to the recognition
thatdifferent amounts, timing, and types ofcarbohydrate are needed
to achievethese different effects, and that thedifferent effects
may overlap in variousevents.36,125 The Table summarizes thecurrent
guidelines for exercise fueling,noting opportunities where it may
playa metabolic role (events of >60 to 90minutes) and the newer
concept of“mouth sensing,” where frequentexposure of the mouth and
oral cavityto carbohydrate is likely to be effectivein enhancing
workout and pacingstrategies via a central nervous systemeffect.126
Of course, the practicalachievement of these guidelines needsto fit
the personal preferences and ex-periences of the individual
athlete, andthe practical opportunities providedin an event or
workout to obtainand consume carbohydrate-containingfluids or
foods. A range of everydayfoods and fluids and formulated
sportsproducts that include sports beveragesmay be chosen to meet
these guide-lines; this includes newer productscontaining mixtures
of glucose andfructose (the so-called multiple trans-portable
carbohydrates) that aim to
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increase total intestinal absorption ofcarbohydrates.127
Although this couldbe of use in situations of prolongedexercise
where higher rates of exoge-nous carbohydrate oxidation
mightsustain work intensity in the face ofdwindling muscle glycogen
stores, theEAL found that evidence for benefits iscurrently
equivocal (Figure 1, Question#9).Glycogen restoration is one of
the
goals of postexercise recovery, partic-ularly between bouts of
carbohydrate-dependent exercise where there is apriority on
performance in the secondsession. Refueling requires
adequatecarbohydrate intake (Table) and time.Because the rate of
glycogen resyn-thesis is only w5% per hour, earlyintake of
carbohydrate in the recoveryperiod (w1 to 1.2 g/kg/h during
thefirst 4 to 6 hours) is useful in maxi-mizing the effective
refueling time.117
As long as total intake of carbohydrateand energy is adequate
and overallnutritional goals are met, meals andsnacks can be chosen
from a variety offoods and fluids according to personalpreferences
of type and timing ofintake.36,117 More research is needed
toinvestigate how glycogen storagemight be enhanced when energy
andcarbohydrate intakes are suboptimal.
Protein Intake GuidelinesProtein consumption in the
immediatepre- and postexercise period is oftenintertwined with
carbohydrate con-sumption because most athletesconsume foods,
beverages, and supple-ments that contain
bothmacronutrients.Dietaryprotein consumed in scenarios
oflow-carbohydrate availability128 and/orrestricted energy intake53
during theearly postexercise recovery period hasbeen found to
enhance and accelerateglycogen repletion. For example, it hasbeen
established that recovery of per-formance129 and glycogen
repletionrates53 were similar in athletesconsuming 0.8 g
carbohydrate/kgBWþ0.4gprotein/kgBWcomparedwithathletes consuming
only carbohydrate(1.2 g/kg BW). This may support
exerciseperformance and benefit athletesfrequently involved in
multiple trainingor competitive sessions over the sameday or
successive days.Although protein intake may support
glycogen resynthesis and, when con-sumed in close proximity to
strength
March 2016 Volume 116 Number 3
and endurance exercise, enhancesMPS,59,130 there is a lack of
evidencefrom well-controlled studies that pro-tein supplementation
directly im-proves athletic performance.131,132
However, a modest number of studieshave reported that ingesting
w50 to100 g protein during the recoveryperiod leads to accelerated
recovery ofstatic force and dynamic power pro-duction during
delayed onset musclesoreness.133,134 Despite these findingsother
studies show no performanceeffects from acute ingestion of
proteinat intake levels that are much morepractical to consume on a
regular basis.Furthermore, studies that imply posi-tive findings
when the control groupreceives a flavored water placebo133 ora
placebo that is not isocaloric are un-able to rule out the
influence of post-exercise energy provision on theobserved
effect.134
Protein ingestion during exerciseand during the pre-exercise
periodseems to have less of an influence onMPS than the
postexercise provisionof protein but may still enhancemuscle
reconditioning depending onthe type of training that takes
place.Coingestion of protein and carbohy-drate during 2 hours of
intermittentresistance-type exercise has beenshown to stimulate MPS
during theexercise period135 and may extend themetabolic adaptation
window partic-ularly during ultraendurance-typeexercise bouts.136
Potential benefitsof consuming protein before and dur-ing exercise
may be targeted to ath-letes focused on the MPS response
toresistance exercise and those lookingto enhance recovery from
ultra-endurance exercise.EAL Questions #5 to #7 (Figure 1)
summarize the literature on consumingprotein alone or in
combination withcarbohydrate during recovery onseveral outcomes.
More work is neededto elucidate the relevance and practi-cality of
protein consumption on sub-sequent exercise performance and
ifmechanisms in this context are exclu-sive to accelerating muscle
glycogensynthesis. The utility of a protein sup-plement should also
be measuredagainst the benefits of consuming pro-tein or amino
acids from meals andsnacks that are already part of a
sportsnutrition plan to meet other perfor-mance goals.
