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Names: Benardot, Dan, 1949– author.

Title: ACSM’s nutrition for exercise science / Dan Benardot, PhD, DHC, RD,LD,
FACSM, Professor of Nutrition, Emeritus, Georgia State Universityl,Atlanta,
Georgia.
Description: Philadelphia : Wolters Kluwer Health, 2018. | Includesbibliographical
references and index.
Identifiers: LCCN 2018028069 | eISBN 9781975134167
Subjects: LCSH: Athletes—Nutrition. | Exercise—Physiological aspects. |
BISAC: MEDICAL / Allied Health Services / Physical Therapy.
Classification: LCC RC1235 .B46 2018 | DDC 613.7/11—dc23LC record available
at https://lccn.loc.gov/2018028069

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 DEDICATION
To my loving and wonderfully supportive wife, Robin, and other members of my
supportive and loving family—Jake, Lexie, Eva, Nora, Leah, Ethan, Evan, Zoe,
Edoardo, Olivia, and Alex.
The year was 1993. My family and I had settled into
university life in Hattiesburg, Mississippi. I had been at the
University of Southern Mississippi for nine years after having
spent the first six years of my career at Swedish Covenant
Hospital in Chicago in hospital administration. I traveled to
Georgia State University in Atlanta a few times doing
American College of Sports Medicine certification workshops,
so I knew the university well—or at least I thought so.
In the fall of 1993, I received a phone call from the
department chair of kinesiology and health who was looking
for an interdisciplinary research center director. The center
was to be housed in two colleges and the director would
have two bosses, both college deans. This situation was not
at all attractive, and reporting to two deans was predictably
a disaster. Reluctantly, I found myself being called for an
interview to a job that was never going to be successful. I
traveled to Atlanta to meet with the search committee co-
chairs, the department of kinesiology and health chair, and
the person representing the department of nutrition, Dan
Benardot.
Sitting in an Outback Steakhouse presumably to talk
about the new center director position, Dan introduced
himself not as the world-renowned sports nutritionist that I
knew him to be but as the loving dad of two great kids. We
discovered at that first meeting that our two oldest children,
Jake and Jessica, were born on the exact same day, month,
and year. We also discovered that our second children, Leah
and Aaron, were the same age. Now 25 years later we have
worked together, cried a little, and laughed a lot. He is not
only one of the most well-known, highly respected, and an
internationally recognized expert, but also my friend.
Needless to say, I took that job 25 years ago and never
looked back.
ACSM’s Nutrition for Exercise Science is a book that will
make an extraordinary impact both in the classroom and in
health clubs all over the world. It is the first of its kind to be
written by a nutritionist for exercise science students. Fitness
professionals working in corporate wellness programs,
medical fitness centers, community-based organizations, and
commercial clubs will find this book to be a great resource
when counseling clients and members.
The book starts with an introduction like no other. Dr.
Benardot has been the nutritionist to many athletes
including Olympic gold medalists and champions of elite
marathons, and so the first chapter, the one that provides
guiding principles when working with athletes, provides the
groundwork for the rest of the book. Chapter 1 is followed by
discussions of carbohydrates, protein, lipids, vitamins, and
minerals. Chapters 7 through 14 include specific topics of
hydration, managing body weight and body composition,
muscle soreness, muscle recovery following exercise, age
and gender, travel, dietary supplements and ergogenic aids,
athlete health, disease, and injury. The last chapter provides
diet planning, a chapter seldom seen in books on nutrition.
The American College of Sports Medicine is extraordinarily
fortunate to have Dr. Dan Benardot author this book. He is
the world’s authority on sports nutrition, and I have been so
very fortunate for the past 25 years to call him my friend.

Walt Thompson
Walter R. Thompson, PhD, FACSM
61st President of the American College of Sports Medicine
(2017–2018)
Only until recently, general guidelines were available to help
athletes achieve their very best. They were predictably
vague, and only a few “experts” would agree on the advice.
The scientific knowledge in the field of sports nutrition today,
however, is rapidly expanding and increasingly providing
science-based and situation-specific recommendations. The
information now available is specific to the sport, age,
gender, ability, and conditioned capacity of the athlete. In
the past, for example, we may have recommended the
consumption of water or a nondescript sports beverage to
help an athlete achieve and/or sustain a desired hydration
state. Contemporary recommendations include volume,
temperature, electrolyte concentration and composition, and
energy substrate concentration and composition for different
aspects of the athletic endeavor, including what is
recommended before, during, and after training/competition.
The science of sports nutrition is also changing long-held
beliefs about how athletes should eat and drink to perform at
their highest potential. The belief that if a small amount of
any nutrient is good for you then more must be better is
pervasive in sporting environments. This belief is
increasingly being unraveled with scientific information
suggesting that more than enough is not better than enough,
with recent evidence suggesting that excessive intakes of
even water-soluble vitamins, once thought to be benign
when taken at even high doses, may increase acute and
chronic disease risks. The heavy consumption of protein,
long believed to be the “magic” ingredient in any athlete’s
diet, is now put into proper perspective with both limitations
on how much is useful and optimal strategies for
consumption. Importantly, excessively high consumption of
protein invariably results in low consumption of
carbohydrate, which is also a key ingredient in athletic
performance but inappropriately avoided by many because
of a fear that it is fat producing.
The old paradigm of calories-in–calories-out has been
refined, as we now have good evidence suggesting that
energy availability in real time is critically important and that
randomly satisfying the energy requirement is not sufficient.
We have come to learn that even an athlete who has
satisfied energy needs in a 24-hour period may still be at risk
for hormonal and body composition struggles if the timing of
energy consumption has resulted in periods of significant
energy balance deficits. The paradigm for energy intake has
shifted to one that should encourage athletes to eat in a way
that dynamically satisfies energy expenditure in real time
rather than in three daily doses. The endocrine system really
does work in real time. Imagine the pancreas waiting until
day’s end to assess what and how much food was consumed
earlier in the day as a way of determining how much insulin
it should produce. It just does not happen that way, but the
traditional calories-in–calories-out strategy assumes
precisely that. A key emphasis for this book, therefore, is to
break through our old understandings of how athletes and
physically active people should eat and drink to optimize
performance by providing an interpretation of the new
nutrition science so it can be applied to exercise science.
Included in an enormous body of new scientific literature in
sports nutrition are many recent publications that have
provided key information for this endeavor, including the
joint position statement on Nutrition and Athletic
Performance from the American College of Sports Medicine,
the Academy of Nutrition and Dietetics, and Dietitians of
Canada; the recently published International Olympic
Committee (IOC) consensus on Dietary Supplements and the
High-Performance Athlete; the IOC consensus on Relative
Energy Deficiency in Sport; and several publications on the
impact of within-day energy deficiency in male and female
athletes.
Ultimately, this book was written to make the science
accessible and applicable to undergraduate and graduate
student majors of exercise science and others who work with
athletes or physically active people. Nutrition has an impact
on multiple areas, including injury prevention and injury
recovery, muscle and skeletal development, exercise
recovery, psychological sense of well-being, general health,
and resistance to illness. Under ideal circumstances, all
members of the sports medicine team, including sports
nutritionists, exercise physiologists, sports medicine
physicians, sports psychologists, and athletic trainers, should
have some understanding of how nutrition will affect their
specific areas of expertise. Therefore, while the primary
focus of this book is to help exercise science students
understand the science of sports nutrition, it can also help
others on the sports medicine team understand the scientific
basis of important nutritional issues that have an impact on
athlete health and performance. By doing so, this book will
contribute to the cohesiveness and functionality of the sports
medicine team and to the ultimate benefit of the athlete.
This book is also likely to find other readers who have an
interest in athlete health and success, including parents and
coaches.
Since an important goal of this book is to make the
science accessible, easily understood, and applicable, any
reader in a college/university should be capable of reading
and understanding the book contents without prerequisite
knowledge. A number of courses are taught at the
undergraduate and/or beginning graduate level for which
this book would be appropriate, including courses with titles
such as Nutrition for Physical Activity, Nutrition for Exercise
Science, Sports Nutrition, and related titles. Assuming the
student is in any field related to applied science and public
health, there should be no course prerequisites needed to
take a course using this book.

Organization and Special Features

An important goal of this book is to make it a comprehensive

source of nutrition information that relates to athletic needs.
All chapters begin with a Case Study that provides a real-
world example of the potential problems an athlete can face,
followed by Case Study Discussion Questions. Logical
and practical solutions are reinforced in each subsequent
chapter. Throughout the book, the chapters emphasize the
science while making the science accessible and applicable.
This is true for each chapter, as follows:

Chapter 1 provides an overview of critical issues and

terms, common myths, an introduction to nutrients, and
information on standards of nutrient intake adequacy.
Each topic covered in Chapter 1 is covered in much
greater detail in the subsequent chapters.
Chapters 2, 3, and 4 cover the energy substrates
(carbohydrate, protein, and fat) with the same goal of
breaking through myths by providing the science in a
way that demonstrates how to make the right
recommendations to athletes seeking to perform at their
highest potential.
Chapters 5 (vitamins) and 6 (minerals) review the many
myths of vitamins and minerals, while providing
strategies to assure adequate intakes and avoiding
deficiencies and/or toxicities.
Chapter 7 addresses the critically important issue of
hydration and related problems associated with
consuming the wrong fluid in inappropriate volumes,
which at times fails to satisfy optimally the nutritional
requirement.
Chapter 8 focuses on the importance of assessing body
composition rather than body weight (mass) to better
understand the energy and nutrient needs that help the
athlete achieve a physique associated with improved
performance.
Chapter 9 provides information on how modifications in
nutrient intake can alter oxygen transport and utilization
to working muscles, and how doing the right things
nutritionally can also help to improve muscle recovery
and reduce muscle soreness.
Chapter 10 emphasizes that athletes of different ages
and genders may well have different nutritional needs. A
failure to understand these differences may compromise
an athlete’s potential for optimal performance and could
predispose the athlete to nutritional complications that
may compromise health.
Chapter 11 takes a close look at how athletes involved
in different sports (i.e., power, endurance, and team)
may well face different nutritional needs that, unless
satisfied, may have an impact on athletic performance.
Chapter 12 covers how travel and environmental
conditions affect nutritional requirements, with strategies
that can help to lower nutritional risks.
Chapter 13 expands on Chapters 5 and 6 by reviewing
more information on dietary supplements and aids that
are intended to improve performance. There are many
myths uncovered in this chapter, which make it a must-
read for anyone working with athletes. Ideally,
involvement in sports should be health enhancing,
particularly if the correct nutritional strategies are
followed.
Chapter 14 addresses nutritional issues that relate to
athlete health so that those who work with athletes have
 a better long-term view of how the strategies that are
followed today have implications for athlete health
tomorrow.
Chapter 15 focuses on practical issues related to diet
planning by pulling in the information provided earlier in
the book that answers this question: Now that I have the
science, how should I eat to achieve my goals? The
chapter is packed with practical information that includes
dietary assessment strategies and practical information
for how to satisfy needs in different sports that have
different natural breaks (i.e., half-time, intermission,
etc.), different training durations (marathoners need
different nutrition strategies than do sprinters), and how
to eat before, during, and after training.

Several special features appear frequently throughout the

book to enhance the learning experience:

Glossary boxes are placed near the first bolded

mention of terms for easy reference.
Important Factors to Consider emphasizes selected
key points for the reader to keep in mind.
Examples are used to help the student work through
specific applications of the information.
Plentiful tables and figures support the content and
illustrate complex concepts.

Each chapter ends with the following:

Practical Application Activity providing the reader an

opportunity to apply what was learned in the chapter to
a real-world situation
Chapter Questions for student review, along with
Answers to Chapter Questions
Summary of bulleted points providing chapter highlights
References researched and culled from the most up-to-
date evidence-based science
 The information-rich Appendices provide key reference
materials (Dietary Reference Intakes, nutrient content of
high-risk nutrients, etc.), and a sample health history
questionnaire. The appendix also provides a doorway to
online resources, which include sample dietary analyses and
nutrition problem resolution strategies for both male and
female athletes of different ages and in different sports.

A Comprehensive Resource

From beginning to end, this first edition of Nutrition for

Exercise Science is intended to provide the reader with a
comprehensive resource to help guide the nutritional advice
given to athletes and to know when it is appropriate to make
a referral to a credentialed health professional (e.g.,
registered dietitian, physician, certified athletic trainer) when
the athlete’s condition necessitates a referral.
It is with high hopes that you will find this book to be
useful in your professional and sporting activities.

Dan Benardot
Professor of Nutrition, Emeritus
Georgia State University
Atlanta, Georgia

Online-Only Resources

ACSM’s Nutrition for Exercise Science includes additional

resources for students and instructors that are available on
the book’s companion Web site at http://thepoint.lww.com.
Students can access:

Question Bank
Critical Nutrient Content appendices
 Sample Athlete Food Plans

Approved adopting instructors will be given access to the

following resources:

Test Generator
PowerPoints
Case Studies

See inside the front cover of this text for more details,
including the passcode you will need to gain access to the
Web site.
Updates for the book can be found at
http://certification.acsm.org/updates.
There are far too many people to name who have helped
give me the energy and guidance required to put together a
book like this, but there are several people who are always
available when I need advice, feedback, and edits, and I
want to mention them by name. Interestingly, all of these
people are excessively busy in their own endeavors, but they
seem to always be available when assistance is requested.
When I need initial advice on whether I’m barking up the
right tree, there is nobody better than my dietitian wife
Robin, who is always willing and honest with her feedback in
the best possible way. My long-time friend and colleague, Dr.
Walt Thompson, professor of kinesiology and health and
professor of nutrition, always finds time to discuss what I’m
thinking about writing and is also a superb editor of my initial
drafts. Dr. Sid Crow, a recently retired professor of biology
and a close colleague, really knows cells and how they work.
Ultimately, everything in nutrition involves a cellular
response, and Sid always leads me down the right garden
path. Two of my past graduate students, Moriah Bellissimo
and Ashley Delk Licata, both now attending prestigious
universities to complete PhDs, have been terrific sounding
boards on this book with fresh perspectives on how to best
communicate ideas to undergraduate students. The
American College of Sports Medicine assigned Angela
Chastain as development editor to work with me on
submitting chapters and chapter edits, and Angie has been
an absolutely wonderful colleague in this process. The
publisher, Wolters Kluwer, assigned Robin Levin Richman as
development editor, and she also has been a phenomenal
person to work with. All of these people, and many more at
Georgia State University and the publisher, including Amy
Millholen, have made this book possible. I gratefully
acknowledge their significant contributions to this book and
offer my sincere thanks to all of them.
Katherine A. Beals, PhD, FACSM
University of Utah
Salt Lake City, Utah

Louise M. Burke, PhD, FACSM

Australian Institute of Sport
Belconnen, Australian Capital Territory, Australia

Cory L. Butts, PhD

University of Arkansas
Fayetteville, Arkansas

Sara Chelland Campbell, PhD, FACSM

Rutgers University
New Brunswick, New Jersey

Nancy Clark, RD CSSD, FACSM

Sports Nutrition Counselor
Newton Highlands, Massachusetts

Warren D. Franke, PhD, FACSM

Iowa State University
Ames, Iowa

Raquel C. Garzon, DHSc, RDN

Revitalize Project, Inc.
Las Cruces, New Mexico
Tanya M. Halliday, PhD, RD
University of Colorado School of Medicine
Aurora, Colorado

Linda K. Houtkooper, PhD, RD, FACSM

University of Arizona
Tucson, Arizona

Laura J. Kruskall, PhD, FACSM, ACSM-EP, ACSM-EIM2

University of Nevada
Las Vegas, Nevada

D. Enette Larson-Meyer, PhD, FACSM

University of Wyoming
Laramie, Wyoming

Ronald J. Maughan, PhD, FACSM

University of St. Andrews
St Andrews, Fife, Scotland
United Kingdom

Brendon P. McDermott, PhD, ATC, FACSM

University of Arkansas
Fayetteville, Arkansas

Douglas Paddon-Jones, PhD, FACSM

University of Texas
Galveston, Texas

Kelly Pritchett, PhD, RDN, CSSD

Central Washington University
Ellensburg, Washington

Amy D. Rickman, PhD, FACSM

Slippery Rock University
Slippery Rock, Pennsylvania
Nancy R. Rodriguez, PhD, FACSM
University of Connecticut
Storrs Mansfield, Connecticut

Thomas H. Trojian, MD, FACSM

Drexel University
Philadelphia, Pennsylvania

Stella L. Volpe, PhD, RD, FACSM, ACSM-CEP

Drexel University
Philadelphia, Pennsylvania
Foreword
Preface
Acknowledgments
Reviewers
1 The Bottom Line — Guiding Nutrition Principles for
the Athlete
2 Carbohydrates
3 Protein
4 Lipids
5 Vitamins: Good Foods Give You What You Need
6 Minerals: Important for Health and Performance
7 Hydration Issues in Athletic Performance
8 Managing Weight and Body Composition in Athletes
9 Nutrition Issues Related to Oxygen Transport and
Utilization, Reducing Muscle Soreness, and Improving
Muscle Recovery
10 Optimizing Nutrition Strategies for Age and Sex
11 Nutrition Strategies for Power, Endurance, and
Combined Power/Endurance Sports
12 Impact of Travel, High Altitude, High Heat, and
Humidity on Nutrition
13 Dietary Supplements, Foods, and Ergogenic Aids
Intended to Improve Performance: Myths and
Realities
14 Nutritional Issues Related to Athlete Health, Disease,
 and Injury
15 Diet Planning for Optimal Performance
Appendix A Uses of Dietary Reference Intakes for
Healthy Individuals and Groups
Appendix B Dietary Reference Intakes (DRIs):
Recommended Dietary Allowances and Adequate
Intakes, Elements
Appendix C Dietary Reference Intakes (DRIs):
Tolerable Upper Intake Levels (ULs), Elements
Appendix D Dietary Reference Intakes (DRIs):
Recommended Dietary Allowances and Adequate
Intakes, Vitamins
Appendix E Dietary Reference Intakes (DRIs):
Tolerable Upper Intake Levels, Vitamins
Appendix F Dietary Reference Intakes (DRIs):
Recommended Dietary Allowances and Adequate
Intakes, Total Water, and Macronutrients
Appendix G Dietary Reference Intakes (DRIs):
Acceptable Macronutrient Cholesterol, Fatty Acid, and
Added Sugars Recommended Intake Ranges
Appendix H Principles and Components of a Sample
Nutrition Assessment
Appendix I Calcium Content of Foods Within Food
Categories (From High to Low)
Appendix J Iron Content of Foods Within Food
Categories (From High to Low)
Appendix K Digestion and Absorption
Appendix L Case Study: A Runner Having Difficulty
Achieving Her Goal
Index
CHAPTER OBJECTIVES
Introduce the basic rules of nutrition that can and should be
considered for enhancing both athlete health and
performance.
Compare the important ways that nutrition and physical
activity interact, demonstrating that a focus on one without
the other is likely to result in below-optimal outcomes.
Discuss the possible factors associated with athletes who are
poorly nourished, including issues related to sport tradition,
nutrition misinformation, excessive food restriction related to
wishing to achieve a desired weight, food allergies,
intolerances, and sensitivities.
Introduce the classes of nutrients that include water,
vitamins, minerals, protein, fats, and carbohydrates and how
each is important for health and the athletic endeavor.
Verify the importance of achieving a balance between
nutrients, as overemphasizing a single nutrient over others
results in poor health and performance outcomes.
Assess the differences between essential and nonessential
nutrients, showing that these nutrients are all required, but
that humans have the capacity to manufacture the
nonessential nutrients, provided there has been sufficient
consumption of essential nutrients.
Identify available dietary guidelines and dietary reference
intakes (DRIs), and how these are best used with physically
 active people.
Examine physical activity guidelines for different age groups
and their purpose.
Identify information on how to read and interpret food labels,
and meaning of common terms used on food labels.
Recall position statements on nutrition and athletic
performance that have been jointly published by professional
groups, including the American College of Sports Medicine
(ACSM), the Academy of Nutrition and Dietetics (AND), and
the Dietitians of Canada (DOC).
Identify position stands published by the ACSM that relate to
the athletic endeavor, including positions on bone health,
cardiovascular fitness, and the Female Athlete Triad.
Critique information on common nutritional myths, and how
these myths detract from achieving good health and athletic
performance.
Introduce the types of research commonly used to obtain
nutritional information, presenting the relative strengths and
weaknesses of different types of research studies.
Explore information on scope of practice, providing basic
information on what types of nutrition information can legally
be provided to individuals.

Case Study

John, a new college student and former high school athlete, is

majoring in exercise science to become a certified athletic
trainer. As with many other fellow students, he carries with
him many nutrition beliefs. He believes, for instance, that it is
a terrible thing to consume too few vitamins and minerals, as
the health outcome would be devastating. He also believes
that the vitamin supplements he took during his high school
days helped his athletic performance. These supplements,
depending on the nutrient, had between 200% and 800% of
the recommended daily intake, but this was no problem
because having more vitamins and minerals than tissue
requirements can only help — it is having too little that is the
problem.
 He also did a good deal of dieting during his high school
days on the recommendation of his coaches, to help make
him a bit lighter and quicker. He is a bit “heavy” now, so he is
planning on dieting again to get down to his ideal weight. One
of his favorite ways to diet is to skip breakfast, as that is easy
and he does not have to think about reducing the size of his
meals later in the day. He also makes sure to not eat anything
after 7:00 PM, as everyone knows that eating late at night will
make you fat. John still tries to exercise most days for about
90 minutes of treadmill running and weights and makes sure
to always have water available to drink.
Then John took a class on nutrition and physical activity
and came to realize that virtually all of his beliefs about
nutrition were wrong. Having excessively large amounts of
nutrients on a regular basis could cause problems; not eating
something at night may result in a negative energy balance
that lowers lean mass and increases fat mass; dieting may
make people fatter; drinking water, instead of a fluid that
contains carbohydrate and electrolytes, may serve to reduce
performance. John has come to learn that nutrition is a
science, and common beliefs about nutrition often serve to
make matters worse rather than better.

CASE STUDY DISCUSSION QUESTIONS

1. What do you think were the errors that John made about
his weight?
2. Was it okay for John to take these supplements? If not,
what would you change?
3. Is weight a good measure to determine if someone is
exercising and eating well?
4. If you were a coach, and you wanted someone to achieve
desirable performance fitness, what would you tell this
person to do nutritionally?
5. How would you know if they were successful in achieving
the fitness goal?
 Introduction to Sports Nutrition

Nutrition is an applied science with guidelines and principles

that, with many years of scientific evidence, are known to be
associated with disease resistance, enhanced injury recovery,
better physical performance, and an improved sense of well-
being. Nevertheless, there is tremendous pressure from media,
friends, and the workplace environment to breach these
guidelines and principles, with the enticement that there is a
better, easier, faster, and more effective way to achieve better
health and improved performance. In truth, there is no magic
bullet that can satisfactorily overcome poor nutritional habits, and
believing that there is creates a delusional mindset that does
nothing more than make it more difficult to achieve the desired
performance result. Importantly, the guiding science-based
nutrition principles for achieving enhanced health and
performance are relatively simple to follow and, if persistently
pursued, are likely to be self-motivating. That is, following these
rules will make people feel discernibly better and motivate them
to continue doing the right nutritional things. This chapter
presents an overview of guiding nutrition principles that are
applicable to all athletes (Box 1.1).

Box 1.1 Basic Guidelines of Nutrition

1. More than enough is not better than enough

If a small amount of nutrient is needed to ensure optimal
health, having more than this amount is not necessarily
better and may cause problems. For instance, if you need
“X” amount of protein, having more than that is not better
and creates problems by reducing the intake of other
required nutrients.
2. Eating a wide variety of foods is necessary to ensure exposure
to needed nutrients.
There is no such thing as a perfect food that contains all
the nutrients in perfect proportion to cellular needs.
 Consumption of a wide variety of foods is necessary to
ensure optimal nutrient exposure.
3. Eat enough to satisfy energy and nutrient needs in real time.
There should be a dynamic relationship between the
requirement for energy and nutrients, and the
consumption of energy and nutrients. Never overfill the
tank, and never let it go empty. It is not possible to drive
from New York City to San Francisco by providing the car
all the fuel it needs for the trip on arrival in San Francisco.
The human body cannot do that either.

Nutrition

A biological science that focuses on the nutrients consumed and

how these nutrients are involved in development, tissue
metabolism and repair, and health. This term is often misused
as follows: “John’s nutrition is good.” A more appropriate
sentence would be: “John’s nutrient intake is good” or “John’s
nutriture is good.”

Nutriture

The current nutritional status of an individual often used in

reference to a specific nutrient. Example: Jane’s iron nutriture is
excellent.

Nutritional Status

The degree to which tissue requirements for nutrients have

been met. For instance, someone with poor nutritional status
has not adequately satisfied the need for one or more nutrients
because of an inadequate intake of the nutrient(s).

Food is the carrier of vitamins, minerals, fluids, and energy,

and to ensure that people receive all of the nutrients required to
sustain needs, the right food exposure is required. This basic
principle of nutrition demands that people eat a wide variety of
foods to ensure that cells are exposed to everything they need.
Every cell has a specific need for specific nutrients in specific
amounts. Providing too much of any single nutrient may squeeze
out other nutrients that the cell needs, and providing too little of
any nutrient may allow too much of another nutrient to enter the
cell. Both scenarios may result in cellular malfunction that has
implications for both health and athletic performance.

Nutrients

A substance that provides needed chemical(s) to sustain life,

including vitamins, minerals, carbohydrates, proteins, fats, and
water.

No single food contains all the required nutrients, so

consumption of a variety of foods is a necessary component of
good nutrient exposure. Eating patterns that have the same few
foods being repeatedly consumed (i.e., generally the same
breakfasts, and perhaps two or three different lunches and
dinners) tend to overexpose cells with some nutrients, while
underexposing cells with other nutrients. The result is
malnutrition and, for the athlete, a nutrient exposure that may
compromise the ability for the athlete to perform up to his or her
conditioned capacity. It is possible that some people have come to
realize that food consumption fails to optimally satisfy the need
for nutrients, and this causes them to try to satisfy nutritional
requirements through nutrient supplements, which carry their
own set of problems. However, it is clear that many coaches and
athletes do not know how nutrients work and how the human
body deals with nutritional mistakes. This chapter will review the
essential elements of nutrients, what they do, and how they work.

Malnutrition

A condition of poor health resulting from:

 Inadequate, excessive, or imbalanced intake of one or more
nutrient,
Poor absorption of consumed nutrient(s),
Abnormal metabolism of consumed and absorbed
nutrient(s).

Interactions Between Nutrition and Physical

Activity

Important Factors to Consider

Physical activity increases the requirement for energy

(calories) per unit of time. Energy requires other nutrients to
enable cells to obtain and use the needed energy. Since
food is a carrier of both energy and nutrients, anyone
performing physical activity should develop an eating
strategy with food that helps them obtain the needed
energy and associated nutrients.
Metabolizing more energy is heat creating, and the major
means humans have for dissipating this excess heat is to
sweat. The fluid for sweat comes from the blood volume,
which has many functions. It is harder to maintain the sweat
rate and these other functions (i.e., oxygen delivery) if
blood volume drops, so anyone who exercises must have a
good strategy for fluid consumption to keep blood volume
normal.

The field of sports nutrition represents an interaction between

physical activity and nutrition, and the interaction between these
two fields can be seen in many ways (Figure 1.1). It is well
established that a change in physical activity results in a parallel
change in multiple nutrient requirements, including the rate of
energy (i.e., calorie) utilization. For instance, as you sit reading
this sentence you have a relatively low rate of energy utilization
for each minute you spend sitting. But if you were to get up from
your chair and run outside, the energy consumed by your tissues
would be measurably higher for each minute you were running
than if you were sitting. In simple terms, higher activity intensity
translates into higher energy requirements.

FIGURE 1.1: Interaction between physical activity and nutrition.

This is only the beginning point, however, for the interaction

between physical activity and nutrition. As activity intensity
increases, the type of nutrients used to satisfy the need for fuel
also changes. It is well established that the higher the activity
intensity, the greater the utilization of carbohydrate as a fuel.
Since humans have relatively low carbohydrate storage, those
engaging in relatively high-intensity activity should have a
nutrition strategy for assuring the carbohydrate storage “tank”
never runs out.

Physical Activity

Any activity that results in body movement and requires more

energy (i.e., calories) above rest is considered physical activity.
 The greater the energy requirement per unit of time, the more
intense the physical activity.

Calorie

The term used in nutrition that is synonymous with kilocalorie.

Note that the uppercase C differentiates this from the lowercase
c used in calorie.

Kilocalorie

The commonly used term in nutrition to refer to the calories in

food. Example: This bagel has 400 calories actually means 400
kilocalories. This represents the amount of heat energy needed
to raise the temperature of 1,000 g (i.e., 1 kg) of water by 1°C,
and is 1,000× greater than a calorie.

calorie

The heat energy required to elevate the temperature of 1 g of

water by 1°C at sea level. In nutrition, the standard term
calorie, Kcal, or Kilocalorie is 1,000 times this amount.

We also know that energy substrates (i.e., the nutrients that

provide carbon to our cells for energy: carbohydrate, protein, and
fat) cannot be metabolized (used) by cells to satisfy their energy
requirements simply because these substrates are present in the
cell. Specific vitamins, mainly the B vitamins, are needed to use
the energy substrates so that cells can create the energy they
require to function. Greater time spent at higher activity intensity
requires more energy substrates and more specific vitamins to
satisfy energy needs. Vitamins do not provide energy, but they
help us derive energy from the foods we consume that contain
the energy substrates.
Some of the energy that we derive from the foods we consume
is burned with oxygen (aerobic metabolism), whereas other
consumed energy can be burned without oxygen (anaerobic
metabolism). Fat can only be metabolized for energy aerobically,
whereas carbohydrate is a flexible fuel that can be metabolized
aerobically and anaerobically. However, even the leanest person
has plenty of body fat stores to serve as an energy reserve,
whereas humans have limited storage of carbohydrate. Therefore,
the ability to burn fat is critically important for endurance. Iron, a
mineral, is involved in several ways in aerobic metabolism and is,
therefore, a critical nutrient for metabolizing fat for energy.
Athletes with insufficient iron have poor delivery of oxygen to cells
and, as a result, have below-optimal oxidative metabolism that
results in subpar performance.
Exercise also alters fluid requirements because humans are
only 20%–40% efficient at burning fuel to create muscular
movement. Therefore, for every 100 calories burned, 60–80 of
these calories creates heat. This heat cannot be retained (i.e.,
body temperature cannot be allowed to increase from the heat
created from the metabolism of energy), so we dissipate the heat
through the production of sweat. The evaporation of sweat
removes this excess heat and lowers body temperature. The
greater the intensity of activity, the greater the energy
metabolized and the greater the heat produced that must be
dissipated through sweat.

Exercise

Exercise represents physical activity that is performed for the

purpose of improving muscle, heart, and lung fitness. Physical
activity is typically referred to as exercise (i.e., activity requiring
physical effort) when it is performed in a planned, structured,
and repeated fashion for the purpose of improving health and
fitness.

In summary, physical activity alters the total energy

requirement, the type of energy required, the vitamins and
minerals needed to metabolize the energy, and the fluid
necessary to dissipate the heat associated with greater energy
metabolism (Box 1.2). These interactions are sufficiently
important, that having a discussion about exercise without also
including a related discussion about the nutritional factors that
help drive the exercise would be an incomplete discussion. In
simple terms, these factors are the basis of sports nutrition: An
increased rate of energy expenditure results in an increased rate
of body fluid loss. Although seemingly relatively simple concepts,
there is a great deal of science related to what energy substrates
are best to consume for different activities, what is the best
timing to consume these substrates, foods that can be consumed
at different times to improve muscle recovery and reduce muscle
soreness, the composition of fluids that is best for different events
in different environmental conditions, strategies for sustaining an
optimal hydration state, and the best eating modalities for
assuring that cells have optimal exposure to all the nutrients
necessary for the athlete to perform up to his or her conditioned
capacity.

Box 1.2 Two Major Issues in Sport

Regardless of the sport (power, team, endurance), the big

issues revolve around two major factors:

1. Optimally satisfying energy needs in terms of amount, type,

and timing of intake.
2. Optimally satisfying fluid needs in terms of amount, type,
and timing of intake.

Why Are so Many Athletes Poorly Nourished?

Important Factors to Consider

Many factors influence athlete nutritional status, but two major

factors include:

The traditions of the sport and the traditions of the

organizations that supervise and control the sport may
influence how athletes in that sport eat, often with poor
outcomes.
 Athletes in sports where weight (e.g., wrestling) and
appearance (e.g., synchronized swimming, gymnastics,
diving) are important aspects of the sport may place the
athlete at nutritional risk because few athletes or those who
coach them know about how best to achieve these goals.

Sports Organizations and Supplement Use

There are numerous reasons why athletes fail to optimally satisfy
nutritional needs. Many athletic event organizers seek sponsors to
help defray the costs of the event, and these sponsors provide
their nutritional products and inhibit the usage of other products.
These products may or may not be appropriate for each
competing athlete, but it is safe to say that not all products
contain the ideal distribution of nutrients (energy substrates,
electrolytes concentrations, etc.) for each athlete in each
sponsored event. This leaves athletes who have nutritional needs
that cannot be optimally fulfilled with the available products in a
state of poor nutrition that may keep them from performing up to
their conditioned capacities (19) (Table 1.1).

Table 1.1 Factors That Contribute to Poor Nutrition in

Athletes
Organization
Event Sponsorships: Products available to
athletes that may not be optimal.
Credentialed Nutritionists/Dietitians
Unavailable: There is often no certified or
credentialed nutrition expert at
training/competition.
National Governing Body: There may be a
perpetuation of bad nutritional behavior with
limited oversight that can result in long-term
nutritional difficulties.
Supplements: Purveyors push supplements
with convincing advertisements.
Bad Rules: Training venues that inhibit easy
availability of appropriate foods/beverages.
 Knowledge
Inappropriate Modeling: Copying admired
athletes.
Belief vs. Science: Myths associated with
thinking of nutrition as a belief system and not
a science.
Misattribution of Perceived Benefit: Consuming
certain foods/beverages may not help for the
reasons believed.
Good and Bad Foods: Oversimplification
results in problems.
Magic Bullet: Looking for the easy fix.

Tradition
Sport Traditions: Perpetuation of coach/sport-
induced nutrition-related problems.
Weight Focus: Excessive focus on weight,
when the focus should be on body composition
and strength:weight ratio.
Protein Solves Everything: High-protein intake
will successfully resolve all potential nutrition
problems.
Reliance on Supplements: Lowers food intake
and creates World Anti-Doping Agency issues.

Food
restriction Allergies: Avoidance of foods that cause a
potentially life-threatening allergic response.
Intolerances: Avoidance of foods that cause
discomfort, typically related to insufficient
digestive enzyme, such as lactose intolerance.
Sensitivities: Discomfort, bloating, and various
other symptoms from foods, often not well
identified, that cause gastrointestinal
inflammation.

National governing bodies are the organizational structures for

each sport (i.e., there is a national governing body for track and
field, another for gymnastics, another for hockey) and, depending
on the organization, may perpetuate bad nutritional behaviors
because of limited oversight. This can result in long-term
nutritional difficulties. For instance, athletes in certain sports are
often rewarded for having a “thin” appearance that is known to be
desired by judges. However, the drive to achieve this thinness
may result in a lifetime of poor eating behaviors that can
negatively affect health and could shorten an athlete’s
competitive life. Ideally, national governing bodies should develop
rules that encourage healthy body compositions that would also,
ultimately, improve sport-specific performance.
Many athletes are also excessively dependent on supplements,
which can be due to a multitude of factors that include convincing
advertisements, often using sports celebrities as the
spokespersons; an understanding that eating behaviors are less
than optimal so supplements are used as a nutritional “security
blanket”; advertisements for supplements in the official magazine
of the sport, which give the supplement unjustified credibility; and
the belief that nutrient supplementation will improve athletic
performance. In truth, supplements taken without evidence of an
established biological weakness may cause more problems than
they resolve and, as seen later in this chapter, supplements may
also contain banned substances that are not listed on the label.
Some training venues may have established bad rules that
inhibit easy availability of appropriate foods and beverages. For
instance, there may be a rule that prohibits sports beverages in
the training room. These rules may make it difficult for the athlete
to optimally benefit from the training for multiple reasons,
including increasing dehydration risk, limiting energy substrate
availability to working muscles, and allowing a low blood sugar
state to occur, which results in stress hormone (cortisol)
production, with a resultant breakdown of both lean and bone
mass. This is certainly not the desired outcome of a training
program.
Many of these organizational problems could be overcome with
the presence of a credentialed dietitian/nutritionist. This void
leaves it to others who have an inadequate background in
nutrition to provide nutrition information to the athletes. All too
often, this advice is not based on science or is intended to “push”
products that have a weak scientific basis.

Knowledge
An important contributor to why so many athletes are poorly
nourished is because they have poor knowledge of nutritional
strategies that could help them achieve their desired athletic
goals. The poor understanding of nutrition makes these athletes
easy prey to advertisements and also may cause them to
inappropriately model what other highly admired athletes are
doing. These athletes who are the focus of admiration may have
the best coaches in the world and access to superb athletic
training facilities, which are both likely to be more important
contributors to the athlete’s success than the supposed
performance-enhancing supplement they consume; however,
those who admire them will take the performance-enhancing
supplement with the belief that this alone will help. Related to this
is the problem that many athletes perceive nutrition to be a belief
system rather than a science. All too often athletes follow certain
inappropriate nutritional strategies because they believe those
strategies will help them. In fact, there is likely to be good
established science that would be a far better guide to the most
appropriate nutritional strategies.
Some athletes misattribute the perceived benefit they are
receiving from the foods they consume. For instance, a high level
of protein consumption is widely believed to be the critical factor
in human performance, so many athletes consume extremely high
levels of protein from both foods and supplements. Doing this
when coupled with an appropriate exercise regimen may result in
higher muscle mass, but the benefit may not be from the protein
itself but from the higher level of calories the protein has provided
to support the larger mass. Protein is certainly important, but
using protein as a calorie source is not optimal because the
nitrogenous waste that is produced may result in both
dehydration and lower bone density. This suggests that there are
better ways to satisfy energy (i.e., calorie) requirements other
than through an excessively high consumption of protein.
There is also a good food versus bad food belief system that
could create nutritional problems for athletes. Some athletes may
believe that a particular food is a “good food,” so they consume it
with great frequency and in high amounts. Although the food in
question may certainly be a fine food, no single food carries all of
the needed nutrients. Therefore, overreliance on this food
because of its “good food” label may create its own set of
nutritional problems, just as avoidance of a certain food because
it is perceived to be a “bad food” may keep the athlete from
obtaining a key nutrient present in that food. It is important to
remember that there is no magic bullet or perfect food that will
help the athlete run faster, jump higher, and move more quickly.
All of the nutritional needs must be met in a balanced way for
athletic performance to improve and that can only be done
through the consumption of a wide variety of foods. Athletes who
consume a monotonous diet because they are convinced that a
far too limited set of foods is the ticket to crossing the finish line
first are badly fooling themselves.
A common statement made by athletes is, “I eat this because I
know it’s good for me.” The second most common statement
athletes say is, “I don’t eat that because it’s bad for me.”
Although these statements may be true, they are also bad
mindsets to have, because they fail to consider context. What’s
good or bad has to do with the context of other foods that are
consumed, both in the short and long term. If an athlete believes
that cottage cheese is a perfect food and eats it every day for
lunch and most days for dinner then that athlete is a prime target
for malnutrition. It may just be possible that the best food a non-
vegetarian could have is an occasional hamburger for lunch. It
has rightly been said that human breast milk is the perfect food
for a newborn infant. But after 6 months, even infants need to try
some other foods, or they’ll become anemic (breast milk is a poor
source of iron). The truth is, there is no perfect food and athletes
who eat a monotonous diet because they are convinced that a
limited set of foods is the ticket to crossing the finish line first are
badly fooling themselves.

Tradition
Sports traditions may also play a role in athlete malnutrition. It is
not uncommon for some coaches to apply nutrition strategies that
they learned when they were athletes themselves and because it
is tradition in the sport. It may be tradition in the sport to keep
athletes from consuming fluids during practice because it has
never been done (tradition) and because it is wrongly believed
that practicing in a dehydrated state will make the athlete more
tolerant to dehydration during competition. We know this tradition
to be blatantly wrong, as it is well established that there is no
adaptation to dehydration, but the tradition continues in many
sporting activities.
Making a desired weight is also common in many sports. For
instance, linemen in football are often encouraged to get bigger
(i.e., have a higher weight), but the focus on weight may be
inappropriate from a performance standpoint. Rather, there
should be a focus on what constitutes weight (i.e. body
composition) because performance is more specifically associated
with that. As an example, try to imagine a football player lineman
who went from 250 to 275 lb on the advice of the coach and
training staff, but in doing so experienced the weight gain almost
entirely from an increase in fat mass. Now this lineman must
move a larger mass with the same muscle he had before the
weight increase, mandating that the muscle work harder to do the
same intensity of work, with the likely outcome that the muscle
will fatigue more quickly and with an associated reduction in
performance. Also, imagine an athlete in an appearance sport
where the coach feels she will have a better competition score if
she looks smaller, so she is asked to lose weight through a
calorically restricted diet. However, caloric restrictions are likely
to lower muscle mass more than fat mass, so this athlete
becomes weaker as a result of the weight loss (4). The faster rate
of fat recovery relative to muscle recovery following low-calorie
diets may also increase health risks that include lower bone
density and eating disorders (4). On the other hand, if the focus
was to increase muscle while losing only fat, this athlete could
maintain her current weight and still look smaller because muscle
is more dense than fat, and her performance would increase
because she would have more muscle moving less nonmuscle
mass. Weight is the wrong metric in both examples, but often
remains the common measure in many athletic endeavors. For
this reason, body mass index (BMI), a weight-to-height index
(kg/m2), is a poor measure of athlete fitness. BMI was developed
as a population index for determining the prevalence of
population overweight and obesity, with categories for
underweight (16–18.5), normal weight (18.5–25), overweight (25–
30), and obesity (30 or higher). Obesity represents a condition of
having excess body fat. BMI is now commonly used as an obesity
measure for individuals, but should not be as it fails to assess the
degree to which fat is a contributor to weight. Athletes, because
they often carry a high level of muscle for height, can be
mischaracterized as being obese (i.e., BMI > 30) when they are
not, and some “thin” individuals, who have relatively little muscle
mass but a high level of fat mass, can be characterized as normal
weight with BMI but because fat contributes significantly to
weight, should be characterized as obese.
The maximal human capacity to use protein anabolically to
build and repair tissue, make enzymes and hormones, etc., is
∼1.7 g of protein per kg of body mass. But the consumption of
protein to derive the optimal anabolic (tissue-building) benefit is
far more complicated than the simple consumption of this much
protein in a day. Human systems can only process about 30–40 g
(120 calories) of protein at a single meal, depending on
musculature and, to ensure that this protein can be used
anabolically, it must be consumed while in a state of good energy
balance (17). It is not unusual for athletes to consume large
protein meals containing 80 or more grams of protein, but
because only 30–40 g of this can be used anabolically, athletes
are fooling themselves into thinking that this high level of protein
at a single meal is contributing to total protein requirements (28).
The remaining 50 g is either used as a source of calories or stored
as fat. It would be more productive to distribute the required
protein throughout the day in amounts that optimize tissue
utilization.
Another possible reason for why athletes may be at risk for
poor nutrition is the excessive reliance on nutrient supplements.
The common belief is that “if a little bit is good for me, then
taking a lot will make it even better.” This breaches a key rule of
nutrition: More than enough is not better than enough. This is
based on the Latin saying Sola dosis facit venenum, which is
attributed to Paracelsus, and translates to “The dose makes the
poison.” The DRIs published by the National Academy of Sciences
are often wrongly viewed as a minimal requirement rather than
what they are, which is the average requirement to stay healthy
plus two standard deviations above this level (14). Despite this,
athletes are the target of advertisements that try to have them
consume products containing many multiples, often 300% to
400% or more of the recommended DRI value without any
evidence that this intake will enhance health and/or performance.
On the contrary, there is an increasing body of evidence
suggesting that these excessively high levels of supplemental
nutrient intake cause problems (8). There is also evidence that,
when taken as supplements, some nutrients may results in the
precise opposite of the desired effect. A study assessing vitamin E
supplementation (800 IU/day for 2 months) before the Triathlon
World Championship in Kona, Hawaii, found that it promoted lipid
peroxidation and inflammation during exercise, a finding strongly
implying that the triathletes would have been better off without it
(25). Studies of dietary supplements have also found the
presence of substances banned by the International Olympic
Committee (IOC) and the World Anti-Doping Agency, despite
these substances not being included on the product label (18).
Clearly, consumption of these supplements by an unknowing
athlete would put the athlete at risk.

Food Restriction From Allergies, Intolerances, and

Sensitivities
Athletes may be predisposed to poor nutritional status because of
issues related to food allergies, food intolerances, and food
sensitivities. The symptoms of a food allergy are caused by the
ingestion of specific antigens that result in an immunoglobulin E
(IgE)-mediated allergic response that occurs within minutes to 2
hours postingestion. The symptoms involve the gastrointestinal
(GI) tract, respiratory system, eyes, and skin and can be life
threatening. The most common food allergies are related to the
consumption of peanuts, tree nuts, egg, milk, wheat, soybeans,
fish, and crustacean shellfish, with a food-specific protein being
the usual offending substance.
 Food Allergy

Food allergy represents an immune response to the

consumption of a specific food or an ingredient in a food. An
allergic reaction (rash, swelling of tongue, vomiting, diarrhea,
etc.) occurs when the body’s immune system reacts to the food
by binding IgE to the food, resulting in the release of
inflammatory chemicals, including histamine. Common food
allergies include milk, eggs, shellfish, peanuts, wheat, rice, and
fruit.

Immunoglobulin E

These are antibodies produced by the immune system and are

involved in allergic reactions. Anyone with an allergy has an
excessive immune system response to the allergen, resulting in
IgE release. The IgE travels to cells that are the cause of the
allergic reaction (i.e., swelling, rash).

Food sensitivities are non-IgE-mediated reactions involving

the immune system. Symptoms occur as a result of cytokine and
mediator release from granulocytes and T cells, which release
mediators, including prostaglandins, histamines, cytokines, and
serotonin, that adversely affect gut function through tissue
inflammation, smooth muscle contraction, mucus secretion, and
pain receptor activation. The food source of symptoms may
remain elusive without food sensitivity testing and a personalized
elimination diet.

Food Sensitivity

Food sensitivities result in non-IgE localized inflammatory

responses in the GI tract. The inflamed GI tract may allow some
substances to enter the blood that would otherwise not enter,
contributing to inflammatory conditions that include irritable
bowel syndrome (IBS), migraine headaches, metabolic
syndrome, arthritis, and others. Food sensitivities are more
 prevalent than food allergies or food intolerances, but they
often go undiagnosed because the reaction to the offending
food(s)/food substance(s) may take several days.

The causes of food intolerances involve insufficient or

missing digestive substances, such as enzymes or bile salts,
causing the rapid onset of distressing GI symptoms. For example,
symptoms of lactose intolerance are present in about 10% of the
population and occur when the enzyme lactase is not produced in
sufficient amounts to adequately break down dairy product
lactose.
All of these food-related issues (allergies, sensitivities, and
intolerances) have implications for acute and chronic disease
states, but they also may cause a dramatic reduction in nutrient
exposure by eliminating whole categories of foods. People
identified as having any of these conditions require special
attention to ensure the diet can deliver the needed nutrients. It is
also possible that athletes may unnecessarily restrict foods
because they have heard that some foods or food components
are “bad” or they believe they have a condition that has not been
diagnosed. For instance, athletes may unnecessarily restrict or
avoid consuming gluten-containing foods despite have no gluten-
related issues; some athletes may unnecessarily restrict dairy
foods because they believe they may have lactose intolerance.
These unnecessary restrictions may limit the foods they are
willing to consume and, therefore, may make it more difficult to
consume needed nutrients.

Food Intolerance

Food intolerance does not affect the body’s immune system,

and typically occurs because the individual cannot digest a food
ingredient because of a missing digestive enzyme, cannot
absorb a nutrient because of a missing transport protein, or
cannot properly metabolize the consumed food ingredient once
it is absorbed because of a missing cellular enzyme. Example:
One of the common food intolerances is lactose intolerance
(affecting ∼10% of the adult population), which results from
 insufficient production of lactase, the digestive enzyme for the
sugar lactose.