JOURNAL OF THE ACAD
Dietary Supplements andErgogenic AidsExternal and internal
motives toenhance performance often encourageathletes to consider
the enticing mar-keting and testimonials surroundingsupplements and
sports foods. Sportssupplements represent an ever-growing industry,
but a lack of regula-tion of manufacture and marketingmeans that
athletes can fall victim tofalse advertising and
unsubstantiatedclaims.137 The prevalence of supple-mentation among
athletes has beenestimated internationally at 37% to89%, with
greater frequencies beingreported among elite and older ath-letes.
Motivations for use includeenhancement of performance or re-covery,
improvement or maintenanceof health, an increase in
energy,compensation for poor nutrition, im-mune support, and
manipulation ofbody composition,138,139 yet few ath-letes undertake
professional assess-ment of their baseline nutrition-relatedhabits.
Furthermore, athletes’ supple-mentation practices are often
guidedby family, friends, teammates, coaches,the Internet, and
retailers, rather thansports dietitians and other sport sci-ence
professionals.138
Considerations regarding the use ofsports foods and supplements
includean assessment of efficacy and potency.In addition, there are
safety concernsdue to the presence of overt and hid-den ingredients
that are toxic andthe poor practices of athletes inconsuming
inappropriately largedoses or problematic combinations ofproducts.
The issue of compliance toantidoping codes remains a concernwith
potential contamination withbanned or nonpermissible
substances.This carries significant implications forathletes who
compete under antidop-ing codes (eg, National CollegiateAthletic
Association or World Anti-Doping Agency).139 A
supplementmanufacturer’s claim of “100% pure,”“pharmaceutical
grade,” “free of ban-ned substances,” “Natural HealthProduct e
NHPN/NPN” (in Canada) orpossessing a drug identification num-ber
are not reliable indications thatguarantee a supplement is free
ofbanned substances. However, com-mercial, third-party auditing
programscan independently screen dietarysupplements for banned and
restricted
EMY OF NUTRITION AND DIETETICS 517
-
Category Examples Use Concerns Evidence
Sports food Sports drinksSports barsSports confectionerySports
gelsElectrolyte supplementsProtein supplementsLiquid meal
supplements
Practical choice to meetsports nutrition goalsespecially when
access tofood, opportunities toconsume nutrients,
orgastrointestinal concernsmake it difficult toconsume traditional
foodand beverages
Cost is greater than wholefoodsMay be used unnecessarily or
ininappropriate protocols
Burke andCato(2015)141
Medicalsupplements
Iron supplementsCalcium supplementsVitamin D
supplementsMultivitamin/mineraln-3 Fatty acids
Prevention or treatmentof nutrient deficiencyunder the
supervision ofappropriate medical/nutrition expert
May be self-prescribedunnecessarily withoutappropriate
supervision ormonitoring
Burke andCato(2015)141
Specificperformancesupplements
Ergogenic effects Physiological effects/mechanism ofergogenic
effect
Concerns regarding usea Evidence
Creatine Improves performance ofrepeated bouts of high-intensity
exercise withshort recovery periods
- Direct effect oncompetitionperformance
- Enhanced capacityfor training
Increases creatine andphosphocreatineconcentrationsMay also have
othereffects such asenhancement ofglycogen storage anddirect effect
on muscleprotein synthesis
Associated with acute weightgain (0.6-1 kg), which may
beproblematic in weight-sensitivesportsMay cause
gastrointestinaldiscomfortSome products may notcontain appropriate
amounts orforms of creatine
Tarnopolsky(2010)143
Caffeine Reduces perception offatigueAllows exercise to
besustained at optimalintensity/output forlonger
Adenosine antagonistwith effects on manybody targets,
includingcentral nervous systemPromotes Ca2þ releasefrom
sarcoplasmicreticulum
Causes side effects (eg, tremor,anxiety, increased heart
rate)when consumed in high dosesToxic when consumed in verylarge
dosesRules of National CollegiateAthletic Associationcompetition
prohibit the intakeof large doses that produceurinary caffeine
levelsexceeding 15 mg/mLSome products do not disclosecaffeine dose
or may containother stimulants
Astorino andRoberson(2010)144
Tarnopolsky(2010)143
Burke andcolleagues(2013)145
Sodiumbicarbonate
Improves performance ofevents that wouldotherwise be limited
byacid-base disturbancesassociated with high
When taken as an acutedose pre-exercise,increases
extracellularbuffering capacity
May cause gastrointestinal side-effects that cause
performanceimpairment rather than benefit
Carr andcolleagues(2011)146
(continued on next page)
Figure 2. Dietary supplements and sports foods with
evidence-based uses in sports nutrition. These supplements may
perform asclaimed but inclusion does not imply endorsement by this
position stand.
FROM THE ACADEMY
518 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS March 2016
Volume 116 Number 3
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Category Examples Use Concerns Evidence
rates of anaerobicglycolysis
- High-intensityevents of 1-7 min
- Repeated high-in-tensity sprints
- Capacity for high-intensity “sprint”during
enduranceexercise
b-alanine Improves performance ofevents that wouldotherwise be
limited byacid-base