The Nutrients

Important Factors to Consider

People often think that some nutrients are more important

than others. This is dangerous thinking, as this may cause
them to overconsume these nutrients at the expense of
others. Nutrients work together to produce the desired
result, and having all the nutrients in the right balance is an
important key to good nutrition.
No single food is a good source of all nutrients. Therefore,
frequent consumption of the same food(s) fails to expose
tissues to a full array of nutrients, predisposing a person to
malnutrition. Consumption of a variety of foods is a key
aspect of assuring a good nutritional status.

The six established classes of nutrients include water, vitamins,

minerals, proteins, fats, and carbohydrates. Another quasinutrient
class is referred to as phytonutrients, which are not classically
described as nutrients, but which have nutrient-like functions.
Phytonutrients are the focus of a great deal of current research,
the findings of which are providing useful information on cellular
function and repair (Table 1.2). We derive energy (fuel) from foods
that contain three of these nutrient classes — carbohydrates,
proteins, and fats. We can also derive energy from alcohol, but
regular consumption is likely to interfere with normal energy
metabolic processes while increasing the potential for
dehydration.

Table 1.2 The Nutrients

Nutrient Subcategories Functions
Table 1.2 The Nutrients
Nutrient Subcategories Functions
Carbohydrates Sugars Muscular fuel to derive
Starches energy (from starch, sugars,
Fiber and glycogen)
Cholesterol/fat control (from
dietary fiber)
Digestion assistance (from
dietary fiber)
Nutrient/water absorption
(from sugars)
Lipids (fats and Essential fatty Delivery of fat-soluble
oils) acids vitamins (vitamins A, D, E,
Nonessential and K)
fatty acids Delivery of essential fatty
Monounsaturated acids (fatty acids the body
fatty acids needs but cannot make)
Polyunsaturated Energy/muscular fuel (for
fatty acids low-intensity activity)
Saturated fatty Satiety control (helps make
acids you feel satisfied from
eating)
Substance in many hormones
Table 1.2 The Nutrients
Nutrient Subcategories Functions
Proteins Essential amino Energy source (if
acids carbohydrates are depleted)
Nonessential Delivery of essential amino
amino acids acids (amino acids the body
needs but cannot make)
Essential for developing new
tissue (important during
growth and injury repair)
Essential for maintaining
existing tissue (helps control
normal wear and tear)
Basic substance in the
manufacture of enzymes,
antibodies, and hormones
Fluid balance (helps control
water level inside and
outside cells)
Carrier of substances in the
blood (transports vitamins,
minerals, and fats to and
from cells)
Table 1.2 The Nutrients
Nutrient Subcategories Functions
Vitamins Water soluble Tissue function and health
Fat soluble (e.g., vitamin A helps the eye
work correctly)
Immune function (e.g.,
vitamins A and C are well
known for this function)
Energy metabolism control
(e.g., B vitamins, in
particular, are involved in
helping cells burn energy)
Nutrient absorption (e.g.,
vitamin D helps calcium and
phosphorus from the food
you eat be absorbed into
your bloodstream)
Nervous system maintenance
(e.g., folic acid and thiamin
are important in nerve
system development and
function)
Antioxidants (e.g., help
protect cells from oxidative
damage)
Table 1.2 The Nutrients
Nutrient Subcategories Functions
Minerals Macrominerals Skeletal strength (e.g.,
Microminerals calcium, phosphorus, and
Ultratrace magnesium are keys to
minerals strong bones; fluoride keeps
teeth strong by protecting
them from bacterial acids)
Nerve function (e.g.,
magnesium and calcium are
both involved in nerve
communication)
Control of the body’s pH
(acidity level)
Oxygen transport (e.g., iron
is essential for getting
oxygen to cells and removing
carbon dioxide from cells)
Control of the body’s water
balance (sodium and
potassium play important
roles in blood volume)
Water None The body’s coolant (helps
maintain body temperature
through sweat production)
Carrier of nutrients to cells
Remover of waste products
from cells
Important constituent of
muscle
Involved in many body
reactions (both in digestion
of food and in processes
inside cells)
Phytonutrients* Phenols Cell protection agents
Terpenes Cell repair agents
Polyphenols Cell longevity agents
Sterols
*
Phytonutrients are not officially considered a class of nutrients, but they are receiving
a great deal of research attention with findings that they have functions similar to
vitamins. They are chemicals naturally found in plants for which there are no current
recommended intakes. Plants produce phytonutrients for their own protection against
viruses, bacteria, fungi, insects, and the environment, and it is believed they also
provide protection for the human body.

There are many people who attribute energy-providing

properties to vitamins and minerals, but vitamins and minerals
are not a source of energy. They are, however, needed to derive
energy from carbohydrates, proteins, and fats that are consumed.
Athletes who reduce food intake because they believe that the
reduction in energy consumption will create no difficulty because
of their consumption of vitamins are wrong. Many vitamins have
very little to work on if there is limited availability of energy.
Water, discussed in Chapter 5, is a nutrient that constitutes a high
proportion of total body weight and quite literally ties all of the
tissues together. Blood, which is mainly water, circulates vitamins,
minerals, fats, proteins, and carbohydrates to tissues and
removes the metabolic waste of this tissue utilization. The water
in blood is also essential for maintaining body temperature,
through sweat production, during exercise.

Nutrient Balance
Each nutrient is uniquely important because each nutrient has
specific functions. Athletes cannot eliminate any class of nutrients
from the foods they eat and hope to do well athletically (much
less survive in good health!) Critical to understanding nutrients is
the concept that nutrients work together, both within and
between nutrient classes. For instance, it becomes more difficult
to burn fat for energy without having some carbohydrate present
because “fat burns in a carbohydrate flame.” It is also impossible
to imagine having healthy red blood cells with sufficient iron
intake but inadequate vitamin B12 and folic acid intake. Having
enough total energy intake (from carbohydrate, protein, and fat)
is an excellent strategy for optimizing athletic performance.
However, doing this with an inadequate fluid intake will impede
an athlete’s ability to metabolize these energy compounds by
limiting their delivery to cells, limiting the removal of metabolic
by-products from cells, and limiting the cooling capacity from the
heat created when energy compounds are metabolized.
On the other hand, having too much of any one nutrient may
damage the opportunity for the normal nutrient absorption and
metabolism of other nutrients being consumed at an adequate
level. For instance, calcium supplements are commonly taken to
help ensure strong and healthy bones that are resistant to stress
fractures (a common injury in sport) and to reduce the risk of
osteoporosis. However, taking too much calcium at the same time
as taking iron, magnesium, and zinc may inhibit the absorption of
these other nutrients, which are equally important in maintaining
health and athletic performance. Again, these are issues of
nutrient balance. Having one nutrient without the other simply
does not work, and having too much of one nutrient may cause
difficulties with other nutrients. Therefore, when you review Table
1.2 and see a summary of nutrients and their various functions, it
is incorrect to infer that taking a single nutrient will, by itself,
encourage that function. Think balance.

Essential and Nonessential Nutrients

Nutrients may be referred to as either essential or nonessential,
but care should be taken not to misinterpret these terms. An
essential nutrient is one that cannot be manufactured by body
cells from other nutrients, so it is essential that we consume this
nutrient from the foods we consume. As an example, we have
essential amino acids that we are incapable of making ourselves,
so we must consume these amino acids from the foods we eat.
The same is true for fatty acids, most of which are considered
nonessential because we are fully capable of manufacturing them
from other nutrients. However, we still have a small number of
fatty acids that are considered essential to consume because we
cannot manufacture them.
Do be careful not to think of nonessential nutrients as less
important than essential nutrients. We need them all (both
essential and nonessential nutrients) to function normally, but
must purposefully consume the essential nutrients to ensure
normal cellular function. Typically, balanced diets that include a
variety of foods deliver all of the essential nutrients and also
provide the nonessential nutrients. Problems related to essential
nutrients are nearly always related to dietary restrictions related
to special diets, food allergies, food intolerances, and/or food
sensitivities. For instance, people may put themselves on an
extremely low-fat diet that eliminates whole categories of foods,
such as corn oil, sunflower oil, soybean oil, nuts, and seeds, that
are the primary sources of linoleic fatty acid, an essential fatty
acid. Over time, this could result in a linoleic acid deficiency, with
symptoms ranging from poor growth, fatty liver, skin lesions, and
reproductive failure (3). Chapters 2, 3, and 4 on the energy
substrates, vitamins, and minerals, respectively, will have a more
comprehensive discussion on specific nutrients, their food
sources, and the amounts typically required to sustain health.
These chapters also cover the impact that physical activity has on
specific nutrient requirements, with strategies for athletes on how
to ensure they can obtain all of the essential and nonessential
nutrients required for health and performance.

Nutrition Guides for Athletes and Nonathletes

Important Factors to Consider

The dietary guidelines are general recommendations to help

ensure a healthy life. These are generally appropriately
used with physically active people, with only a few
modifications: (i) sugar-containing sports beverages are
appropriate for consumption during bouts of physical
activity and (ii) sodium losses through sweat may exceed
current intake recommendations, but should be replaced.
The DRIs are meant to ensure that 98% of the population
will achieve a good nutritional status when daily food
intakes of listed nutrients are achieved. However, it is
important to consider that the DRI value is two standard
deviations above the average requirement, suggesting that
consumption of DRI level is actually above the level
required by most people to sustain a good nutritional status.
The U.S. Department of Health and Human Services and the U.S.
Department of Agriculture jointly publish the Dietary Guidelines
for Americans (dietary guidelines) every 5 years (32). Each edition
of the dietary guidelines reflects the body of nutrition science.
The most recent dietary guidelines were published in 2015. The
dietary guidelines provide evidence-based food and beverage
recommendations for Americans ages 2 and older. These
recommendations aim to:

Promote health,
Prevent chronic disease,
Help people reach and maintain a healthy weight.

Public health agencies, health care providers, and educational

institutions all rely on dietary guidelines recommendations and
strategies. The dietary guidelines also have a significant impact
on nutrition in the United States because they:

Form the basis of federal nutrition policy and programs,

Help guide local, state, and national health promotion and
disease prevention initiatives,
Inform various organizations and industries (e.g., products
developed and marketed by the food and beverage industry).

The intent of the dietary guidelines is to summarize what we

know about individual nutrients and food components into an
interrelated set of recommendations for healthy eating that can
be adopted by the public. Taken together, the dietary guidelines
recommendations encompass two overarching concepts: (i)
maintain calorie balance over time to achieve and sustain a
healthy weight and (ii) focus on consuming nutrient-dense foods
and beverages (32).

Maintain Calorie Balance

The first concept is to maintain calorie balance over time to
achieve and sustain a healthy weight. People who are most
successful at achieving and maintaining a healthy weight do so
through continued attention to consuming only enough calories
from foods and beverages to meet their needs and by being
physically active. To curb the obesity epidemic and improve their
health, many Americans must decrease the calories they
consume and increase the calories they expend through physical
activity. As part of this recommendation, there is an emphasis on
increasing physical activity and reducing the time spent in
sedentary activities to lower the risk of developing obesity or for
achieving a better weight if currently overweight or obese. One
goal of increasing physical activity is to help achieve a calorically
balanced state (i.e., calories consumed equals calories expended)
to prevent obesity or to achieve a negative energy balance (i.e.,
calories consumed is less than calories expended) to lower
weight. (More on weight and body composition can be found in
Chapter 6.)

Consume Nutrient-Dense Foods and Beverages

The second concept is to focus on consuming nutrient-dense
foods and beverages. Americans currently consume too much
sodium and too many calories from solid fats, added sugars, and
refined grains. Added sugars are considered caloric sweeteners
that are added to foods during processing, preparation, or
consumed separately. Solid fats are considered fats with a high
content of saturated and/or trans fatty acids, which are usually
solid at room temperature. Refined grains are considered to be
grain products missing the bran, germ, and/or endosperm, that is,
any grain product that is not a whole grain. These replace
nutrient-dense foods and beverages and make it difficult for
people to achieve the recommended nutrient intake while
controlling calorie and sodium intake. A healthy eating pattern
limits intake of sodium, solid fats, added sugars, and refined
grains and emphasizes nutrient-dense foods and beverages —
vegetables, fruits, whole grains, fat-free or low-fat dairy products,
seafood, lean meats and poultry, eggs, beans and peas, and nuts
and seeds. Care should be taken, however, to not misinterpret
limiting an intake with avoiding an intake. For instance, both low-
sodium and high-sodium intakes are associated with higher
mortality, so the key is to find an appropriate balance of intake:
not too much and not too little (11).
 Recommended Nutrient Intake

Nutrient intake guidelines for different ages and genders have

been established by various governmental (e.g., National
Institutes of Health) and nongovernmental (e.g., World Health
Organization) groups. The DRIs (the current U.S. guideline for
recommended nutrient intake) provide intake levels for each
nutrient that will, statistically, sustain good nutritional status for
98% of the population.

Nutrient-dense foods are foods that, for the calories delivered,

have a high concentration of nutrients. An example of a food with
low nutrient density is sugar, which is a source of energy but has
no other nutrients associated with it. Seeking a high nutrient
density is logical, as it has been found that the diet of severely
obese individuals is unbalanced, with relatively high caloric
intakes coupled with inadequate intake of vitamins and minerals
(13). There is also an emphasis on consuming alcohol in
moderation if it is consumed, by limiting consumption to no more
than one drink per day for women and two drinks per day for
men, assuming legal drinking age. Alcohol is a source of energy (7
calories/g), but interferes with the metabolism of a number of
nutrients that can increase disease risk. There are also nutrition
recommendations for specific populations, including women of
childbearing age who are encouraged to consume sufficient iron
and folic acid to reduce pregnancy and fetal complications,
women who are pregnant who are encouraged to limit the
consumption of certain fish with a high mercury content and to
ensure good iron status, and people who are over 50 years of age
who are encouraged to ensure that vitamin B12 status is not
compromised.

Important Factors to Consider

Obesity and overweight have different meanings:

Obesity means having too much body fat

Overweight means weighing too much for your height
 Weight may come from:

Lean Mass (More = Good)

Bone Mass (More = Good)
Fat Mass (More = Bad)
Body Water (More = Good)

Overweight

Overweight represents someone who is above the desired

weight for height, age, and gender. Interpretation of
“overweight” is difficult because athletes with a higher level of
muscle per unit height may be classified as overweight, but this
cannot be considered undesirable. The terms overweight and
obese are often wrongly used interchangeably, as obesity is a
condition of excess body fat regardless of weight, whereas
overweight represents high weight for height regardless of body
fat.

Obese Obesity

A condition characterized by an excess level of body fat,

regardless of body weight. People with a body fat percent (the
percent of mass that is fat) that exceeds 25% for men or 32%
for women are considered obese. Athletes typically have body
fat percent levels that are significantly lower than these values.

Dietary Reference Intakes

The DRIs are developed and published by the Institute of Medicine

(IOM) and represent the most current scientific knowledge on
nutrient needs of healthy populations (Figure 1.2). The DRIs are
composed of the following five components (6):

Estimated Average Requirement (EAR): The average daily

nutrient intake level estimated to meet the requirement of
 half the healthy individuals in a particular life stage and
gender group.
Recommended Dietary Allowance (RDA): The average daily
dietary nutrient intake level sufficient to meet the nutrient
requirement of nearly all (∼98%) healthy individuals in a
particular life stage and gender group. This level amounts to
two standard deviations above the average requirement.
Adequate Intake (AI): The recommended average daily intake
level based on observed or experimentally determined
approximations or estimates of nutrient intake by a group (or
groups) of apparently healthy people that are assumed to be
adequate — used when an RDA cannot be determined.
Tolerable Upper Intake Level (UL): The highest average daily
nutrient intake level that is likely to pose no risk of adverse
health effects to almost all individuals in the general
population. As intake increases above the UL, the potential
risk of adverse effects may increase.
Estimated Energy Requirement (EER): This represents the
average dietary energy intake predicted to maintain energy
balance in a healthy adult of a defined age, gender, weight,
and height who has a level of physical activity that is
consistent with good health. The EER for children, pregnant
women, and lactating women includes the higher energy
needs associated with growth and development, pregnancy,
or lactation.

As can be seen from Figure 1.2, the DRIs should not be

considered a minimum intake level of nutrients to ensure a state
of good health. Most healthy people have nutrient requirements
that are considerably less than the RDA (i.e., close to the average
requirement and not two standard deviations above the
requirement), and a small proportion of people have nutrient
requirements above the RDA. As indicated in Figure 1.2, having
too much of any nutrient increases the risk of an adverse effect
(i.e., at a level above the UL), and having too little also increases
the risk of an adverse health effect (i.e., at a level below the EAR).
Therefore, the DRI should be considered a safe range of nutrient
intakes that most people should strive for. Given the all-too-
common prevalence of nutrient supplement intakes, particularly
in athletes, there is reason to be concerned that many people are
at greater risk of exceeding the UL than having less than the RDA.

FIGURE 1.2: Dietary reference intakes (DRIs). AI, adequate

intake; EAR, estimated average requirement; RDA, recommended
dietary allowance; UL, upper intake level. (From Ferrier D.
Lippincott Illustrated Reviews: Biochemistry. 7th ed. Philadelphia
(PA): LWW (PE); 2017.)

For the individual who exercises regularly, the RDA is an

excellent starting point to determine nutrient adequacy. Because
exercise results in greater energy utilization than in the average
nonexercising person, energy requirements are likely to be higher
than those established in the energy RDA. Since burning more
energy also requires more nutrients (particularly B vitamins), and
performance is closely tied to several minerals (iron and zinc in
particular), consuming the nutrient RDA of these nutrients is a
good idea. Serious athletes should periodically have a blood test
to determine whether nutrient intake is adequate and to
determine if consuming the RDA level is right for them. In
particular, checking adequate iron intake status by evaluating
hemoglobin, hematocrit, and ferritin is important and may also be
an indicator of the intake adequacy of other nutrients. The DRI
tables of EARs, RDAs, AIs, and ULs can be found on the inside
cover of this book for easy reference.

Using the DRIs for Planning

The DRI tables are an excellent resource for planning and
evaluating nutrient intake adequacy in individuals and groups
(Figure 1.3). For individuals, the following guidelines apply:

FIGURE 1.3: Using the DRIs for planning for individuals and
groups. AI, adequate intake; DRI, dietary reference intake; EAR,
estimated average requirement; RDA, recommended dietary
allowance; UL, upper intake level (From Institute of Medicine
Subcommittee on Interpretation and Uses of Dietary Reference
Intakes; Institute of Medicine Standing Committee on the
Scientific Evaluation of Dietary Reference Intakes. Using Dietary
Reference Intakes in Planning Diets for Individuals. In: Dietary
Reference Intakes: Applications in Dietary Planning. Washington
(DC): National Academies Press; 2003. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK221374/)

EAR should NOT be used as a nutrient intake goal for an

individual.
RDA is an appropriate value to use for an individual. A typical
intake at or slightly above this level should result in a low risk
of nutrient inadequacy.
AI is an appropriate level of intake for an individual. A typical
intake at or slightly above this level should result in a low risk
of nutrient inadequacy.
 UL is not an appropriate level to plan for an individual, as this
level may pose a risk for adverse effects from excessive
intakes

For groups, the following guidelines apply:

EAR is appropriate to use for an acceptably low risk of

insufficient nutrient intakes within a group.
RDA should not be used to plan the intakes of groups, as the
values represent two standard deviations above the average
requirement.
AI is appropriate to use for a group, as the average usual
intake implies a low prevalence of insufficient nutrient intake.
UL can be used in planning to minimize the risk that a
proportion of the population may receive an excessively high
nutrient intake.

Physical Activity Guidelines

The Office of Disease Prevention and Health Promotion of the U.S.

Department of Health and Human Services also publishes Physical
Activity Guidelines for Americans, last published in 2015 (31).
These guidelines are intended to outline the amount and type of
physical activity associated with promoting health and reducing
the risk of chronic disease. The major health-related research
findings that are the basis of the physical activity guidelines
include the following:

Regular physical activity reduces the risk of many adverse

health outcomes.
Some physical activity is better than none.
For most health outcomes, additional benefits occur as the
amount of physical activity increases through higher intensity,
greater frequency, and/or longer duration.
Most health benefits occur with at least 150 minutes (2 hours
and 30 minutes) a week of moderate-intensity physical
activity, such as brisk walking. Additional benefits occur with
more physical activity.
 Both aerobic (endurance) and muscle-strengthening
(resistance) physical activity are beneficial.
Health benefits occur for children and adolescents, young and
middle-aged adults, older adults, and those in every studied
racial and ethnic group.
The health benefits of physical activity occur for people with
disabilities.
The benefits of physical activity far outweigh the possibility of
adverse outcomes.

The specific key physical activity guidelines for different groups

are described as follows:

Children and Adolescents

Children and adolescents should do 60 minutes (1 hour) or

more of physical activity daily.
Aerobic: Most of the 60 or more minutes a day should be
either moderate- or vigorous-intensity aerobic physical
activity and should include vigorous-intensity physical
activity at least 3 days a week.
Muscle-strengthening: As part of their 60 or more minutes
of daily physical activity, children and adolescents should
include muscle-strengthening physical activity on at least
3 days of the week.
Bone-strengthening: As part of their 60 or more minutes
of daily physical activity, children and adolescents should
include bone-strengthening physical activity on at least 3
days of the week.
It is important to encourage young people to participate in
physical activities that are appropriate for their age, that are
enjoyable, and that offer variety.

Adults

All adults should avoid inactivity. Some physical activity is

better than none, and adults who participate in any amount of
physical activity gain some health benefits.
 For substantial health benefits, adults should do at least 150
minutes (2 hours and 30 minutes) a week of moderate-
intensity, or 75 minutes (1 hour and 15 minutes) a week of
vigorous-intensity aerobic physical activity, or an equivalent
combination of moderate- and vigorous-intensity aerobic
activity. Aerobic activity should be performed in episodes of at
least 10 minutes, and preferably, it should be spread
throughout the week.
For additional and more extensive health benefits, adults
should increase their aerobic physical activity to 300 minutes
(5 hours) a week of moderate-intensity, or 150 minutes a
week of vigorous-intensity aerobic physical activity, or an
equivalent combination of moderate- and vigorous-intensity
activity. Additional health benefits are gained by engaging in
physical activity beyond this amount.
Adults should also do muscle-strengthening activities that are
moderate or high intensity and involve all major muscle
groups on 2 or more days a week, as these activities provide
additional health benefits.

Older Adults
The key guidelines for adults also apply to older adults. In
addition, the following guidelines are just for older adults:

When older adults cannot do 150 minutes of moderate-

intensity aerobic activity a week because of chronic
conditions, they should be as physically active as their
abilities and conditions allow.
Older adults should do exercises that maintain or improve
balance if they are at risk of falling.
Older adults should determine their level of effort for physical
activity relative to their level of fitness.

Older adults with chronic conditions should understand

whether and how their conditions affect their ability to do regular
physical activity safely.

Women during Pregnancy and the Postpartum Period

 Healthy women who are not already highly active or doing
vigorous-intensity activity should get at least 150 minutes of
moderate-intensity aerobic activity a week during pregnancy
and the postpartum period. Preferably, this activity should be
spread out throughout the week.
Pregnant women who habitually engage in vigorous-intensity
aerobic activity or who are highly active can continue physical
activity during pregnancy and the postpartum period,
provided that they remain healthy and discuss with their
health care provider how and when activity should be
adjusted over time.

Adults With Disabilities

Adults with disabilities, who are able to, should get at least
150 minutes a week of moderate-intensity, or 75 minutes a
week of vigorous-intensity, aerobic activity or an equivalent
combination of moderate- and vigorous-intensity aerobic
activity. Aerobic activity should be performed in episodes of at
least 10 minutes and, preferably, it should be spread
throughout the week.
Adults with disabilities, who are able to, should also do
muscle-strengthening activities of moderate or high intensity
that involve all major muscle groups on 2 or more days a
week, as these activities provide additional health benefits.
When adults with disabilities are not able to meet the
guidelines, they should engage in regular physical activity
according to their abilities and should avoid inactivity.
Adults with disabilities should consult their health care
provider about the amounts and types of physical activity that
are appropriate for their abilities.

Adults With Chronic Medical Conditions

Adults with chronic conditions obtain important health

benefits from regular physical activity.
When adults with chronic conditions do activity according to
their abilities, physical activity is safe.
 Adults with chronic conditions should be under the care of a
health care provider. People with chronic conditions and
symptoms should consult their health care provider about the
types and amounts of activity appropriate for them.

Important Factors to Consider

Food labels are important to study, to understand the level

of selected nutrients contained in a food. However, it is also
important to consider that many of the best foods to be
consumed, including fresh fruits and vegetables, have no
food label. It is important, therefore, to use other sources to
understand the content of these foods.
Some of the terms used on food labels may be misleading.
For instance, the term Lite in a label may mean that the
food derives less than 50% of its calories from fat, but may
still be relatively high in sugar and/or calories. For instance,
“Lite Potato Chips” may only mean that they are a third
lower in fat content than a regular potato chip, but may still
not be considered a low-calorie food.

Safe Physical Activity for All Groups

To do physical activity safely and reduce the risk of injuries and
other adverse events, people should

Understand the risks and yet be confident that physical

activity is safe for almost everyone.
Choose to do types of physical activity that are appropriate
for their current fitness level and health goals, because some
activities are safer than others.
Increase physical activity gradually over time whenever more
activity is necessary to meet guidelines or health goals.
Inactive people should “start low and go slow” by gradually
increasing how often and how long activities are done.
Protect themselves by using appropriate gear and sports
equipment, looking for safe environments, following rules and
 policies, and making sensible choices about when, where, and
how to be active.

Although not specifically stated in the dietary and physical

activity guidelines, but inherently important is that there should
be a dynamic relationship between nutrient and energy intake
and energy and nutrient utilization. So, the individual who has
increased physical activity should be careful not to achieve a
relative energy deficiency (RED) that could create difficulties. For
instance, higher energy expenditures associated with physical
activity should be closely matched with higher energy intakes to
avoid a loss of lean mass and a loss of bone mass, both of which
can have short- and long-term negative health effects. Put simply,
increasing physical activity without making appropriate changes
in the diet may inhibit the potentially positive impact of physical
activity from occurring. It is also important to consider that the
focus of the DRIs on individual nutrients may detract from the
importance of nutrient intake balance and that the mix of
nutrients consumed from different foods is important. Dietary
fiber, for instance, is important for GI health and lowered risk of
developing certain cancers. This information may motivate people
to consume more pure isolated dietary fiber, such as bran.
However, a study has pointed out that whole grain cereals, which
are also good sources of dietary fiber, may be more important for
health than fiber alone because of the other nutrients and
phytonutrients that present in whole grains but not in fiber (15).
The focus should be on delivering a mix of balanced nutrients to
improve health and reduce disease risk. More on strategies for
dynamically matching energy intake and expenditure are included
in Chapter 6.

Food Labels

Learning to read food labels is an excellent strategy for

understanding the nutrient contents and caloric content and
energy distribution of packaged foods (Figure 1.4). There are
some standards for food labels that include the following (33):
FIGURE 1.4: Reading Nutrition Facts food labels. (From U.S. Food
and Drug Administration. Changes to the Nutrition Facts Label
[Internet]. 2017. Available from:
https://www.fda.gov/food/guidanceregulation/guidancedocuments
regulatoryinformation/labelingnutrition/ucm385663.htm#images)

Every food label must state a common or usual name of the

food/product; the name and address of the manufacturer,
packer, or distributor; the net contents of the package by
weight, measure, and count; and the ingredients in
descending order of predominance by weight.
Food labels must provide more information if a nutrient is
added to it or if a nutrition-related claim is made about the
food. (For instance, “This food will lower your cholesterol” or
“This food will lower your risk of cancer.”) The health message
must be truthful and not misleading, must be in general
agreement with established medical and nutrition principles,
and must have a reference on the label that allows consumers
to see a Food and Drug Administration–approved summary of
the health claim. Up-to-date labeling requirements can be
found at:
https://www.fda.gov/downloads/Food/GuidanceRegulation/UC
M265446.pdf
Information on the food label must include:
Serving or portion size: This is how much of the food is
considered a serving. Packages may contain multiple
servings, so if more is consumed than the serving size
listed, the amount of nutrients/calories consumed must be
adjusted.
Servings or portions per container: Represents the
number of servings (based on the servings size listed) in
the container.
Food energy per serving: The amount of energy (calories)
in the food per serving.
Protein per serving in grams: This is one of the
components in the food that provides energy (i.e., an
energy substrate). Protein calories are calculated as
grams × 4.
Carbohydrate per serving in grams: This is one of the
components in the food that provides energy (i.e., an
energy substrate). Carbohydrate calories are calculated
as grams × 4.
Fat per serving in grams: This is one of the components in
the food that provides energy (i.e., and energy substrate).
Fat calories are calculated as grams × 9.
Sodium per serving in milligrams: Sodium is a component
of salt, which is sodium chloride. Most people should
consume less than 1,500 mg of sodium/day, which is in a
little more than 0.5 tsp of salt.
Protein, vitamins, and minerals as a percent of the U.S.
RDA: This lets you know approximately what proportion of
the daily requirement is derived by consuming a standard
serving of the food.
% Daily Value (DV): This is intended to help people
understand how a food contributes to typical nutrient
requirements.
DVs are average nutrient levels for people consuming
2,000 calories/day. Therefore, a food that contains
10% DV of dietary fiber represents 10% of the fiber
requirements for an individual consuming 2,000
calories over an entire day.
 People consuming more or less than 2,000
calories/day should adjust the DV for the calories
consumed to better understand how the individual
food serving contributes to the estimated nutrient
needs for the day.
One way of interpreting the DV is to assume that 5%
or less suggests the food serving has a low
concentration of a given nutrient, and 20% or more
suggests the food has a high concentration of a given
nutrient. It is generally good to seek foods low in
saturated fat, trans fat, cholesterol, and sodium and
high in vitamins, minerals, and fiber.

It is important for consumers to become fully educated on the

meaning of the information on food labels as it can be misleading
and is often used solely for the purpose of marketing. For
instance, when an olive oil label has No Cholesterol listed on it,
the consumer should know that it would be impossible for olive oil
to have cholesterol, which can only come from animal products.

Professional Organization Position

Statements

Important Factors to Consider

Position statements by professional organizations represent

critically important scientifically based guides that bring
together the state-of-the-art information on specific health
and nutrition-related topics.
The 2009 and 2016 position statements on Nutrition and
Athletic Performance published jointly by several
professional organizations present critical scientific
summaries of how best to achieve both good health and
optimal athletic performance.
The ACSM, AND, and the DOC continue to publish position
statements related to nutrition and physical activity. These
position statements provide excellent science-based summaries
of the state-of-the-art research in the field and provide a good
overview of information in a variety of sports nutrition–related
areas. The 2009 and 2016 positions on “Nutrition and Athletic
Performance,” published jointly by the ACSM, AND, and DOC,
have come to the following conclusions (29, 30):

Athletes need to consume adequate energy during periods of

high-intensity and/or long-duration training to maintain body
weight and health and maximize training effects. Low-energy
intakes can result in loss of muscle mass; menstrual
dysfunction; loss of or failure to gain bone density; an
increased risk of fatigue, injury, and illness; and a prolonged
recovery process.
Body weight and composition should not be used as the sole
criteria for participation in sports; daily weigh-ins are
discouraged. Optimal body fat levels depend on the sex, age,
and heredity of the athlete and may be sport-specific. Body
fat assessment techniques have inherent variability and
limitations. Preferably, weight loss (fat loss) should take place
during the off-season or begin before the competitive season
and involve a qualified sports dietitian.
Carbohydrate recommendations for athletes range from 6 to
12 g/kg body weight/day, depending on exercise intensity
(30). Carbohydrates maintain blood glucose levels during
exercise and replace muscle glycogen. The amount required
depends on the athlete’s total daily energy expenditure, type
of sport, gender, and environmental conditions.
Protein recommendations for endurance and strength-trained
athletes range from 1.2 to 2.0 g/kg body weight/day, with
higher intake levels indicated for short periods during
intensified training or when athletes reduce total energy
consumption (30). These recommended protein intakes can
generally be met through diet alone, without the use of
protein or amino acid supplements. Energy intake sufficient to
maintain body weight is necessary for optimal protein use and
performance.
Fat intake should range from 20% to 35% of total energy
intake. Consuming ≤20% of energy from fat does not benefit
performance. Fat, which is a source of energy, fat-soluble
vitamins, and essential fatty acids, is important in the diets of
athletes. High-fat diets are not recommended for athletes.
Athletes who restrict energy intake or use severe weight loss
practices, eliminate one or more food groups from their diet,
or consume high- or low-carbohydrate diets of low
micronutrient density are at greatest risk of micronutrient
deficiencies. Athletes should consume diets that provide at
least the RDA for all micronutrients.
Dehydration (water deficit in excess of 2%–3% body mass)
decreases exercise performance; thus, adequate fluid intake
before, during, and after exercise is important for health and
optimal performance. The goal of drinking is to prevent
dehydration from occurring during exercise, and individuals
should not drink in excess of sweating rate. After exercise,
∼16–24 oz (450–675 mL) of fluid for every pound (∼0.5 kg) of
body weight lost during exercise should be consumed.
Before exercise, a meal or snack should provide sufficient fluid
to maintain hydration, be relatively low in fat and fiber to
facilitate gastric emptying and minimize GI distress, be
relatively high in carbohydrate to maximize maintenance of
blood glucose, be moderate in protein, be composed of
familiar foods, and be well tolerated by the athlete.
During exercise, primary goals for nutrient consumption are to
replace fluid losses and provide carbohydrates (∼30–60
g/hour) for maintenance of blood glucose levels. These
nutrition guidelines are especially important for endurance
events lasting longer than an hour when the athlete has not
consumed adequate food or fluid before exercise or when the
athlete is exercising in an extreme environment (heat, cold, or
high altitude).
After exercise, dietary goals are to provide adequate fluids,
electrolytes, energy, and carbohydrates to replace muscle
glycogen and ensure rapid recovery. A carbohydrate intake of
∼1.0–1.2 g/kg/hour is required for the first 4 hours, followed
by resumption of daily fuel needs (30). Proteins providing ∼10
g essential amino acids (or 0.25–0.3 g/kg body weight) should
 be consumed early in the recovery phase (0–2 hours
postexercise) for aiding in muscle recovery and muscle
protein synthesis (30).
In general, no vitamin and mineral supplements are required
if an athlete is consuming adequate energy from a variety of
foods to maintain body weight. Supplementation
recommendations unrelated to exercise, such as folic acid for
women of childbearing potential, should be followed. A
multivitamin/mineral supplement may be appropriate if an
athlete is dieting, habitually eliminating foods or food groups,
is ill or recovering from injury, or has a specific micronutrient
deficiency. Single-nutrient supplements may be appropriate
for a specific medical or nutritional reason (e.g., iron
supplements to correct iron-deficiency anemia).
Athletes should be counseled regarding the appropriate use of
ergogenic aids (products advertised as performance
enhancers). Such products should only be used after careful
evaluation for safety, efficacy, potency, and legality.
Vegetarian athletes may be at risk for low intakes of energy,
protein, fat, and key micronutrients such as iron, calcium,
vitamin D, riboflavin, zinc, and vitamin B12.

Consultation with a sports dietitian is recommended to avoid

these nutrition problems.
In addition, there are other position stands published by the
ACSM that have important nutritional implications. These include
positions on the following topics, which will be covered in greater
depth later in this book:

Exercise and cardiovascular fitness (7)

Physical activity and bone health (16)
Prevention of heat- and cold-related illnesses during distance
running (1)
The Female Athlete Triad (24)
Weight loss in wrestlers (27)

The IOC and international governing bodies (e.g., Fédération

Internationale de Gymnastique, which is the international
governing body for gymnastics in sport) also publish nutritionally
relevant scientifically based guidelines. Each sporting category,
such as swimming, track and field, soccer, has an international
governing body. The IOC has published an important consensus
statement outlining the problems faced by athletes who
experience RED in sport. This consensus statement outlines
numerous problems that occur when RED occurs (i.e., when a
person exercises without having consumed sufficient calories to
support the activity). These problems are wide-ranging and
include both performance-related issues (Figure 1.5) and health-
related issues (Figure 1.6). This consensus is an important
scientific statement on the importance of considering both
exercise and nutrition as jointly critical for achieving optimal
health and performance (21).
FIGURE 1.5: Potential performance effects of relative energy
deficiency in sport. RED-S, relative energy deficiency in sport
(From Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC
consensus statement: beyond the Female Athlete Triad-Relative
Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014;48:491–
7.) (*Aerobic And anaerobic Performance.)
FIGURE 1.6: Potential health consequences of relative energy
deficiency in sport. RED-S, relative energy deficiency in sport
(From Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC
consensus statement: beyond the Female Athlete Triad-Relative
Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014;48:491–
7.) (*Psychological consequences can either precede or be the
result of RED-S.)

Nutrition Myths and Misinformation

 Important Factors to Consider

Nutrition myths are commonly held by many people and

often become the standard of understanding for how to
achieve desired nutritional goals. This makes it exceedingly
difficult to help people achieve desired goals through
science-based rather than myth-based strategies. For
instance, athletes wishing to reduce weight will follow a
standard calorie-restricted weight reduction diet, even
though there is scientific evidence that these diets are
counterproductive in achieving optimal athletic
performance.
There are many protein-related myths in athletic
environments that fail to produce the desired outcome of
more muscle and less body fat. Science-based strategies for
how to best consume protein to achieve these goals are far
more effective and provide a good way to help athletes
believe in the science rather than the myth.

There are many myths associated with nutrition that make it more
difficult to help people achieve a good nutritional status. Some of
these myths have become so embedded in our culture that they
are treated unquestioningly as fact. For instance, there is a
common belief that eating anything after 7:00 PM will serve to
increase obesity risk. However, some cultures that eat late at
night have lower obesity rates than those that do not, and the
physiological reason for this is clear: blood sugar fluctuates in 3-
hour units. That is, blood sugar reaches its peak about 1 hour
after you eat and is back to premeal levels 2 hours after that. So,
if dinner is finished at 7:00 PM and bedtime is 11:00 PM, it is
possible that low blood sugar will be achieved before bedtime and
will stimulate the production of stress hormone (cortisol), which
lowers lean mass and bone mass (5). So although weight may
temporarily go down with this strategy, it is possible that the
proportion of fat mass rises. Here are some of the common myths,
more fully addressed in subsequent chapters, that are related to
nutrition and physical activity:
Going on a severe caloric restriction will make you less obese.
In fact, caloric restriction is likely to result in a greater loss of
metabolic mass than fat mass, increasing relative body
fatness and risk of obesity (4, 20, 26).
3,500 calories equals 1 pound. This relationship is typically
used to demonstrate that if you restrict energy intake by 500
calories every day, you will accrue a 3,500 calorie deficit by
the end of the week and will have lost 1 lb. There are no
studies showing that this relationship between energy
consumption and expenditure is valid for humans (12).
Ideally, athletes should consider the importance of
dynamically matching energy intake and energy expenditure
during the day, rather than simply calculating “energy IN vs.
energy OUT” over 24 hours as if the endocrine system does
not respond to energy balance fluctuations in real time.
Eating late at night will make you fat. Fat loss and fat gain are
complex metabolic issues, but it is clear that a failure to
sustain normal blood sugar may increase stress hormone
production, which may cause a loss of lean tissue and make
you relatively fatter. Avoiding severe hunger, including eating
a small amount in the evening if that is what it takes, is a
good strategy for lowering the risk of developing higher body
fat.
Eating extra protein will build muscle. Building muscle is
complex and includes having sufficient energy, protein,
nutrients, and muscle stimulation (i.e., exercise) to cause the
muscle to increase. Simply eating more protein by itself will
not build muscle.
Cholesterol-free foods are heart-healthy. Heart disease may
occur from multiple factors, including genetic predisposition,
body fat level, and the consumption of fats and sugars. Some
cholesterol-containing foods (for instance, eggs) are relatively
low in fat and do not contribute significantly to heart disease
if consumed without added fats. In general, high-fat diets,
even if they are cholesterol free, contribute to heart disease.
Athletes do not develop low bone density. A major factor in
higher bone density is putting additional stress on the
skeleton, which most athletic events tend to do. However,
athletes who fail to eat sufficient energy have inadequate
calcium intakes and have poor vitamin D status, or
amenorrheic female athletes (often the result of insufficient
energy consumption) may develop low bone density and put
themselves at increased risk of fracture.
Food cravings are a good sign that the foods you crave will
provide the nutrients you need. There is no evidence that
food cravings target nutritional need. Most food cravings are
the result of multiple factors including, but not limited to,
environmental stimuli, coping strategies, past eating habits,
or a restrictive eating behavior that may lead to the desire to
consume a food that was restricted.
Herbal products are natural so therefore they are safe. Herbal
products may or may not be safe, depending on whether the
contents listed on the label are truly the contents of the
supplement. Herbal supplements should contain a secondary
label indicating that the contents have been tested by an
independent lab to increase confidence that they are safe.
Additionally, herbal products may be unsafe due to medical
conditions, drug–herb interactions, and other medically
related issues that should make athletes cautious about their
random and unsupervised use.
Water is the perfect hydration beverage. When a person
exercises, they lose water and electrolytes, and because of a
higher brain and muscle tissue demand, blood sugar may
drop rapidly. The ideal hydration beverage should, therefore,
contain what is being lost/used (water, electrolytes,
carbohydrate), particularly for exercise/activity lasting longer
than 1 hour.
All fats are bad. Some fats contain the essential fatty acid(s),
so are necessary for sustaining good health, and some fats
have anti-inflammatory effects that are desirable. So, not all
fats are bad. However, overconsumption of saturated or trans
fats increases the risk of obesity and heart disease, so the
amounts consumed should be considered a critical factor in
both health and performance.
Carbohydrates will make you fat. Not all carbohydrates are
the same. Fresh vegetables and fruits and whole grain cereals
are carbohydrates that are likely to reduce the risk of obesity
and contain dietary fiber that is important for glycemic control
 and gut health. Highly refined carbohydrate (sugars and
refined grains) if consumed in excess may stimulate fat
production through excess insulin production.
Periodic fasting helps to cleanse toxins from your body. The
human system, assuming good hydration and nutritional
status, has an excellent ongoing strategy for removing toxins
that does not require periodic fasting.

Nutrition Science

Nutrition is a science that draws upon multiple sources of

information derived from different types of studies. Nutrition
research draws upon epidemiological, experimental, and clinical
trial evidence to determine the best strategies for people to eat
for health and performance.

Research

This represents a systematic and structured investigation to

confirm the cause of an existing condition, discover new facts
about a condition, or develop new conclusions about a
condition. As the name implies, it is a repeated search for the
truth. Different types of research may provide different levels of
understanding about a research question, so care must be
taken to not come to conclusions that are not warranted. For
instance, some research finds associations between factors, but
these associations are not causative. As an example, reading
that those with cardiovascular disease consume high amounts
of decaffeinated coffee should not make you think that
consumption of decaffeinated coffee causes heart disease. It is
more likely, in this example, that this association exists because
people with cardiovascular disease are told to consume
decaffeinated rather than regular coffee.

Following are three types of research studies:

 Epidemiological research: The study of defined populations to
assess the patterns of conditions, their causes, and how these
conditions may impact health and disease.
Experimental research: A type of study that has an
intervention (treatment, program, procedure, etc.) introduced
to determine how it affects the studied population. Control
groups are often used to see how the intervention group
differs from the control group.
Clinical trial research: An experiment conducted on relatively
large populations to determine the effectiveness of a
treatment, such as a food or a dietary supplement. This is
experimental research, but conducted on a larger segment of
the population to determine safety and efficacy.

Nutrition studies often assess the impact of food or nutrients,

asking this question: Will the person consuming this food or
nutrient do better in this outcome? The outcome can be any
number of factors, such as lower cholesterol, better iron status,
improved endurance, or better exercise recovery. Human studies
in the area of nutrition are difficult because the subjects of the
studies are typically free-living and, therefore, it is hard to control
all aspects of their lives that may influence the outcome of study.
Also, the information derived from the subjects is often self-
reported, with no capacity to check on the accuracy of the
information provided. It is common, for instance, to obtain a 24-
hour dietary recall as a research strategy to understand the
nutrient and calorie exposure a person has. However, people may
forget all the foods they consumed, how the foods were prepared,
or how much of a food they consumed, all of which may result in
inaccurate results. To counteract this problem, researchers try to
obtain information from as many subjects as possible so that a
more true population average is obtained. For instance, one
subject who overreports intake will be countered by another
subject who underreports intake. Also, some nutrients require
more days of intake information to fully understand the typical
intake, because people do not eat the same thing every day. As
an example, typical calorie intake can be estimated from 2 to 3
days of food intake, whereas vitamin C intake may require 20–30
days of intake to obtain a true average consumption pattern
(Figure 1.7) (2). To make the interpretation of dietary studies even
more complex, few studies go beyond assessing nutrient
exposure from diet. We know, however, that it is also important to
understand if the consumed nutrients were actually absorbed and
used, or if a nutrient is excreted.

FIGURE 1.7: Days required to estimate average nutrient intake.

(Modified from Basiotis PP, Welsh SO, Cronin FJ, Kelsay JL, Mertz
W. Number of days of food intake records required to estimate
individual and group nutrient intakes with defined confidence. J
Nutr. 1987;117:1638–41.)

Conditions Affecting Nutritional Status

Following are various conditions that have an impact on
nutritional status:

Inadequate intake: People may not eat enough for a variety of

reasons, including inadequate income, loss of appetite
because of a medical or psychological problem, physical
incapacity that makes it difficult to eat, food allergies that
may limit the intake of whole categories of foods, or drugs
that should not be taken with certain foods.
Inadequate absorption: Some individuals may have a GI
problem, such as IBS or celiac disease that affects their ability
to absorb some of the nutrients they have consumed. Some
drug therapies also may produce side effects that inhibit the
absorption of specific nutrients. Other issues that may have
 an impact on nutrient absorption include parasites in the GI
tract and surgical removal of a proportion of the small
intestine.
Defective utilization: This occurs when nutrients are
consumed and absorbed, but a metabolic failure makes it
impossible to properly use the nutrient. There are numerous
reasons that this may occur, including:
inborn errors of metabolism, such as phenylkenonuria,
which makes it impossible to use the amino acid
phenylalanine;
drug–nutrient interference (the drug Dilantin [phenytoin],
for instance, interferes with the utilization of vitamin C);
and
alcohol-related liver problems (b-vitamin coenzymes may
not be manufactured properly with heavy alcohol
consumption).
Increased excretion: Vomiting and diarrhea cause people to
lose nutrients that may otherwise have been absorbed and
used. Also, a draining abscess is a common source of nutrient
loss.
Increased requirements: A number of conditions may increase
the requirement for energy and/or nutrients, which must be
factored into whether a person is consuming an appropriate
amount. For instance, an increase in physical activity, an
infection, pregnancy, any growth period, a burn, any source of
stress, and hyperthyroidism all increase the requirement for
both energy and nutrients.

Care should be taken to not assume that an inadequate intake

may be best resolved through the intake of a supplement, as the
supplement may cause unexpected problems. For instance, a
study found that vitamin E supplements, when compared with a
placebo and taken prior to a competitive triathlon, promoted lipid
peroxidation and inflammation during the triathlon (25). Another
study found that there is no convincing evidence that immune-
boosting supplements, including high doses of antioxidant
vitamins and zinc, prevented exercise-induced immune
impairment (10). A study assessing dietary supplements and
mortality rate in older women (The Iowa Women’s Health Study)
found that, with the exception of calcium supplementation, all
other vitamin and mineral supplements were associated with
higher mortality rates (22). More discussion on specific vitamin
and mineral requirements and how best to resolve issues of
deficiency and toxicity can be found in Chapters 3 and 4.

Scope of Practice

Important Factors to Consider

Many people claim to be nutritionists and provide

individuals with information that is intended to enhance
health and/or performance. However, most states have laws
that restrict the type of nutrition guidance that can be
provided, depending on the certification(s) of the individual.
Certified fitness professionals without state-mandated
certification (often dietetic licensure) typically are
considered to be outside their scope of practice if they
make recommendations to resolve a clinical condition
through nutritional means. For instance, it would be
inappropriate for someone without the appropriate state
license to recommend a supplement or a diet to someone
who has been diagnosed with heart disease or metabolic
syndrome.

Currently, 47 of 50 states have laws regulating the practice of

nutrition and dietetics, with guidelines clarifying what can or
cannot be discussed with clients. As this is a matter of law, people
who practice within the field of nutrition and dietetics are subject
to prosecution if they exceed the stated boundaries within the
law. Importantly, there are guidelines for all health professionals
who discuss matters related to nutrition with their clients. These
guidelines are important because many fitness professionals with
inadequate nutrition training, no certifications, or lack of state
licensure often exceed their scope of practice by making
inappropriate recommendations for special diets that are meant
to resolve clinical conditions and/or recommend dietary
supplements that are intended to resolve a disease state. It is also
inappropriate for fitness professionals to recommend a nutrient
supplement to enhance performance if the nutrient content of the
supplement exceeds the recommended DRI amount. There are
numerous reasons for why these recommendations should not be
made, including not knowing the health history of the individuals
to whom the recommendation is made, potentially increasing
health risks. See Box 1.3 for terms commonly used when
discussing the scope of practice.

Box 1.3 Common Terms Related to Scope of Practice

Registered Dietitian (RD) or Registered Dietitian

Nutritionist (RDN): Individuals who have completed a
specific course of study and practice hours are eligible to sit
for a national registration examination which, when passed,
allows them to have the title RD or RDN. People with this
certification have the largest scope of practice in the area of
nutrition and dietetic practice.
Licensure: Most states have dietetic/nutrition licensure,
where people acting outside their established scope of
practice can be prosecuted. Typically, only individuals with
the RD or RDN certifications can become licensed.
Certification: Some states have certification where RD or
RDN certifications qualify for state certifications. In these
states, noncertified people are not allowed to refer to
themselves as nutritionists, but they have greater scope of
practice in nutrition than in states that have licensure.
Registration: The State of California has registration that
makes it possible for RDs and RDNs to practice in the area
of nutrition and dietetics, and that makes it illegal for
unregistered individuals to refer to themselves as
“nutritionists” or “dietitians.” However, there is no
registration examination and enforcement of registration
rules is minimal.
 There are, however, a number of ways that someone who is
not an RD or RDN can work to help people make better nutritional
choices. Importantly, to make these nutritional recommendations
people must understand the health implications of the
recommendations they are making by knowing the science behind
the recommendations. It is also important to understand that
recommendations must be limited to nutritional recommendations
that are based on the federal dietary guidelines, discussed earlier
in this chapter. Noncertified/licensed/registered individuals should
not make recommendations that are intended to resolve a clinical
condition on diagnosed disease, as this is considered to be out of
the established scope of practice. For instance, it is acceptable to
discuss with individuals and groups the general principles of good
nutrition. But it is not acceptable for a
noncertified/licensed/registered individual to answer a question
from anyone in that group who raises his or her hand and says: “I
have just been diagnosed with hypertension. Can you tell me
what I should do nutritionally?” or “I have just been told I have
heart disease. Is there something I should be doing nutritionally?”
These are complex issues that require the full knowledge of the
person’s medical background, health history, eating behaviors,
and prescribed medications. It is inappropriate for anyone without
this knowledge and without the proper licensure or certifications
to make any statement or recommendations regarding these
questions. Put simply, noncertified, nonlicensed, and
nonregistered individuals may talk about the general nutrition
guidelines associated with sustaining a good state of nutritional
health, but are considered out of their scope of practice if they
discuss nutrition in the context of a disease state.
According to the American Council on Exercise position
statement, there are many appropriate avenues for nonlicensed
professionals to discuss nutrition for health without exceeding the
scope of practice (23). These include:

Developing cooking classes to show healthy cooking

techniques
Establish recipe exchanges for high-nutrient-density meals
Creating creative handouts and information packets that
motivate people to make appropriate nutritional changes
 Giving nutrition sessions to groups that target key points in
the U.S. Dietary Guidelines
Scheduling individual sessions to discuss strategies for
improving nutrient and calorie exposure

Importantly, scope of practice considerations are meant to

improve client outcomes. The best outcomes are based on
scientific evidence that includes research, national guidelines and
policies, professional organization consensus statements,
systematic analysis of clinical experience, quality improvement
data, and the specialized educational background, knowledge
base, and skills of those providing the information and service (9).

Summary

Nutrition is a science with several established rules that have

evolved through many years of cumulative scientific
evidence. These basic rules include the following:
Consuming more of any nutrient than your body requires
does not make you healthier, and it does not improve
athletic performance. Example: The recommended daily
intake for vitamin C is ∼60 mg, and there is no evidence
that having 500 or 1,000 mg will somehow magically
make you healthier or perform better. With some
nutrients, having more than you require actually makes
matters worse.
Consuming a variety of foods is critical to assuring that
body tissues are exposed to all the energy substrates,
vitamins, minerals, and phytonutrients your body
requires. Thinking that any single food is “perfect” and
should, therefore, be consumed with great frequency
simply limits exposure to other required foods. No single
food is perfect.
Energy consumption should ideally dynamically match
requirement to avoid long periods in the day with
excessively high or excessively low energy balance.
Physical activity increases the rate of energy utilization that
must be matched with energy availability. Just consuming
more vitamins, for instance, does nothing to satisfy the
requirement for energy, and just consuming more protein fails
to provide the vitamins needed to metabolize the protein and
fails to satisfy tissue and blood carbohydrate requirements.
Increased energy utilization requires the consumption of more
foods that contain a variety of energy sources, vitamins, and
minerals to satisfy need.
Physical activity increases energy metabolism, which is heat
creating. Because the heat of exercise cannot be retained,
exercise is associated with increased sweat production as the
body attempts to dissipate the exercise-associated heat
production. Failure to consume sufficient fluids of the right
kind and in the right amount to sustain blood volume is a sure
way to reduce athletic performance, and the resultant
dehydration places the athlete at greater risk of heat illness.
The higher the intensity of physical activity, the greater the
proportionate reliance on carbohydrate as a fuel.
Sport traditions often inhibit athletes from pursuing
appropriate nutritional strategies to optimally benefit from
training and may place athletes at risk of developing
nutritionally related disorders.
Making “weight” through caloric restriction is now known to
be counterproductive, as a failure to satisfy energy needs
results in adaptive-thermogenesis (i.e., a metabolic
adaptation that excessively lowers the rate of energy
metabolism), and is likely to lower more lean mass rather
than fat mass.
Protein intake often far exceeds requirement, as athletes
often believe that protein consumption will, by itself, help to
build and maintain musculature. In fact, the recommended
protein intake for athletes, ranging from 1.2 to 2.0 g/kg, is
easily obtained from food without the need for additional
protein supplementation.
The manner in which protein is consumed, often as part of
large infrequent meals, is not the best way to ensure that the
protein can be used to build and repair tissue. Ideally, protein
should be consumed in relatively small amounts (∼30
g/meal), with enough meal frequency to satisfy need.
Some nutrients are referred to as essential, whereas others
are referred to as nonessential, but this can be misleading as
all nutrients are needed to sustain health. An essential
nutrient is a nutrient that our tissues cannot manufacture
from other body chemicals, so it is essential that we consume
it. A nonessential nutrient is one that our tissues can
manufacture from other body chemicals, so it is not essential
that we consume it. An example is essential and nonessential
amino acids. If we consume the essential amino acids, we can
manufacture the nonessential amino acids.
DRIs have been established to help people understand how
much of any nutrient is appropriate to consume on a daily
basis (the RDA) and how much of any nutrient is excessive
(the safe UL). It is important to understand that these are
guidelines and that body tissues can store nutrients, allowing
for some daily fluctuation in nutrient intake without
compromising health.
Dietary guidelines are also available to provide eating
guidance by encouraging people to maintain energy balance
and by focusing on nutrient-dense foods. Following the dietary
guidelines will help people avoid the development of common
chronic disorders, including cardiovascular disease and
diabetes.
Regular physical activity is an important component of
maintaining health and fitness. Guidelines for physical activity
frequency, time, and type have been developed for children,
adults, pregnant women, people with disabilities, and older
adults.
Food labels should be reviewed carefully, as they provide
important information on the nutrient content and energy
density of the food. Because food labels contain established
terms (i.e., diet or dietetic), it is important to fully understand
the meaning of these terms.
Professional organizations, including the ACSM, have a variety
of science-based position papers on nutrition and athletic
performance (the most recent paper on this topic is 2016).
These position papers include important information on the
best nutrition strategies for achieving optimal performance
while sustaining good health.
 Conditions affecting nutritional status include inadequate
nutrient/energy consumption, inadequate absorption of
consumed foods, defective utilization of absorbed nutrients,
increased excretion of nutrients, and conditions requiring
more nutrients.
Scope of practice is an important consideration before giving
out nutrition information, as most states have nutrition-
associated licensure requirements (i.e., licensed dietitian) for
anyone providing clinically based nutrition information. Those
without the appropriate nutrition certification(s) have limits on
the kind of nutrition information they can provide.

Practical Application Activity

You are likely to find that the nutrients and energy in the foods
and beverages you consume are not what you may think. But
with an analysis you can begin to see the weaknesses in your
diet. Using the National Nutrient Database for Standard
Reference (available from:
https://ndb.nal.usda.gov/ndb/search/list?
SYNCHRONIZER_TOKEN=461cf78c-0645-4c15-a298-
d43422cf8a2a&SYNCHRONIZER_URI=%2Fndb%2Fsearch%2Flist
&qt=&ds=Standard+Reference&qlookup=&manu=), analyze a
standard day of intake for selected nutrients and compare your
intake with the RDA for your age and sex, according to the
following directions:

1. Create a spreadsheet organized as follows (select the

nutrients listed and any additional nutrients you are
interested in for which there is an RDA):
 2. When you log into the National Nutrient Database using the
preceding link, select the Food Search option, enter a
description of the food you wish to analyze (e.g., Corn Cob;
Broccoli Cooked), and press Go.
a. A list of foods in the database that match your entry will
appear. Select the food that comes closest to what you
ate. The nutrients associated with the food will appear,
with different amount options.
b. Find a unit of measure (cup, package, etc.) that you can
adjust for the amount that you consumed. For instance,
if one of the standard units of measure is “Cup” and you
had 1.5 cups, put the amount you consumed in the unit
of measure you selected.
c. Select the nutrients under “Cup” (or any other unit of
measure you adjusted) to enter into your spreadsheet.
d. Repeat the above until all the consumed foods have
been analyzed.
3. Review the analysis to see the vitamins and minerals that
are below the RDAs.
4. Make an adjustment in your food intake by eliminating
foods that are poor sources of nutrients and/or adding those
foods that can deliver the nutrients that you need more of.
5. Keep adjusting the foods until you can see an
approximation of what you would need to eat to expose
your tissues to the required nutrients in the spreadsheet.

Chapter Questions

1. Scope of practice represents the legal scope of work based on

academic training, knowledge, and experience. Which
profession is able, within their scope of practice, to provide
dietary information for helping an athlete for a nutritionally
related condition?
a. Nutritionalist
b. ACSM-Certified Health/Fitness Instructor
c. ACSM-Registered Clinical Exercise Physiologist
d. RD
 e. b, c, and d
2. Correlation refers to
a. A causal relationship between the same variable between two
different groups
b. A noncausal relationship between different variables
c. The degree to which two groups of people are the same on
any given factor (variable).
d. A relationship that implies direction (i.e., as weight goes up in
one group, weight goes down in another).
3. According to the Dietary Supplement Health and Education Act,
the term dietary supplement is defined as a “vitamin, mineral,
herb, botanical, amino acid, metabolite, constituent, extract, or
a combination of any of these ingredients.”
a. True
b. False
4. The term macronutrients typically refers to:
a. any nutrient that provides energy
b. the eight key nutrients needed for good health
c. carbohydrates, proteins, and fats
d. vitamins and minerals
5. Which of the following best describes the term DRIs?
a. Minimum amount of nutrients needed by an individual each
day
b. Maximum amount of nutrients that should not be exceeded
each day
c. Current nutrient standard for individuals
d. Eight key nutrients needed for good health
6. If a food contains 350 calories, how many kilocalories does it
contain?
a. 148
b. 350
c. 1,480
d. 3,250
7. All of the following may negatively affect nutritional status,
except:
a. Inadequate intake
b. High absorption
c. Defective utilization
d. Increased excretion
 e. Increased requirements
8. An effective strategy for lowering obesity is to pursue a
calorically restrictive diet.
a. True
b. False
9. Following exercise, consumption of _______ carbohydrate for the
first 30 minutes following exercise, and again every 2 hours for
4–6 hours is sufficient to replace glycogen stores.
a. 0.5–0.8 g/kg
b. 1.0–1.5 g/kg
c. 2.0–3.0 g/kg
d. 6.0–7.0 g/kg
10. On food labels, the term cholesterol-free means that there is
no cholesterol in the food.
a. True
b. False

Answers to Chapter Questions

1. d
2. b
3. a
4. c
5. c
6. b
7. b
8. b
9. b
10. b

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m#images
CHAPTER OBJECTIVES

Understand the structure of different types of dietary

carbohydrates and the foods that are good sources of each
type.
Review the primary functions of dietary carbohydrates.
Know how to calculate the carbohydrate calories derived from
consumed foods and whether the carbohydrate intake will
satisfy metabolic requirements.
Identify the different digestive enzymes that are specific to
carbohydrates and the origin of these enzymes.
Know the energy producing carbohydrate metabolic pathways.
Understand the function of insulin, epinephrine, and glucagon,
and how these are related to blood sugar.
Know the difference between glycemic index and glycemic load
and how the glycemic effect of foods can affect carbohydrate
metabolism.
Identify human carbohydrate storage systems, the typical
maximal storage capacity, and how storage in each storage
depot may be affected by diet and activity.
Review the different possible pathways for blood glucose, and
the likely pathway(s) with different blood glucose levels.
Based on the sugar, starch, and dietary fiber content of foods,
explain how different carbohydrate sources are preferred in
different circumstances (i.e., pregame, during activity,
postactivity, and long-before activity).
Discuss the preferred carbohydrate composition and
concentration in sports beverages.
 Review the possible sources for making carbohydrate from
noncarbohydrate sources (gluconeogenesis).

Case Study

Sally was working hard to be a world-class distance runner with

the goal of making the marathon team for the next Olympic
Games in 3 years. She had moved to train with a well-regarded
coach, with whom a plan was developed that included a strict
training regimen for daily/weekly mileage and selected
competitions to confirm that the training was going as
expected. Both Sally and her coach were weight conscious,
trying to make sure that Sally ate just enough to support her
weight but not so much that her weight would increase. There
was some justification for this, as the trend for successful
Olympic marathon runners was to be smaller (recent successful
male Olympians were typically less than 115 lb, and successful
female Olympians were less than 110 lb). However, the “fear of
calories” and, especially carbohydrate, that was associated with
the “fear of higher weight” resulted in a failure to optimally
satisfy energy requirements, particularly as the training
progression resulted in longer, harder, faster training mileage.
After a year, Sally lost her period, and she started losing some
sleep (a common outcome of overtraining). She was losing
speed and she felt weaker, so she started eating less
carbohydrate and more protein to try to maintain her muscle
mass. After 6 months, she developed a stress fracture in her
right tibia that stopped the training altogether for 12 weeks.
Luckily, the orthopedist who diagnosed the stress fracture had a
registered dietitian working with her who was herself a runner
and was fully aware of the training demands of elite distance
runners. They had long conversations, and the dietitian knew
exactly what had happened to Sally. Insufficient energy intake is
associated with multiple problems, including low estrogen
production that results in a loss of menses, and estrogen is an
inhibitor of osteoclasts (the cells that break down bones). Also,
inadequate carbohydrate intake resulting in low blood sugar is
associated with high cortisol (stress hormone) production,
which breaks down both muscle mass and bone mass even if
extra protein is consumed. The extra protein Sally was
consuming was all being used to satisfy energy requirements
(i.e., the protein was being utilized as a source of energy rather
than used to sustain or improve the muscle mass). To make
matters worse, not eating enough often leads to extra insulin
being produced when food is consumed, so more fat is
produced, which may cause the runner to want to eat even less.
Therefore, the dietitian showed Sally how to dynamically match
energy intake with expenditure on a reasonable diet that
included plenty of carbohydrates, some fats, and some proteins.
The result was precisely what you would expect when people do
the right things nutritionally, and Sally was on the path to
making the Olympic team.

CASE STUDY DISCUSSION QUESTIONS

1. If you were working with a distance runner, what would you

do to help ensure that energy intake satisfied needs, while
lowering the risk of too little energy consumption?
2. Why would cortisol be elevated, and what would you do to
help bring cortisol down to normal (nonstress) levels?
3. Would a male distance runner experience the same
negative effects of insufficient energy consumption?
4. How often would you need to consume some carbohydrate
to help ensure normal blood sugar?
a. when awake but doing normal daily activity
b. when asleep
c. when physically active

Cortisol

A glucocorticoid steroid hormone that is produced by the adrenal

gland in response to stress and hypoglycemia (low blood sugar). It
functions to increase blood sugar through the breakdown of
tissues that are converted to glucose (gluconeogenesis). It is
important to note that cortisol breaks down muscle, bone, and fat
tissue.
 Insulin

A hormone produced by the β cells of the pancreas that helps to

avoid hyperglycemia (high blood sugar) by enabling cells to take
blood sugar (glucose). A fast rise in blood sugar from
consumption of a large volume of sugar and/or consumption of
high glycemic foods results in a high insulin response that enables
movement of sugars to tissues. However, this may exceed the
tissue requirement for sugar, resulting in tissue conversion of
sugar to fat, leading to an increase in body fat levels. A
chronically high insulin response may lower tissue sensitivity to
insulin, increasing type 2 diabetes risk.

Introduction

Important Factors to Consider

Humans can derive energy from carbohydrate, protein, and

fat, all of which are considered energy substrates. Of these,
carbohydrate is considered a “flexible” fuel because it is the
only energy substrate that can be metabolized both with
oxygen (aerobic metabolism) and without oxygen (anaerobic
metabolism).
The human storage capacity for carbohydrate is limited, with
only ∼300 calories of liver glycogen (which sustains blood
glucose) and ∼1,500 calories of muscle glycogen. By contrast,
even a relatively lean human can store over 62,000 calories
of fat. The limited carbohydrate storage requires that
carbohydrate be consumed frequently to ensure that blood
glucose and muscle glycogen are sustained.

Generations ago, we had culturally appropriate strategies (long

since forgotten) for ensuring that basic physiological needs were
satisfied. With the onset of the industrial revolution, however, we
forgot why we did what we did, and we have been in trouble ever
since. To illustrate this point, consider blood sugar fluctuations.
Blood sugar is the primary fuel for the brain, and it fluxes
approximately every 3 hours while doing normal casual daily
activities (Table 2.1). That is, blood sugar reaches its peak about 1
hour after eating and is back to premeal levels 2 hours after that
(4).

Table 2.1 Tissue Glucose Utilization in the Fasting

and Postprandial* State
Fasting (Mainly Postprandial (Mainly
Insulin Independent) Insulin Dependent)
Tissue/Organ % of Total % of Total
Brain 40–45 ∼30
Muscle 15–20 30–35
Liver 10–15 25–30
GI tract 5–10 10–15
Kidney 5–10 10–15
Other (e.g., skin 5–10 5–10
and blood cells)
*
Period during or immediately after food consumption.
Source: From Gerich JE. Role of the kidney in normal glucose homeostasis and in the
hyperglycaemia of diabetes mellitus: therapeutic implications. Diabet Med.
2010;27(2):136–42.

Failing to consume a source of energy that can stabilize blood

sugar at that time results in a series of hormonal events that can
make a person feel worse and provides a stimulus for the creeping
obesity that currently besets many Western cultures. There is such
a fear of calories that people now migrate toward diet products with
caffeine, which stimulates the brain and masks the very real
physiological hunger that is being experienced. In generations past,
we had a much more effective strategy, referred to as “morning
tea” and “afternoon tea,” to ensure that most people had stable
blood sugar. There is a cost to pay if hunger is allowed to go
unanswered, and the cost gets bigger with each successive day that
the same mistakes are repeated.
Physical activity increases the rate at which energy (i.e.,
calories) is expended, further increasing the risk that energy
demands may not be adequately met. It is troubling that surveys of
physically active people suggest that they often fail to support their
energy needs (7). Specific strategies, therefore, may be required to
ensure that physically active people obtain the needed extra energy
they require.
This chapter discusses carbohydrate, one of the energy
substrates, and the natural push and pull between energy delivery
and the endocrine system so as to create a balance between the
delivered energy and the cellular need for survival (Box 2.1).
Understanding this relationship can help physically active people
eat in a way that optimizes performance, weight, body composition,
and a sense of well-being. There are also common
misunderstandings about proteins and fats, with many
recommending very high intakes of proteins and/or fats to satisfy
energy requirements and to enhance performance. The
performance issues related to the energy substrates are discussed
in this chapter (Box 2.2).

Box 2.1 Energy Delivery of the Energy Substrates

Carbohydrates: 4 calories/g
Proteins: 4 calories/g
Fats: 9 calories/g

Box 2.2 Common Questions About Carbohydrate and

Physical Activity

How much carbohydrate should be consumed immediately

before, during, and after physical activity to optimize
performance?
Should the amount of carbohydrate consumed be different for
endurance vs. power vs. team sport athletes?
If consuming a sports beverage during physical activity, what
is the best concentration of carbohydrate?
Is there any advantage or disadvantage to having different
types of carbohydrate in the sports beverage?
Should physically active people be concerned that
consumption of carbohydrate will increase the risk of
increasing body fat?
 Are there any types of carbohydrate that should be avoided
before exercise? During exercise? After exercise?

Carbohydrate is one of the energy substrates, meaning that it

is a component of food from which we can derive the energy
needed to support body functions. The other energy substrates,
discussed in Chapters 3 and 4, are protein and fat. All
carbohydrates are derived from photosynthesis in plants, and the
most basic forms of carbohydrate in plants are referred to as
monosaccharides and disaccharides, which are also called
sugars (Box 2.3). More complex forms of carbohydrates are made
by plants through the synthesis of monosaccharides into
polysaccharides, which are also called starches and fiber. The
older the plants, the greater the proportion of polysaccharides,
causing them to taste less sweet and have a less tender
consistency. The fruits that are made by plants, however, are
initially high in polysaccharides, but as they age, the
polysaccharides are broken down into their component
monosaccharides and disaccharides, so they become sweeter.
Therefore, the age and ripeness of the plant or fruit consumed
influences the type of carbohydrate that is ingested. Carbohydrate
requirements and sources of carbohydrates in foods are in Box 2.4.

Box 2.3 Carbohydrates Come From Photosynthesis

Solar energy + carbon dioxide from the atmosphere + water

from the ground yield carbohydrate
Solar energy + CO2 + H2O = glucose
Carbo (carbon) + hydrate (water) = carbohydrate

Box 2.4 Carbohydrate Requirements and Food Sources

50–100 g/d of carbohydrate to prevent ketosis (Average U.S.

daily intake is 200–300 g)
 14 g/1,000 calories/d of dietary fiber (average U.S. daily
intake is 10–15 g, or about half the recommended level)
Carbohydrate should provide approximately 45%–65% of total
calories, mainly from complex carbohydrates sources:
Grains
Legumes
Seeds
Fruits
Vegetables

Types of Carbohydrates

Carbohydrates

A class of macronutrients composed of carbon, hydrogen, and

oxygen that is a major source of cellular energy provided by
foods, including grains, vegetables, fruits, and legumes.

Monosaccharides

Often referred to as “sugar,” the main dietary monosaccharides

are the hexoses (6-carbon) glucose, galactose, and fructose, and
the pentoses (5-carbon) ribose and xylose.

Disaccharides

Table sugar is the disaccharide sucrose, which is composed of the

monosaccharides glucose and fructose. Other dietary
disaccharides are lactose (milk sugar), which is composed of the
monosaccharides glucose and galactose; and maltose (grain
sugar), which is composed of the monosaccharide glucose.

Polysaccharides

Carbohydrate that is either digestible (starch and glycogen) or

indigestible (cellulose, hemicellulose, gums, pectins) depending
on the chemical bonds holding the sugar molecules together.
Humans have the digestive enzymes to break the α-1,4 and α-1,6
bonds in digestible polysaccharides, but do not have the enzymes
to break the β-1,4 bonds in indigestible polysaccharides. These
are complex molecules that are composed of many (ten to
thousands) monosaccharides bonded together.

Important Factors to Consider

The Dose Makes the Poison

The physician Paracelsus (1493–1541) stated: “All substances

are poisons: there is none which is not a poison. The right
dose differentiates a poison and a remedy.”
Sugar is clearly one of those substances that is a required
energy source for tissues and a basic building material for the
creation of other substances. However, provided in excess it
can result in tissue damage and disease (20).

Monosaccharides
Monosaccharides (mono = single; saccharides = sugars) represent
the most elemental form of carbohydrates and require no additional
digestion to be absorbed into the blood. The common dietary
monosaccharides are the 6-carbon glucose, galactose, and fructose
(Box 2.5).

Box 2.5 Monosaccharides (mono = 1; saccharide =

sugar. “Monosaccharide” means a 1 molecule sugar)

Hexoses (6 carbon)
Glucose
Fructose
Galactose
Pentoses (5 carbon)
Ribose
Xylose
 Glucose (also referred to as dextrose) is the principal source of
energy for cells and is a moderately sweet sugar derived primarily
from fruits and vegetables. Because of its important function in
cellular energy metabolism, sustaining blood glucose level is an
important strategy for sustaining athletic performance. Sorbitol, the
sugar alcohol of glucose, is commonly used as an agent in
processed foods to retain moisture (3).
Galactose is found as part of the disaccharide lactose (also
called “milk sugar”; see below), which is composed of one molecule
of glucose and one molecule of galactose. Galactose is part of
several compounds called glycolipids (carbohydrate + fat), and
glycoproteins (carbohydrate + protein), and can be manufactured
by mammals from glucose so as to enable the production of lactose.
Fructose is also referred to as levulose and fruit sugar. It is a
component of honey and fruits and has the sweetest taste of all of
the mono- and disaccharides. High levels of fructose may result in
gastrointestinal (GI) distress and diarrhea (54). When high levels are
absorbed into the blood, the liver capacity to convert the fructose
to glucose may be exceeded, with a portion of the fructose being
converted to triglycerides (fats) (1). Some excess fructose may also
be converted to uric acid, which can result in the symptoms of gout
and include joint pain (40).
Ribose is a 5-carbon sugar that is part of the genetic compound
ribonucleic acid (RNA) and deoxyribonucleic acid (DNA). It can also
be converted by cells to provide the carbon chain needed for the
synthesis of the amino acids tryptophan and histidine.
Xylose is a 5-carbon sugar that is the main component of
hemicellulose, an indigestible dietary fiber component, which is
found in many plants/trees. Because it is largely indigestible in the
form commonly consumed, the energy concentration of xylose is
only 2.4 calories/g (68). This alcohol fermentation product of xylose,
xylitol, is sweet tasting but, unlike other sugars, cannot be
recognized as a “food” by oral bacteria. Because it is not
metabolized by these bacteria, xylitol is noncariogenic (i.e., it does
not encourage the development of dental cavities) (Table 2.2) (51).
Table 2.2 Acid Production Rate in
Mouth in Response to
Consumption of Various
Carbohydrates
Sugar Relative Acid Production Rate
Sucrose 100
Glucose 100
Invert sugara 100a
Fructose 80–100
Lactose 40–60
Sorbitol 10–30
Xylitol 0

When bacteria (Streptococcus mutans) metabolize carbohydrate, acids are produced that
have the potential of corroding the tooth enamel and producing cavities.
a
Invert sugar is an equal mix of glucose and fructose from the breakdown of sucrose.
Found naturally in honey and fruits.

Disaccharides
The disaccharides sucrose, lactose, and maltose are common
constituents of consumed foods and are composed of two
monosaccharides joined together with a bond that can be broken
with enzymes specific to the disaccharide (Box 2.6).

Box 2.6 Disaccharides (di = 2; saccharide = sugar.

“Disaccharide” means a 2-molecule sugar.)

Sucrose (glucose + fructose)

Lactose (glucose + galactose)
Maltose (glucose + glucose)

Sucrose is composed of one molecule of glucose and one

molecule of fructose and is a naturally occurring disaccharide of
plants. It is found in particularly high levels in sugar cane and beets,
from which it is extracted for human consumption and is referred to
as “table sugar.” The digestive enzyme sucrase, which is present in
the human small intestine, can break apart sucrose into its
component monosaccharides, and these monosaccharides can then
be absorbed through the intestinal wall into the blood.
Lactose is composed of one molecule of glucose and one
molecule of galactose and is a natural component of mammalian
milk; hence the common name “milk sugar.” The concentration of
lactose in human milk (63–70 g/L) is higher than in cow’s milk (44–
56 g/L) (16). The digestive enzyme lactase, which is present in the
human small intestine, can break apart sucrose into its component
monosaccharides, and these monosaccharides can then be
absorbed through the intestinal wall into the blood. Lactase activity
is high at birth and through infancy but declines after weaning to
solid foods. Because of the gradually reducing lactase production in
many populations, an intolerance to milk (lactose intolerance) is
often observed (74). The indigested lactose then becomes a readily
available “food” for gut bacteria, resulting in bloating, gas, diarrhea,
and GI pain. Most adults, however, produce sufficient lactase to
consume small amounts of lactose dispersed throughout the day
without difficulty, so full avoidance of milk products is not
necessary. Some populations have been found to sustain a high-
lactase production throughout life, suggesting large population
variability in desirable eating patterns. Because milk is an excellent
source of calcium, protein, and riboflavin, there is no reason to
avoid milk unless an intolerance or allergy is present. Some milk
products are fermented (e.g., yogurt, kefir, and cheeses), resulting
in a lower lactose content and improved tolerance by people with
lactose intolerance. There are also products available that contain
the equivalent of lactase, which predigests the lactose in the dairy
product and also improves tolerance (25).
Maltose is composed of two molecules of glucose held together
in a 1,4 α-glycosidic bond and is the sugar associated with grains
and seeds. Often referred to as “malt sugar,” it is digested by the
enzyme maltase, which is present in the human small intestine with
the greatest enzyme presence in the duodenum. Because maltose
is digested into two molecules of glucose that can readily enter the
blood stream and because the digestive enzyme appears early in
the digestive tract, foods that are high in maltose can rapidly
elevate blood sugar (i.e., glucose) and may, as a result, produce an
excessive insulin response that removes too much sugar from the
blood and provides excess sugar to cells. Cells are incapable of
utilizing this excess sugar so manufacture it into fat. (Read about
the glycemic index and glycemic load later in this chapter.)
Trehalose, a disaccharide of two glucose units linked in a 1,1 α-
glycosidic bond, is a naturally occurring nonreducing sugar that is
found in a number of microorganisms, plants, and animals. For over
20 years, the ability of trehalose to stabilize proteins has been
known (17, 63). In addition to the stabilization of proteins, it has
been shown that during freeze-drying trehalose enhances the
stability of living cells. Recently, the positive effects of trehalose on
a variety of cellular processes such as osmotic shock (8),
desiccation (79), and temperature tolerance (31) have been
demonstrated (83).
Most disaccharides are disassociated into monosaccharides early
in the digestive tract (most disaccharidases are in the proximal
duodenum), resulting in fast infusion of monosaccharides into the
plasma when a bolus of sugar is consumed. However, the
disaccharidase trehalase is found throughout the entire length of
the small intestine but in relatively small quantities, which results in
a relatively low glycemic effect but a prolonged sustained blood
glucose with the consumption of trehalose. This characteristic may
be the basis for future research related to strategies for recovery or
strategies for sustaining blood sugar in physically active people.
In nature, trehalose may be found in fungi, the encrustations of
insects, including underwater insects such as lobster and crab
insects, and may be directly consumed as such. In all other natural
sources, trehalose does not accumulate. In addition, for all other
forms of natural trehalose, the plant or organism must be extracted
to obtain the trehalose and then the trehalose purified to food-
grade, a process that makes trehalose both very expensive and
available only seasonally. Many cultures commonly consume
insects, which are a source of both protein and trehalose.
Commercially available trehalose that is suitable for human
consumption is now also available. See Table 2.3 for the relative
sweetness of different carbohydrates.

Table 2.3 Relative Sweetness of

Different Carbohydrates,
From Most Sweet to Least
Sweet
 Sugar 2.3
Table Relative Sweetness
Relative SweetnessScore
of
Different Carbohydrates,
From Most Sweet to Least
Sweet

Sugar Relative Sweetness Score

Sucrose (table sugar, which is 100
the standard against which all
other sugars are compared)
High-fructose corn syrup 120–180
Fructose (sweeter when cool) 110
Xylitol (sugar alcohol from 80–110
xylose)
Glucose 60–70
Mannitol (sugar alcohol from 60–70
fructose)
Sorbitol (sugar alcohol from 60
glucose)
Maltose 50
Trehalose 40–50
Galactose 35
Lactose 20–30
Dietary fiber 0
Starch 0

Sources: Data from references Dansukker.com. Nordic Sugar. Available from:

https://www.dansukker.co.uk/uk/about-sugar/types-of-sugar.aspx. Accessed February 19,
2018; Gwak M-J, Chung S-J, Kim YJ, Lim CS. Relative sweetness and sensory characteristics
of bulk and intense sweeteners. Food Sci Biotechnol. 2012;21(3):889–894; Joesten MD,
Hogg JL, Castellion ME. The World of Chemistry: Essentials. 4th ed. Belmont (CA): Thomson
Brooks/Cole; 2007. p. 359 [Sweetness Relative to Sucrose, Table 15.1]; Noelting J, DiBaise
JK. Mechanisms of fructose absorption. Clin Transl Gastroenterol. 2015;6(11):e120.
doi:10.1038/ctg.2015.50

Polysaccharides
Polysaccharides (Box 2.7) are large molecules of at least 10
monosaccharides held together with bonds that humans are
capable of breaking apart (i.e., digestible polysaccharides), or not
capable of breaking apart (i.e., indigestible polysaccharides). The
dietary digestible polysaccharides are commonly referred to as
starch, which is a storage form of carbohydrate in plants. The
storage form of digestible polysaccharides in humans is glycogen.
Both starch and glycogen combine many molecules of glucose
together, but glycogen can be broken down into its component
glucose molecules quickly, making it an important source of energy
for humans (21).

Box 2.7 Polysaccharides (Poly = many; saccharide =

sugar. “Polysaccharide” means a many molecule sugar.)

Digestible (α-1,5 and α-1,6 glycosidic bonds). These are

polysaccharides that humans can digest and derive energy
from.
Starch
Dextrins
Glycogen
Indigestible (β-1,4 and other bonds). These are
polysaccharides that humans cannot digest, so cannot derive
energy from, and are often referred to as “fiber.”
Cellulose
Hemicelluloses
Pectins
Gums
Mucilages

Note: Dietary fiber includes indigestible polysaccharides and

lignin that cannot be digested by human digestive enzymes but
can be partially digested by bacteria in the colon.

Raw starch is difficult to digest because the carbohydrate is

stored within thin-walled cells that are difficult for digestive
enzymes to penetrate. However, cooking causes the fluid inside the
cell wall to expand, causing the starch to swell and burst and
making it an easily available source of carbohydrate. Imagine
eating raw rice or raw popcorn. Neither could be easily digested.
However, heating the rice or corn kernel liberates the starch inside,
making the starch available for digestion and absorption. Dextrins
are a group of carbohydrates made from the breakdown of either
starch or glycogen, with some forms, such as maltodextrin, used as
food additives to make solutions thicker or creamier. Dextrins,
including maltodextrin, can be easily digested to quickly provide
many molecules of glucose into the blood.
The indigestible polysaccharides are commonly referred to as
fiber or dietary fiber and, while they cannot be digested to provide
energy, are important for sustaining the health of the GI tract.
Different types of dietary fiber, including soluble and insoluble fiber,
have different physiological effects. Foods containing soluble fiber
(gums, mucilages, and pectins) include fruits, oats, legumes, and
barley, and have the effect of decreasing gastric emptying time
(i.e., reduce the amount of time foods are in the stomach), but also
decrease the rate at which glucose is absorbed in the small
intestine. This is an important health benefit, since lowering the
rate of glucose absorption also lowers the insulin response, which
would help to sustain normal blood sugar longer and may also lower
the rate of fat manufacture by cells (46). Foods containing insoluble
fiber (cellulose and hemicellulose) come from foods such as wheat,
vegetables, and seeds and have the capacity to absorb many times
its own weight in water. This increases stool bulk, which improves
peristalsis (the movement of consumed food through the
intestines). If consumed with water, insoluble fiber reduces
constipation risk. However, insoluble fiber increases gastric
emptying time (i.e., foods stay in the stomach longer), which may
not be desirable if consumed prepractice or precompetition, when
you want no foods to be in the stomach during exercise. High-fiber
diets, therefore, may intensify GI complaints in physically active
people when consumed immediately prior to exercise (24).

Dietary Fiber

Also referred to as roughage, it is a term used to describe

indigestible polysaccharides and includes both soluble dietary
fiber and insoluble dietary fiber, both of which have health
benefits associated with lower risk of cancer, better blood sugar
control, and lower risk of heart disease.

Soluble dietary fiber is found in oats, barley legumes, fruits,

and vegetables. It can attach to cholesterol, resulting in
 reduced cholesterol absorption and lower risk of heart
disease. It also reduces rapid blood sugar elevation, lowering
the risk of type 2 diabetes. It has a high affinity for water,
enabling a greater stool bulk that helps to maintain bowel
regularity. This fiber type also improves the good bacteria in
the gut (i.e., the gut microbiome), which is associated with
lower disease risk.
Insoluble dietary fiber is found in wheat bran, seeds,
vegetable stalks, and the skins of fruits. Because of its high
binding affinity for water, it improves stool bulk and reduces
the risk of constipation and related problems (e.g.,
hemorrhoids and diverticulitis).

It should be noted that fruits and vegetables, which are both

excellent sources of soluble fiber (gums and pectins), are also good
sources of oxalic acid, which has a high binding affinity for certain
minerals (in particular, iron, zinc, calcium, and magnesium). If these
minerals become bound to oxalic acid, they are no longer available
for absorption (7). The insoluble fibers (cellulose and hemicellulose)
that are commonly found in the bran portion of cereal grains, are
also a good source of phytic acid. If these same minerals (iron, zinc,
calcium, and magnesium) are bound to phytic acid, they also
become unavailable for absorption (77). An easy strategy for
removing oxalic acid from vegetables is to quickly blanch them in
boiling water, and then prepare the vegetables as desired. Since
oxalic acid has a bitter flavor and children are especially sensitive to
bitter tastes, following this strategy has the double benefit of
improving mineral absorption and also making the vegetables more
desirable for children to eat. The general strategy for reducing the
mineral binding potential of phytic acid is to limit the consumption
of foods that are extremely high in it, such as bran, by substituting
whole-grain cereals (i.e., a bran-only cereal vs. a whole-grain
cereal).

Functions of Carbohydrates

Important Factors to Consider

 Carbohydrates have many functions that are necessary
components of good health and athletic performance.
Consumption of more protein and/or fat is not a replacement
for carbohydrate, and these other energy substrates cannot
adequately fulfill carbohydrate functions.
Low-carbohydrate intakes cause proteins to be broken down
to create needed carbohydrate in the liver (gluconeogenesis),
but because humans have no storage of protein, this process
causes a loss of muscle mass from which the protein is
derived. The protein-sparing effect of carbohydrates,
therefore, is an important part of why carbohydrates are
needed.

Carbohydrates have multiple functions that are critical to both

human health and athletic performance. The basic functions include
the following: (1) providing a source of energy for cellular function,
(2) energy storage as glycogen, (3) sparing protein, (4) breaking
down fats for energy, (5) normal GI function, (6) being a part of
other compounds, and (7) converting carbohydrates to fat.
Importantly, carbohydrate in the blood (blood glucose) is the
primary source of energy for the brain (Box 2.8.)

Box 2.8 Functions of Carbohydrates

Source of energy that can be used with and without oxygen (4

calories/g)
Protein sparing
Complete oxidation of fats
Instantaneous source of energy
Part of other body compounds
Can be converted to and stored as fat for eventual use as
energy
Keeps GI tract healthy

Source of Energy for Cellular Function and Energy Storage

Carbohydrates provide 4 calories/g and are unique among the
energy substrates (carbohydrates, proteins, and fats) in that
carbohydrates have the capacity to provide cellular energy both
anaerobically (without oxygen) and aerobically (with oxygen). The
primary source of energy for cells is glucose, which is a
carbohydrate, and some cells are limited in their capacity to derive
energy from anything but glucose (Figure 2.1). The primary fuel for
the brain and central nervous system is blood glucose, so the brain
is sensitive to abnormal fluctuations in blood glucose that can occur
from infrequent eating (resulting in low blood sugar), or excessive
consumption of refined or simple carbohydrates (i.e.,
monosaccharides and disaccharides), which can cause a sudden
and high rise in blood sugar that results in an excessive insulin
response and low blood sugar (5). We can store a limited amount
(approximately 306 calories for 150 lb person) of glucose in the
liver as glycogen and also a limited amount (approximately 1,530
calories for 150 lb person) of glucose as glycogen in muscles (45).

FIGURE 2.1: What happens to blood glucose.

Simple Carbohydrates
 Another term for sugars, which are easily and quickly
digestible/absorbable disaccharides (sucrose, maltose, and
lactose) and monosaccharides (glucose, galactose, fructose,
ribose, and xylose).

Sparing Protein
A failure to satisfy the tissue requirements for glucose will initiate a
process called gluconeogenesis, or the creation of new glucose
from nonglucose substances. Protein is a primary gluconeogenic
substance, because we have well-established pathways for
converting some amino acids (the building blocks of proteins) to
glucose. These amino acids are appropriately referred to as
glycogenic amino acids. However, we have no storage of extra
protein or amino acids for this purpose, so to obtain these amino
acids for glucose synthesis, we break down body proteins (muscle,
as an example) and deliver the amino acids from these proteins to
the liver, where they are converted to glucose. Therefore,
consuming sufficient carbohydrate spares protein from being
broken down to derive glucose. This is an important consideration
for athletes because glucose is rapidly utilized during exercise. A
failure to maintain sufficient carbohydrate availability in the blood
and muscles will break down the very tissues that the exerciser is
trying to build through exercise.

Gluconeogenesis

The process of generating glucose from noncarbohydrates. For

instance, glycerol, the 3-carbon substance that holds three
molecules of fatty acids to make triglycerides (the common
storage form of fat), can be converted to glucose by the liver.
Glycogenic amino acids, such as alanine and glutamine, also have
liver pathways for conversion to glucose. Lactic acid can also be
converted to glucose. All of these conversions of taking
noncarbohydrate substances and making them into glucose are
considered gluconeogenesis.

Complete Oxidation of Fats for Energy

When fats are broken down to be metabolized as a source of
energy, a small amount of glucose is needed to enable the
complete oxidation of fat. Carbohydrate can be synthesized into
oxaloacetic acid, which is required for fat metabolism. Insufficient
carbohydrate availability causes poor oxaloacetic acid creation,
followed by incomplete fat metabolism, which results in the creation
of ketones. Therefore, ketones are an acidic by-product of
incomplete fat metabolism, and when ketone levels become
elevated, the condition is referred to as ketoacidosis (30). A
common ketone is acetone, which has a unique odor and can be
smelled on the breath of someone who is producing ketones
(acetone smells like nail polish remover). Acetone production is
common when undergoing a fast because available glucose is
depleted, resulting in the incomplete oxidation of fats. The
consumption of ketogenic diets (i.e., high protein, low-carbohydrate
diets) as a strategy to lose weight is common (57). These diets
force the metabolism of fats and proteins for energy, but with poor
carbohydrate availability, these diets result in ketone formation
from the incomplete oxidation of fats (39).

Helps Normal Gastrointestinal Function

Dietary fiber, derived from fresh fruits, vegetables, beans, and
whole grains, is important for sustaining normal GI function.
Inadequate fiber consumption is associated with constipation,
hemorrhoids, diverticulitis/diverticulosis, and higher risk of colon
cancer. There is also evidence to show that regular consumption of
dietary fiber can lower serum lipids, including blood cholesterol,
thereby reducing heart disease risk (46).

Being a Part of Other Compounds

Some glucose is converted to ribose and deoxyribose, which are
molecular components of our genetic structure (RNA and DNA).
Glucose can also be manufactured into nicotinamide adenine
dinucleotide phosphate (NADP), which is needed for the synthesis of
fats and cholesterol. NADP also lowers the risk of cellular oxidative
damage. Carbohydrates are also a part of other compounds, such
as glycoproteins and glycolipids. An example of a glycoprotein is
mucin, which is part of saliva and responsible for making the saliva
sticky and more lubricating than water alone. Glycolipids are
involved in cellular communication and recognition, as different cell
types have different surface glycolipids (52). The blood types A, B,
AB, and O are different, for instance, by the type of sugar that is
part of the glycolipid in the cell membrane (44).

Conversion of Carbohydrates to Fats

Excess carbohydrates that enter cells can be manufactured into fat
for storage and later utilization as a source of energy. Fats are more
efficiently stored as energy, containing 9 calories/g versus 4
calories/g for carbohydrates, and we have no upper limit to fat
storage. By contrast, carbohydrate storage as glycogen in the liver
and muscles has a finite upper limit. Although we can store excess
carbohydrate as fat, it is important to consider that there is no
reverse metabolic pathway for converting fats to carbohydrates.
Because of the ongoing requirement for carbohydrates,
consumption patterns of carbohydrates should dynamically match
requirements to avoid excessive use of the limited glycogen stores
(Figure 2.2).

FIGURE 2.2: Two carbohydrate storage systems to consider.

 Digestion, Absorption, and Metabolism of
Carbohydrates

Important Factors to Consider

Starting with saliva in the mouth, there are many components

of carbohydrate digestion that involve the mouth, stomach,
and small intestine. The more complex the carbohydrate, the
greater the time it takes for digestion and absorption to occur,
and for some carbohydrates (dietary fiber) we do not have
the digestive enzymes needed to digest them and derive
energy from them. However, dietary fiber is an important
component of GI health and so should be consumed as a
regular part of the diet.
Consuming a high level of sugars at one time, which requires
little digestion, causes a large number of sugar molecules to
congregate in the GI tract as they await absorption. This
results in fluids going from the blood into the GI tract to dilute
the sugar. The resulting drop in blood volume that occurs
could negatively impact sweat rates, the delivery of nutrients
to working muscles, and the ability to remove metabolic
byproducts from cells. To sustain physical activity, it is
generally better to consume smaller amounts of sugars more
often than to consume larger amounts at once.

Digestion
The purpose of digestion is to break down consumed carbohydrates
into a form that allows them to be transferred through the intestinal
wall and into the blood, where they can be distributed to cells.
Digestion of carbohydrate takes place in the mouth and small
intestine and involves conversion of more complex
carbohydrates (starch and glycogen) to less complex
carbohydrates (disaccharides) and then to single-molecule sugars
(monosaccharides) to be absorbed (70). A small amount of
carbohydrate digestion takes place in the mouth with salivary
amylase, a digestive enzyme in the saliva. To experience this
digestion, put a small amount of starchy carbohydrate (bread,
cereal, etc.) into your mouth, and leave it there without swallowing.
After a short time you will sense that the food tastes sweeter as the
more complex starch is digested into sugars. The pancreas
produces a major carbohydrate digestive enzyme, pancreatic
amylase, which enters early in the small intestine via the common
duct shared by the pancreas and the gallbladder (41). The
pancreatic amylase converts the remaining polysaccharides into
disaccharides, which are then further digested by disaccharide-
specific enzymes (Table 2.4). The monosaccharides are then
absorbed.

Complex Carbohydrates

Another term for digestible polysaccharides (starch, dextrin, and

glycogen), and indigestible polysaccharides (gums, pectins,
cellulose, and hemicellulose). The indigestible polysaccharides
are also referred to as fiber or dietary fiber.

Table Carbohydrate Digestion

2.4
Organ Role in Digestion of Carbohydrate
Mouth
Salivary amylase initiates the digestion of starch and
glycogen to the disaccharides (maltose, sucrose,
lactose).

Stomach
There are no carbohydrate-specific digestive
enzymes that are present in the stomach. However,
the fluid content and acidity of the stomach may aid
in the digestive process.
 Table Carbohydrate Digestion
2.4
Organ Role in Digestion of Carbohydrate
Small
intestine The pancreas produces a digestive enzyme
(pancreatic amylase), which enters early in the small
intestine via the common pancreatic/bile duct.
Pancreatic amylase is the major digestive enzyme
for starch and glycogen, and fully digests the
digestible polysaccharides to disaccharides.
The small intestine produces disaccharidases
(enzymes that break down the disaccharides to their
component monosaccharides.)
Maltase breaks down maltose to 2 molecules of
glucose
Sucrase breaks down sucrose to 1 molecule of
glucose and 1 molecule of fructose
Lactase breaks down lactose to 1 molecule of
glucose and 1 molecule of galactose.
The monosaccharides are absorbed into the blood in
the small intestine.

Note: The digestive enzymes end in ase, while the sugar it digests ends in ose. Amylose is
another word for digestible polysaccharide, or starch.

Absorption
The monosaccharides are transported into the intestinal wall for
transfer into the blood circulation. Glucose and galactose are
absorbed through a specific transporter (SGLT1), while fructose is
transported by another transporter (GLUT5). Because GLUT5
availability is limited, a high level of dietary fructose intake may
overwhelm the transporter, keeping a significant proportion of the
fructose in the intestines rather than getting absorbed (41, 58).
These molecules of fructose impart a high level of osmolar
pressure, causing fluid to move into the intestines, possibly
resulting in bloating and diarrhea (Box 2.7) It is for this reason that
foods containing added free fructose, as in high-fructose corn syrup,
may not be as well absorbed and cause more GI difficulties than
foods that contain naturally occurring fructose (58).
Osmolarity and Osmolality
Osmolarity is defined as the concentration of a solution expressed
as the total number of solute particles per volume of solution liter
(i.e., per liter and per quart) Osmolality is osmotic concentration per
mass of solvent (i.e., kg solvent/kg solution).
A practical application of this is as follows: 100 calories of
sucrose (a disaccharide) has half the number of molecules that 100
calories of glucose does and therefore imparts half the osmotic
pressure. Fluid moves in the direction of the highest osmolarity, so
for the same caloric load, free glucose will have a greater tendency
to “pull” water toward it. Athletic gels are designed to deliver a high
level of carbohydrate calories in a relatively low osmolar product.
They accomplish this by delivering the carbohydrate in a
polysaccharide gel that has many molecules of monosaccharides
held together in a single polysaccharide molecule. Only the number
of particles per unit volume matters in regard to osmotic pressure,
so a single large polysaccharide molecule imparts far lower osmotic
pressure than its component individual molecules of carbohydrate.
When delivered to the circulation, the portion of the absorbed
monosaccharides that is glucose results in an elevation of blood
glucose concentration. The absorbed fructose and galactose must
be converted to glucose, mainly in the liver, and do not
immediately contribute to the initial elevation in blood glucose. The
rise in blood glucose is dependent on the rate of absorption, which
is dependent on multiple factors (10, 15), including:

The complexity of the consumed carbohydrate. More complex

carbohydrates require more digestion and mediate the
availability of glucose for absorption
Other substances consumed with the carbohydrate. Fats and
proteins delay the gastric emptying rate, thereby mediating the
availability glucose for absorption
The distribution of monosaccharides in the foods consumed.
Pure glucose causes a slight delay in gastric emptying, but once
in the intestines is readily absorbed if the volume of glucose
consumed does not exceed transporter (SGLT1) availability.
Assuming the same calories, a mixture of monosaccharides is
more quickly absorbed than any single monosaccharide, as the
mixture can capitalize on the availability of transporters and
absorption sites.
 Insulin is secreted by the β cells of the pancreas in response to
the rise in blood glucose. Insulin is necessary for the update of
glucose by body cells. A fast increase in blood sugar, however, may
result in a hyperinsulinemic response (i.e., excess insulin
production), which takes too much glucose out of the blood and
puts too much glucose into cells, exceeding normal cellular
requirements and storage capacity. Cells then manufacture the
excess glucose into fat, and export the fat with the result that body
fat mass increases. Insulin production may also be influenced by
the protein and fat content of the meal, with higher amounts
buffering the speed with which glucose is absorbed, thereby
affecting the insulin response.

Unabsorbed Carbohydrate
The indigestible polysaccharides absorb many times their own
weight in water, increasing stool bulk and reducing constipation
risk. Prebiotics are carbohydrates (fiber) that cannot be broken
down by digestive enzymes and do not enter the blood circulation
but stimulate the growth of “healthy” bacteria by becoming a
source of energy/nutrients for the bacteria. The polysaccharides
that can be fermented by intestinal bacteria (the gut microflora) do
not increase stool bulk to the same degree as nonfermentable
polysaccharides but have the advantage of improving the gut
microflora (27, 50). The partially digestible polysaccharides,
including the oligosaccharides common in beans, encourage the
growth of beneficial bacteria, such as bifidobacteria, in the GI tract
and are referred to as probiotics, live bacteria that are the same as
the beneficial bacteria in the human gut, and are consumed as part
of dietary supplements or foods, such as “live-culture” yogurt.
Probiotic foods help to support good bacteria in the gut. Synbiotic
refers to a mix of prebiotics and probiotics, which can provide both
the bacteria and the nutrients (fiber) that can help encourage the
bacteria to flourish. The bifidobacteria that colonize the GI tract
help to protect the gut from the potentially damaging effects of
pathogenic bacteria (28, 65).

After Absorption
The monosaccharides, glucose, fructose, and galactose, are
absorbed into the blood, but only glucose is immediately available
to cells to satisfy metabolic requirements. The circulating fructose
and galactose must be converted by the liver to glucose for these
monosaccharides to be available for cellular use. Once converted to
glucose, the liver may store the glucose as liver glycogen (used to
sustain blood glucose) or may release the glucose directly back into
the blood. The amount of glucose that the liver exports to the blood
is hormonally controlled by the pancreas, which produces both
insulin and glucagon, and the liver. Having either high or low blood
glucose can result in negative health consequences.

Glucagon

A hormone made by the α cells of the pancreas that helps to

avoid hypoglycemia by initiating a slow breakdown of liver
glycogen for the resulting glucose to elevate blood sugar.

Blood Sugar Control

Following a meal, insulin is released when blood glucose rises to
make the excess blood glucose available to cells. The pancreas
monitors the level of blood glucose as the blood flows through it.
When it detects that blood glucose is rising above the desired level
(∼120 mg/dL), it releases the hormone insulin, which affects cell
membranes to allow glucose to enter the cell. The effect of insulin is
twofold: (1) to lower blood glucose and (2) to make glucose
available to cells. As blood sugar continues to drop and reaches its
low threshold (∼80 mg/dL), the α cells of the pancreas release the
hormone glucagon (Figure 2.3). Glucagon signals the liver to break
down liver glycogen and release the component glucose molecules
into the blood. The effect of glucagon is twofold: (1) to raise blood
glucose and (2) to lower liver glycogen stores. Up to the limitations
of eating frequency and glycogen storage, insulin and glucagon
serve to maintain blood sugar within the normal range, while
providing needed glucose to the brain and other body cells.
FIGURE 2.3: How the pancreas and liver sustain normal blood
sugar.

Normal blood glucose maintenance occurs in approximately 3-

hour units (4). That is, following a meal, blood sugar reaches its
peak 1 hour later and is back to premeal levels about 2 hours after
that, suggesting that it is again time to eat. When a person is
physically active, however, blood sugar is used at a much faster
rate, making it necessary for carbohydrate to be consumed more
frequently to sustain blood sugar (Figure 2.4). One of the main
functions of carbohydrate-containing sports beverages is precisely
to ensure that blood sugar is maintained within desirable limits
during exercise. The current recommendation, for people who
exercise 1 hour or longer, is to consume a sports beverage (11, 12,
67). Those who exercise at extremely high intensity may require
sports beverages to sustain blood glucose even if the exercise
duration is less than 1 hour. A failure to sustain normal blood sugar
creates difficulties. Low blood sugar (hypoglycemia) results in
nervousness, dizziness, and faintness. Should hypoglycemia occur
during exercise, it will result in mental fatigue, which is associated
with muscle fatigue (even if the muscles are full of glycogen). In
addition, low blood sugar may result in gluconeogenesis, often
resulting in a breakdown of lean mass (see more on
gluconeogenesis later in this chapter).
FIGURE 2.4: Fuel burned at different exercise intensities. Note: At
higher intensities of exercise, there is an increasingly greater
reliance on muscle glycogen to supply the needed fuel. (Modified
from Romijn JA, Sidossis LS, Gastaldelli A, Horowitz JF, Wolfe RR.
Regulation of endogenous fat and carbohydrate metabolism in
relation to exercise intensity and duration. Am J Physiol.
1993;265:E380–91.)

Hypoglycemia

An abnormally low blood sugar (blood glucose) level that is

commonly the result of excess insulin, either from consuming
high glycemic foods or from taking excess insulin if a diabetic.
Normal blood sugar is in the range of 80–120 mg/dL, and
hypoglycemia is defined as having a blood sugar level of 70
mg/dL or below.

Hyperglycemia

An abnormally high blood sugar (blood glucose) level that is

characteristic of metabolic syndrome and diabetes. Normal blood
sugar is in the range of 80–120 mg/dL, and high fasting blood
sugar (after not eating or drinking for 8 hours) is >130 mg/dL.

Consumption of high glycemic index foods and/or diabetes may

result in high blood sugar (hyperglycemia), which is associated
with dehydration and, if severe, coma. Chronic hyperglycemia
resulting from high body fat levels, excess consumption of food,
inadequate activity, or consumption of high glycemic foods results
in chronic hyperinsulinemia (too much insulin production). This
continuous excess insulin production has the effect of reducing
cellular sensitivity to insulin and is associated with type 2 diabetes
(insulin is produced, but it is ineffective in reducing blood glucose,
so blood glucose is elevated). Type 1 diabetes is also associated
with high blood sugar but is the result from a failure of the pancreas
β cells to produce insulin. Type 1 diabetes is often seen in children,
and may be the result of the body’s immune system destroying the
body cells or a bacterial infection that targets and destroys the β
cells. Type 2 diabetes is often called adult-onset diabetes because
the onset of diabetes was most often seen in adults. However, type
2 diabetes is now being seen with ever increasing prevalence in
obese children. Both type 1 and type 2 diabetes are associated with
high blood glucose. Blood glucose that is above the level of 160
mg/dL exceeds the renal threshold and starts to show up in the
urine. Sugar (glucose) in the urine is a sign of uncontrolled diabetes
(48).
Another hormone that has an impact on blood glucose is
epinephrine (adrenaline), which is produced mainly by the adrenal
glands. It has the effect of rapidly increasing the breakdown of liver
glycogen to infuse a high level of glucose into the blood extremely
quickly (73). It also increases muscle blood flow and heart output. It
is thought that the main purpose of epinephrine is survival in the
“flight or fight” response that occurs when in imminent danger. The
ready availability of energy (blood glucose) coupled with high
cardiac output and improved muscular blood flow serves to help the
individual move extremely quickly and with a high level of power.
However, the quick depletion of liver glycogen also results in low
blood sugar and exhaustion soon after the epinephrine has had its
effect. It is because of this later effect that staying calm and being
familiar with the surroundings (i.e., avoiding an adrenaline
production) is helpful for maintaining athletic performance.
Epinephrine is also used as a medication to treat a severe allergic
response called anaphylaxis. People with allergies often carry with
them an EpiPen Auto-Injector (filled with epinephrine) to quickly
enhance the immune response and avoid the potentially dangerous
effects of a serious allergy (47).
 Epinephrine

Also referred to as adrenaline, this hormone initiates a quick

breakdown of liver glycogen for the resulting glucose to quickly
elevate blood sugar. It also increases the insulin-mediated flow of
the high-energy (i.e., high-glucose) blood to muscles, enabling
fast muscle movement, which is an important component of the
fight-or-flight response associated with epinephrine/adrenaline.
Note: the depletion of liver glycogen associated with epinephrine
is related to exhaustion and signs of hypoglycemia after the initial
epinephrine-induced high-energy state.

Glycemic Index and Glycemic Load

The glycemic index (Figure 2.5) compares the potential of foods
containing the same amount of carbohydrate to raise blood
glucose. However, the amount of carbohydrate consumed also
affects blood glucose and, therefore, the insulin response (5). The
glycemic load is calculated by multiplying the glycemic index by
the amount of carbohydrate (g) provided by a food and dividing the
total by 100. Each unit of glycemic load represents the equivalent
blood glucose-raising effect of 1 g of pure glucose. The dietary
glycemic load equals the sum of the glycemic loads for all the foods
consumed in the diet and may be used to describe the relative
quality of the diet. In general, it is good to be consuming foods with
a relatively low glycemic load (Table 2.5).
FIGURE 2.5: Glycemic index is a measure of how foods have an
impact on blood glucose. Consumption of high glycemic index foods
results in a fast high blood glucose, which is responded to with
excess insulin. This removes too much glucose out of the blood and
puts too much glucose into cells, exceeding cellular requirements.
Cells convert the excess glucose into fat (body fat increases).
Chronically consuming high glycemic index foods results in high
body fat, lower insulin sensitivity, and higher risks of type 2
diabetes. (Modified from Ludwig DS. The glycemic index:
physiological mechanisms relating to obesity, diabetes, and
cardiovascular disease. JAMA. 2002;287:2414–23.)

Table Glycemic Index and Glycemic Load for Selected

2.5 Foods
Food Glycemic Serving Carbohydrate/Serving Glycemic
Index Load/Serving
(Relative
to
Glucose,
Which
Equals
100)
Cornflakes 81 1 cup 26 21
Rice cakes 78 3 cakes 21 17
Baked 76 1 30 23
potato medium
White 73 1 slice 14 10
bread
Table 68 2 tsp 10 7
sugar
White rice 64 1 cup 36 23
(boiled)
Brown 55 1 cup 33 18
rice
(boiled)
Orange, 42 1 11 5
fresh raw medium
 Kidney 28 1 cup 25 7
beans,
boiled
Peanuts, 14 1 oz 6 1
roasted

Glycemic Index

Relative to the standard value of 100 for glucose, the glycemic

index indicates a food’s effect on blood glucose. High glycemic
index foods (i.e., with a value near 100) elevate blood sugar
quickly. Low glycemic index foods (i.e., with a value of <55)
elevate blood sugar slowly. High glycemic index foods initiate a
high insulin response, which puts excess blood glucose in cells,
causing cells to create fats from the glucose for storage and later
use.

Glycemic Load

Similar to glycemic index, but the glycemic load indicates the

impact on blood glucose adjusted for a 100 g serving. A glycemic
load of >20 is considered high, while a glycemic load of <10 is
considered low. For instance, the glycemic index of watermelon
has a relatively high glycemic index value of 72, but a 100 g
serving of watermelon has a relatively low glycemic index of 3.6.

As indicated in Table 2.5, 1 cup of brown rice has a glycemic load

(18) below that of cornflakes (21), despite delivering more
carbohydrate (33 vs. 26 g). Delivering the same amount of
carbohydrate as table sugar, a baked potato will exert a higher
glycemic load (21 vs. 23). The type of carbohydrate consumed,
therefore, matters with regard to the expected endocrine response.
For instance, table sugar is composed of sucrose, which is 50%
glucose and 50% fructose. Baked potatoes are composed of starch,
which is mainly a polymer of glucose. The fructose does not
immediately contribute to the glycemic load, so baked potatoes
have a higher glycemic effect. A lower glycemic load will result in a
lower insulin response, a more stable blood sugar, and a lower rate
of fat manufacture. The general recommendations for carbohydrate
consumption are:

Consume fiber-rich fruits, vegetables, and whole grains often

Try to select foods and beverages with little or no added sugars
or sweeteners

Metabolism
Humans have ongoing energy requirements, and carbohydrates
play an important role in the provision of energy. Ultimately, energy
substrates are metabolized into adenosine triphosphate (ATP),
which is the fuel for all cellular work, including digestion, muscle
contraction, nerve transmission, circulation, tissue synthesis, tissue
repair, and hormone production. When the phosphate bond is
broken, energy is released, and ATP is formed into adenosine
diphosphate (ADP). Humans have a small energy reserve of ATP
that must constantly be resynthesized to avoid running out. Some
energy for ATP resynthesis is supplied through the anaerobic
(without oxygen) splitting of phosphocreatine (PCr) into creatine
and phosphate, which releases energy. The creatine and phosphate
can be joined again into PCr. Carbohydrate is the only nutrient that
can provide energy anaerobically to form ATP. Energy released from
breakdown of preformed ATP and PCr can sustain high-intensity
exercise for approximately 5–8 seconds. For instance, the 100-
meter world record time of approximately 9.6 seconds exceeds the
human capacity to supply the needed ATP from stored ATP and PCr,
so the sprinters slow down during the last ∼1.5 seconds because
the highest-intensity fuel sources are exhausted.
There are four basic energy metabolic systems: phosphocreatine
system, anaerobic glycolysis (lactic acid system), aerobic glycolysis
system, and aerobic metabolism (oxygen system):

Phosphocreatine System (PCr). This system can produce ATP

anaerobically from stored phosphocreatine and can be used for
maximal intensity activities that last no longer than 8 seconds.
(After 8 seconds, the PCr is depleted and must be reformed.)
Anaerobic Glycolysis (Lactic Acid System). This system involves
the anaerobic production of ATP from the breakdown of
glycogen, with lactic acid production as a by-product of this
system. This is used for very high–intensity exercise that
 exceeds the person’s ability to consume enough oxygen.
Anaerobic glycolysis can typically produce ATP for no more than
2 minutes.
Aerobic Glycolysis. This describes the production of ATP from
the breakdown of glycogen through the utilization of oxygen.
This system is used for high-intensity activities that require a
high level of ATP but remains within the athlete’s capacity to
supply sufficient oxygen for energy metabolism.
Aerobic Metabolism (Oxygen System). This system (glucose +
6O2 →6CO2 + 6H2O + heat) produces ATP from the combined
breakdown of carbohydrates and fats and is used for low- to
moderate-intensity activities of long duration. This system
avoids the production of lactic acid, which allows the energy
metabolic process to continue for long periods of time. Fats can
only be metabolized via this aerobic system. Protein can be
metabolized to produce ATP, but only after the nitrogen
associated with protein molecules is removed. Once removed,
the remaining carbon chain can be converted to carbohydrate
and metabolized either aerobically or anaerobically or stored as
fat to be metabolized aerobically. As humans have no protein
storage for the purpose of supplying energy, using protein as an
energy source requires the breakdown of tissue protein (i.e.,
muscle and organ tissue), to supply the fuel to create ATP, and
should not, therefore, be considered a preferred source of
energy.

The theoretical yield of ATP molecules from 1 molecule of

glucose is 38 ATP (2 from glycolysis, 2 from Krebs cycle, and 34
from electron transport (59). However, this much ATP production is
not normally achieved because of the ATP cost of moving pyruvate
(from glycolysis), phosphate, and ADP (substrates for ATP synthesis)
into the mitochondria (72) (Figure 2.6).
FIGURE 2.6: Carbohydrate metabolism.

Making Carbohydrate from Noncarbohydrate Sources

As noted earlier, gluconeogenesis refers to the process of making
glucose from noncarbohydrate substances. Blood glucose is critical
for central nervous system function, aids in the metabolism of fat,
and supplies fuel to working cells. However, because of its limited
storage capacity as liver glycogen, which helps to maintain blood
sugar, a minimum level of glucose is always available through the
manufacture of glucose from noncarbohydrate substances (see
Figure 2.2).
There are three main systems for gluconeogenesis (26, 49, 85):

Triglycerides are the predominant storage form of fat in the

human body and consist of three fatty acids attached to a
glycerol molecule. The breakdown of triglycerides results in free
glycerol molecules (a three-carbon substance), and the
combination of two glycerol molecules in the liver results in the
production of one glucose molecule (a six-carbon substance).
The kidney is also capable of manufacturing glucose from
glycerol.
Catabolized muscle protein results in an array of free amino
acids that constituted the building blocks of the muscle. One of
 these amino acids, alanine, can be converted by the liver to
form glucose.
In anaerobic glycolysis, lactic acid is produced. This lactic acid,
or lactate, can be converted back to pyruvic acid for the aerobic
production of ATP, or two lactic acid molecules can combine in
the liver to form glucose. The conversion of lactate to glucose is
referred to as the Cori cycle (lactate removed from the muscle
and glucose returned to the muscle). If blood glucose is low,
pyruvic acid can be converted to lactate, and glucose can be
produced via the Cori cycle.

Carbohydrate Intake Recommendations

The Institute of Medicine (2002) recommends 130 g (520 calories)

of carbohydrate per day, which is the average minimal usage of
glucose by the brain. The desirable range of carbohydrate intake is
45%–65% of total caloric intake (also referred to as the acceptable
macronutrient distribution range, or AMDR). The daily value for
carbohydrate that is on food labels is based on a recommendation
that carbohydrate should constitute 60% of total energy consumed.
These recommendations also generally advise that sugar
consumption be limited to no more than 25% of the carbohydrate
consumed (32, 80).

Important Factors to Consider

The recommended intake of carbohydrate for athletes ranges

from 5 to 10 g/kg. This level of intake is far higher than that
for protein, which has a recommended range of 1.2–1.7 g/kg.
Despite this difference, many athletes still wrongly believe
that focusing on protein as the primary fuel is beneficial for
optimizing athletic performance.
Regardless of whether an athlete is involved in primarily
power or endurance activity, carbohydrate is considered to be
that limiting energy substrate in performance. That is, when
carbohydrate (glycogen) stores become depleted,
performance quickly deteriorates. Because of this, all athletes
should have well-developed strategies for ensuring adequate
 carbohydrate consumption before, during, and following
activity to assure optimal recovery.

Dietary fiber consumption (from indigestible and partially

digestible polysaccharides) should be at the level of 38 g/day for
adult men and 25 g/day for adult women. Adequate fiber
consumption aids in the maintenance of normal blood sugar,
reduces heart disease risk, and lowers constipation risk. The
difference between genders in recommended fiber consumption is
based on the expectation that women typically consume less total
energy.
Athlete requirements for carbohydrate are based on several
factors, including:

providing energy to satisfy the majority of caloric needs;

optimizing glycogen stores;
allowing for muscle recovery after physical activity;
providing a well-tolerated source of energy during practice and
competition;
providing a quick and easy source of energy between meals to
maintain blood sugar.

Carbohydrate consumption has traditionally been recommended

as a proportion of total caloric intake. The recommendation for the
general population is that carbohydrate should supply 50%–55% of
total calories, and the dietary reference intake is 130 g/day (520
calories/day) for male and female adults. However, the amount
typically recommended for athletes is slightly higher, between 55%
and 65% of total calories, assuming an adequate total caloric
intake. The current system for recommending carbohydrate
requirement is by taking into consideration the amount of
carbohydrate to be consumed (in grams) per kilogram of body
mass. The current recommendation for athletes ranges from 3 to 12
g/kg body weight per day, depending on the intensity and duration
of activity (76). This recommendation is based on a large body of
research indicating that carbohydrates maintain blood glucose
levels during exercise and replace muscle glycogen, with the range
of intake based on the total energy expended, the type of sport
(e.g., high-intensity activity is more reliant on carbohydrate as a
fuel), gender, and environmental conditions. Using these values, a
70-kg athlete would be expected to consume between 420 and 700
g/day, a level far greater than that recommended for the general
public. The recommended carbohydrate consumption for a large
136-kg (300 lb) football player would be even higher, ranging from
815 to 1,360 g/day, or 3,260–5,440 calories/day from carbohydrate
alone. However, care should be taken when estimating total
carbohydrate requirements, since a diet containing 500–600 g of
carbohydrate per day for a 70-kg athlete is likely to adequately
support glycogen stores. However, a short athlete consuming 60%
of total energy from carbohydrates may not have sufficient
carbohydrate to satisfy glycogen stores (60). It is important,
therefore, to consider both athlete size and energy expenditure in
determining optimal carbohydrate intakes.

Carbohydrate and Human Performance

In virtually all types of physical activity, carbohydrate availability is
considered to be the limiting energy substrate in performance. That
is, when carbohydrate runs out, the ability to perform physical
activity at a high pace is limited, and performance drops. As is
evident from the information in Table 2.6, the human system has
limited storage of carbohydrate relative to the other energy
substrates, fat and protein, and the availability of carbohydrate is
worse than it seems. Exercise typically accesses specific muscles
that use muscle glycogen at a faster rate than muscles that are not
used, and these muscles can deplete muscle glycogen relatively
quickly. However, the glycogen present in the nonused muscles is
not “shared” by the muscles that use glycogen, so the availability of
glycogen is actually lower than it appears to be in Table 2.5.

Table 2.6 Carbohydrate Stores in the Average Weight

(154 lb), Lean (10% Body Fat) Male, and
Length of Exercise Time if Solely Reliant on
the Specific Energy Source
Source Mass (kg) Energy Exercise Time
(calories) (min)
Liver glycogen 0.08 306 16
Muscle 0.40 1,530 80
glycogen
Table 2.6 Carbohydrate Stores in the Average Weight
(154 lb), Lean (10% Body Fat) Male, and
Length of Exercise Time if Solely Reliant on
the Specific Energy Source
Source Mass (kg) Energy Exercise Time
(calories) (min)
Blood glucose 0.01 38 2
Fat 7.0 62,141 3,250
Protein 13.0 52,581 2,750

Source: Adapted from Maughan RJ, editor. The Encyclopedia of Sports Medicine: Sports
Nutrition. West Sussex: Wiley-Blackwell; 2014.

In actuality, people utilize carbohydrate and fat simultaneously

to derive energy, and the more well conditioned they are, the better
able they are to use fat, which uses less carbohydrate and
increases the time to exhaustion (i.e., the point at which
carbohydrate is depleted). As seen from Figure 2.4, the higher the
intensity of activity, the greater the rate of carbohydrate utilization
to satisfy energy requirements.
The rate of fat utilization still remains significant in high-intensity
activity, but the additional energy for activities at and above 65% of
maximal oxygen consumption all comes from carbohydrate.
Therefore, high-intensity activity will result in a faster depletion of
carbohydrate stores. However, being well conditioned through a
good training program can increase the reliance on fat and
decrease the reliance on carbohydrate, with the result that time to
exhaustion is increased (Figure 2.7).
FIGURE 2.7: Getting “fit” makes a difference: Change in fat
reliance after endurance training. (Modified from Martin WH III,
Dalsky GP, Hurley BF, et al. Effect of endurance training on plasma
free fatty acid turnover and oxidation during exercise. Am J Physiol.
1993;265(5):E708–14.)

Maximizing Glycogen Storage

Because stored glycogen is limited and therefore important to
maximize prior to a competitive event or exercise, it is important to
consider the dietary strategy needed to optimize its storage. This
strategy is often referred to as glycogen loading and was first
described by Bergström (6). This glycogen loading technique
involved depleting muscle glycogen storage through hard exercise
coupled with a low-carbohydrate diet for 3 days. This was followed
by a high-carbohydrate diet and little or no exercise for 3 days. It
was believed that muscle depleted of glycogen would behave like a
sponge to maximize glycogen storage once carbohydrate was made
available. A number of years later, another glycogen loading
strategy was described by Sherman et al. (69). This strategy
involved sustaining a high-carbohydrate diet coupled with a
tapering of exercise. It was found that the latter technique was
equally successful in optimizing glycogen storage, and subsequent
studies have confirmed two basic principles for physically active
people to follow (9, 18):

Reducing the utilization of glycogen through the tapering off of

physical activity is useful for optimizing storage.
Consuming carbohydrate is necessary for maximizing glycogen
storage.

Glycogen synthesis from the consumption of carbohydrates is

reliant on the enzyme glycogen synthase. This enzyme is highest
when glycogen storage is lowest in the period immediately
following physical activity. Therefore, carbohydrate should be
consumed in the time immediately following physical activity to
optimize glycogen synthesis. It has been found that the best
glycogen synthesis occurs in the first 4 hours following exercise,
when carbohydrate is consumed in frequent small feedings (33, 81,
82). It also appears that the form of carbohydrate consumed (liquid
vs. solid) may not be an important factor in glycogen resynthesis
(38). However, low glycemic index foods (i.e., more complex
carbohydrates) are known to be effective in assuring optimal
glycogen storage (9). Energy balance is an important factor in
glycogen synthesis, as it is known that energy restriction results in
lower glycogen storage even when the same amount of
carbohydrate is provided (75).
The maximum storage capacity of glycogen in a well-trained
male athlete is about 400 g, which equates to around 1,530
calories. As the athlete experiences a decrease in blood glucose
and these glycogen stores are depleted, the athlete will experience
fatigue, which results in a decrease in athletic performance. Blood
glucose is responsible for cognitive brain function, so as blood
glucose levels decline, the brain is not adequately perfused with
energy. The decrease in blood glucose causes mental fatigue, which
results in muscular fatigue and a reduction in athletic performance
(84).
Performance during endurance activities has been shown to
heavily rely on carbohydrate availability. Therefore, it is thought
that carbohydrate loading and carbohydrate consumption during
activity will positively affect athletic performance. Carbohydrate
loading is when one consumes high levels of carbohydrate,
generally 10–12 g/kg body weight, 2–3 days prior to an athletic
event. Another recommendation is to consume carbohydrates
during exercise. Carbohydrate consumption during exercise will
supplement the body’s glycogen stores and prevent blood glucose
levels from rapidly declining. This will prevent fatigue and a
decrease in performance. The most recent guidelines state that 30–
60 g of carbohydrate per hour of exercise is recommended (60).
It has been found that the intake of glucose plus fructose will
allow the human body to utilize more carbohydrates, thus
increasing the recommendation of carbohydrate consumption
during exercise (78). The reasoning behind why a consumption of
mixed carbohydrates is more effective than a single carbohydrate is
still unknown. However, it is thought that when mixed
carbohydrates are consumed, separate transporter proteins may
enhance intestinal carbohydrate absorption (84). It is also important
to consume carbohydrates after exercise to replenish the muscle
and liver glycogen stores that were utilized during exercise. This is
strongly recommended for athletes who compete in multiday
competitions or who will compete in two events in 1 day (13).

High-Intensity Sports
In high-intensity sports with a duration of between 30 and 60
minutes, there is evidence that carbohydrate consumption during
the activity improves performance (36). There is also evidence that
the use of a carbohydrate mouth rinse for high-intensity activity
lasting between 30 and 60 minutes improves performance, despite
no carbohydrate being absorbed. This involves drinking a
carbohydrate solution without swallowing, and spitting it out after 5
seconds in the mouth (12, 61). Care should be taken to not apply
these findings to activities that are shorter than 30 minutes or
longer than 60 minutes, as longer duration activities clearly require
the actual ingestion of carbohydrate. The likely basis for the
improved performance using a carbohydrate mouth rinse is brain
stimulation from the taste of carbohydrates in the mouth (14).

Team Sports
Athletes participating in team sports that involve intermittent stop-
and-go activities experience a performance benefit when
carbohydrate-containing beverages are consumed during the
activity (53). The likely benefits from this consumption are from a
lower breakdown of muscle glycogen, as a proportion of the
required muscular fuel is derived from blood glucose and/or a
replenishment of muscle glycogen “fuel” during the activity (53). A
number of more recent studies have suggested that carbohydrate
consumption during intermittent sport improves skill performance
either during (22) or at the end of the activity (2, 86). A study
assessing soccer skills found that consuming a carbohydrate-
containing beverage reduced the typical performance deterioration
in shooting (kicking) (64).

Endurance Sports
Carbohydrate consumption in sports activities with a duration
exceeding 2 hours has been shown to improve time to exhaustion
(i.e., improved endurance) (34). It is likely that this consumption
reduces the rate of muscle glycogen utilization and also helps to
maintain normal blood glucose levels, thereby avoiding the
performance deficits associated with mental fatigue. Studies of
cyclists competing in the Tour de France have extremely high-
carbohydrate consumption patterns of more than 90 g/hour (66). It
also appears that carbohydrate polymer (gel) is well tolerated in
long-duration events, whether it is composed of glucose or glucose-
fructose (56).

Carbohydrate Consumption in Different Activities

Different durations and intensities of exercise require different
carbohydrate intake strategies (Figure 2.8). Total carbohydrate
consumption recommendations range from 30 to 60 g/hour (67) to
up to 90 g/hour (35). It is likely that intakes above this level are
difficult to achieve and may result in GI upset. One limitation for
carbohydrate consumption is absorption capacity. Studies have
found that absorption is enhanced when multiple types of
carbohydrates are consumed, particularly at the levels of 60–90
g/hour. Therefore, it is recommended that combinations of glucose,
maltose, maltodextrin, and fructose be consumed during exercise,
particularly at durations >2.5 hours, rather than any single source
of carbohydrate (33, 34, 78).

FIGURE 2.8: Recommended carbohydrate intake for different

exercise durations in well-conditioned athletes. (Modified from
Jeukendrup AE. Carbohydrate ingestion during exercise. In:
Maughan RJ, editor. Sports Nutrition: The Encyclopedia of Sports
Medicine. West Sussex: Wiley-Blackwell; 2014.)

There is also evidence to suggest that there are wide individual

differences in carbohydrate tolerance, but practicing the
consumption of carbohydrate during exercise improves tolerance to
higher volumes and concentrations of carbohydrate, resulting in
lower risk of GI distress. For instance, athletes running the
marathon often practice without carbohydrate/electrolyte
beverages, but then have the availability of beverages to consume
every 5 km during a race. The athletes who practice consuming
carbohydrate/electrolyte beverages can consume more during the
race with better race outcomes (19, 71).

Summary
 Physically active people should consider that only the energy
substrates (carbohydrate, protein, and fat) provide the carbon
chains needed to produce ATP.
Vitamins and minerals are necessary to help the process of
deriving energy from the energy substrates but do not provide
energy themselves.
Humans have “energy-first” systems, meaning that sufficient
energy must be provided to ensure that all normal body
processes can take place. A failure to provide sufficient energy
in a way that dynamically matches requirements will interfere
with performance. Many athletes “postload” energy
consumption, that is, they consume the required energy at the
end of the day, after they needed it, resulting in poor outcomes.
Physical activity elevates the rate at which blood glucose is
utilized and can result in low blood glucose, which is associated
with premature mental muscular fatigue.
Different carbohydrates are best consumed at different times.
When not exercising (pre- and postexercise), starch-based
complex carbohydrates are best for ensuring optimal glycogen
storage. During and immediately after exercise, a combination
of sugars is best to sustain blood glucose to provide energy to
working muscles and for replenishing glycogen stores.

Practical Application Activity

Carbohydrate intake can be analyzed as a percentage of total

calories consumed (% carb) or as grams of carbohydrate/kg mass
(g/kg). The preferred method is g/kg, as this provides an
adjustment for the carbohydrate intake based on body mass.
Using % carb, it is possible for someone to have what appears to
be a desirable carbohydrate consumption (Example: 55% of total
calories), but if insufficient calories are consumed, the
carbohydrate consumption will be inadequate. It is also important
to know your indigestible carbohydrate consumption (fiber) and
how sugar contributed to your total carbohydrate intake. You can
assess your food intake for all of these using the procedure
described in Chapter 1, accessing the online USDA Food
Composition Database (https://ndb.nal.usda.gov/ndb/search/list);
only, this time, focus on carbohydrate, fiber, and sugar with your
food search:

1. Create a new spreadsheet analysis of a typical day of intake,

creating columns for energy, carbohydrate, fiber (total
dietary), and sugars (total).
2. When completed, analyze your dietary intake for these
nutrients as follows:
a. Calculate grams of carbohydrate/kg by dividing
carbohydrate by your weight in kilograms. Compare your
carbohydrate/kg with the recommended intake.
b. Calculate percentage (%) of total calories from
carbohydrate as follows:
i. Multiply grams of carbohydrate × 4 to obtain calories
from carbohydrate.
ii. Divide total energy (calories) consumed by calories
from carbohydrate to derive the percentage of total
calories from carbohydrate.
iii. Compare this percentage with the recommended
intake.
c. Compare your total dietary fiber intake with the
recommended intake (women = 25 g/d; men = 38 g/d)
d. Calculate percentage of total calories from sugar as
follows:
i. Multiply grams of sugar × 4 to obtain calories from
sugar.
ii. Divide total sugar calories by total calories to derive
the percentage of total calories from sugar.
iii. Calculate “added sugars” by subtracting naturally
occurring sugar from total sugar.
iv. Compare your total sugar intake, as percentage of
total calories, with the recommended intake.
3. Review which foods contribute most to your fiber intake and
your sugar intake. Make an adjustment, if needed, in your
food intake by reducing the foods high in sugar and
increasing the foods high in fiber.
4. Keep analyzing and adjusting until the carbohydrate
consumption is desirable for g/kg, fiber, and sugar, and to
view what type of carbohydrate and how much carbohydrate
you would consume to ideally satisfy your needs.
Chapter Questions

1. Why are many people unable to digest milk sugar?

a. They lack pancreatic amylase
b. They lack the proper intestinal bacteria
c. They were not breastfed
d. They have a lactase deficiency
2. What is gluconeogenesis?
a. The production of glucose from noncarbohydrate sources
b. The oxidation of glucose under anaerobic conditions
c. The maximum amount of glycogen that can be stored
d. The use of ketone bodies for glucose by the brain
3. Carbohydrate that is consumed during endurance exercise
appears to delay fatigue by:
a. providing a steady supply of glucose that exercising muscle can
use
b. sparing muscle glycogen
c. rapidly resynthesizing muscle glycogen
d. all of the above
4. Muscle glycogen is a:
a. Monosaccharide
b. Disaccharide
c. Polysaccharide
d. None of the above
5. Sucrose is a:
a. Monosaccharide
b. Disaccharide
c. Polysaccharide
d. None of the above
6. The physiological response to hyperglycemia resulting from the
consumption of carbohydrate-containing foods:
a. stimulation of α cells in the pancreas and secretion of insulin
b. stimulation of β cells in the pancreas and the secretion of
insulin
c. stimulation of α cells in the pancreas and secretion of glucagon
d. stimulation of β cells in the pancreas and secretion of glucagon
7. Cortisol may be produced when blood sugar is:
a. Normal
 b. Above normal
c. Below normal
d. None of the above
8. One difference between epinephrine and glucagon is that
glucagon can more rapidly break down liver glycogen to glucose.
a. True
b. False
9. Of the following, which is the least sweet tasting?
a. Sucrose
b. Maltose
c. Lactose
d. Fructose
10. Of the following, which is considered an abnormal (not desired)
outcome for glucose:
a. Conversion to liver glycogen
b. Utilization as a source of energy (ATP production)
c. Excretion in the urine
d. Source of fuel for the central nervous system

Answers to Chapter Questions

1. d
2. a
3. a
4. c
5. b
6. b
7. c
8. b
9. c
10. c

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CHAPTER OBJECTIVES

Understand the differences between essential amino acids and

nonessential amino acids and the primary functions of the essential
amino acids.
Be capable of calculating the daily protein requirement for yourself and
for others, both athlete and nonathlete, and to calculate the optimal
distribution of the protein to optimize tissue utilization.
Know the health risks associated with consumption of too much or too
little protein and how other energy substrates help to “spare” protein so
that it can be used anabolically.
Explain how proteins are digested and absorbed, including the ___location
and source of the major protein digestive enzymes.
Understand protein energy metabolic pathways, and the by-products
produced when proteins are used as a source of cellular energy.
Know how supplements of amino acids and other protein-related
substances, such as creatine monohydrate, may have an impact on
health risks and performance.
Understand how the presence and distribution of essential amino acids
influence protein quality.
Recognize the primary functions of proteins as they relate to immunity,
tissue structure, hormones and enzymes, transportation, and fluid
balance.
Discriminate between food sources that are good sources of high-
biologic-value (BV) protein and food sources that are moderate to poor
sources of high BV protein.
Determine foods that, when combined, can improve the protein quality to
a level better than if these foods were consumed individually.
Identify the common methods used for determining the protein quality.
Describe the factors that are involved in improving muscle mass size and
function.

Lots of Protein but Poor Delivery

Inhibits Benefits
T.J. was a massive freshman defensive guard on his college football team,
and he learned from the very beginning, when he was playing football in
the Pop Warner league as a 6-year-old, that lots of protein was needed to
ensure he could grow and build the muscle needed for a career in
football. He was already bigger, heavier, and taller than nearly all of the
other players, but he wanted to be bigger still, even as a youngster. So,
he ate lots of food and made sure that a high proportion of it was protein.
Steak and chicken were his favorite, but he ate fish when his mother
made it. He did not care much for veggies, but that did not matter much
to him because he “knew” that protein would get him where he wanted
to go.
The massive amount of food T.J. ate did help him get bigger, but as a
collegiate athlete there was a great deal more being asked of him than
ever before. His coach also wanted him to be fast and be able to play as
hard in the fourth quarter as he did in the first. Right away, the defensive
coach saw a problem: T.J. was certainly big, but he was not as quick as he
should be and his endurance was terrible. The coach put him on a more
severe training regimen to build his strength, quickness, and endurance.
Of course, T.J. did what he thought he needed to do, and that was to
increase his protein intake, but it did not help. T.J. kept getting fatter from
all the extra food he was consuming, but the extra fat he was carrying
around made him slower and his endurance kept getting worse. So, they
sent him to talk with the sports nutritionist who just started working with
the university teams, and the nutritionist immediately found the problem.
T.J. was consuming a huge amount of protein, but at the expense of
carbohydrate. To make matters worse, his intake of food, including
protein, was not spread out well throughout the day. He mainly had two
large meals: breakfast and a late dinner, and nearly nothing in-between.
This type of eating pattern is associated with many problems that made it
difficult to build muscle but easy to store fat. The nutritionist showed him
that the typical daily requirement for an athlete is 1.2–2.0 g/kg/day,
which is ideally consumed by providing moderate amounts of protein
spread out during the day and following a strenuous training session. T.J.
was consuming a great deal more protein than the requirement, and he
was not distributing it well throughout the day to optimize his body’s
capacity to use it efficiently for building and repairing muscle. So, the
nutritionist showed him how to have seven eating opportunities
(breakfast, mid-morning snack, lunch, afternoon snack, dinner, evening
snack, and bedtime snack), with about 30 g of protein each time both to
provide the recommended level of intake and to optimize protein
utilization. Almost immediately T.J. saw the difference. His body fat was
decreasing and his muscle mass was increasing. He learned one of the
secrets of nutrition: It is not just how much you eat, but how and when
you eat it that matters most.
CASE STUDY DISCUSSION QUESTIONS

1. Calculate the protein in your diet to see if you are consuming an

amount that satisfies need, and that you are distributing the protein
in a way that would optimize protein utilization.
2. Is it likely that active people who eat the standard three meals/day
could distribute protein intake in a way that could enable optimal
protein utilization?
3. What happens to the excess protein consumed? List the potential
problems that may arise from this.
4. How would you set up an athlete environment to help ensure that the
athletes could consume foods in a pattern that would be most useful?

Introduction

Important Factors to Consider

There is limited evidence that increasing protein consumption above

the recommended intake levels as a means of improving musculature is
a useful strategy and it may cause problems with kidney health,
dehydration, and low bone mineral density. In addition, high-protein
intake interferes with a balanced intake of other foods/nutrients.
It is far better to consume the recommended level of protein in
amounts that can be efficiently used by tissues, especially when the
athlete’s energy intake level is satisfied with sufficient intake of
carbohydrates and fats.
Consumption of single amino acids for the purpose of initiating a
desired metabolic outcome (i.e., greater muscle acquisition) may be
associated with problems that could interfere with the desired
outcomes (i.e., muscle protein synthesis [MPS], reduced muscle
soreness, improved muscle repair) and is not likely to be a successful
strategy.
It is far better to eat foods that contain a wide array of essential amino
acids to ensure an adequate energy intake and to allow tissues to
acquire the amino acids they require for metabolic purposes. It is easy
to get too much of a single amino acid that may result in the opposite
of the desired effect. For instance, the branched-chain amino acid
(BCAA) leucine is known to be a MPS stimulator, and studies suggest
that 20 g of good-quality protein containing leucine has been found to
maximally stimulate MPS.
 Branched-Chain Amino Acids

The amino acids isoleucine, valine, and leucine that can be metabolized
locally in muscle tissue and that promote MPS and are involved in glucose
metabolism.

Proteins are one of the energy substrates (with carbohydrates and fats),
meaning that we are capable of producing adenosine triphosphate (ATP, or
energy) from protein molecules, primarily through their conversion to
carbohydrate and fat. Besides this energy-producing capacity, however,
proteins have many other critical functions that require consideration. Many
physically active people consider protein consumption to be the key to
athletic performance success, and even a cursory review of the magazines
and other literature targeting athletes demonstrates this point, with
advertisements for protein supplements and protein-added foods that are
intended to, ultimately, enhance winning potential. Often, physically active
people consume far more protein than is needed, and an obvious problem
with excess protein consumption is that this necessarily translates into
consuming too little of other nutrients that are equally important (6). There is
evidence that consuming ∼30 g protein in a single meal maximally enhances
MPS in both young and elderly subjects, suggesting that higher protein meals
(i.e., those providing more than 30 g protein) may fail to produce greater
muscle enlargement (29, 71). In addition, high-protein consumption may
displace carbohydrate, which is well established as the optimal fuel for all
sporting endeavors, ranging from endurance to short-duration, high-intensity
events (6, 56, 73). In addition, although physically active people often
consume far more protein than body tissues can use to fulfill nonenergy
anabolic (i.e., MPS) requirements, the manner in which this protein is
consumed may inhibit the utilization of the consumed protein (52). Poor
protein utilization will result in at least a portion of the protein having the
nitrogen removed and converted to fat and carbohydrate to be used or stored
as fuel. Although it is clear that athletes may have a requirement that is more
than double the requirement of nonathletes (1.2–2.0 vs. 0.8 g/kg/day), the
manner in which the protein is consumed is important, as is the equal
importance on seeking a balanced intake that exposes athletes to all of the
nutrients they require. This chapter will review food sources of protein,
protein functions, protein requirements, and eating patterns that can help
derive the most out of the protein being consumed. There are many
questions that this chapter will answer, including:

Does increasing protein intake beyond a certain level help to increase

muscle mass?
Does supplemental or high-protein intake provide an ergogenic
(performance-enhancing) benefit?
Does supplemental or high-protein intake improve strength and power?
 Is there evidence that, when normalized on a protein/kg basis, athletes
tend to overemphasize protein to the detriment of other nutrients?

Proteins

Molecules consisting of multiple amino acids held together by peptide

bonds in a sequence and structure that influence protein function.

Structure of Protein

Proteins are made of amino acids, which contain carbon, oxygen, hydrogen,
and nitrogen (Figure 3.1).

FIGURE 3.1: Basic structure of an amino acid, the building block of proteins.

Of the energy substrates, only protein contains nitrogen. The nitrogen

content of proteins is an important consideration because when proteins are
broken down to be used for energy or stored as fat, this nitrogen must be
removed from the protein molecule, and this nitrogen waste is potentially
toxic and must be removed from body tissues. The nitrogenous waste
produced from protein breakdown produces toxic compounds, which must be
excreted via the kidneys using a large dilutional water volume for this
excretion (Figure 3.2).
FIGURE 3.2: Protein breakdown and nitrogen excretion. ATP, adenosine
triphosphate

Blood Urea Nitrogen

Blood urea nitrogen (BUN) is a measure of the urea nitrogen content in

the blood that mainly represents the nitrogen released from the
metabolism of protein. It is from the waste product urea. Urea is produced
when amino acids are catabolized and the carbon chain is used to supply
energy or stored as fat. The nitrogen removed from the amino acid forms
urea, which is removed from the body via urine.

Urine

Urine is a liquid produced by the kidneys to excrete the by-products of

metabolism. A primary function of urine is to excrete nitrogenous waste
(urea) that is a by-product of protein catabolism. High-protein diets that
exceed the tissue capacity to use the protein anabolically result in protein
catabolism and higher nitrogenous waste that must be excreted via urine.

Amino acids are the building blocks of protein, with several amino acids
held together to form polypeptides and several polypeptides held together
to form a protein. There are 20 different amino acids, and humans can
manufacture 11 amino acids by using the nitrogen discarded by the
breakdown of proteins and the carbon, hydrogen, and oxygen available from
carbohydrate. The 11 amino acids that we can manufacture are referred to as
nonessential or dispensable amino acids, because it is not essential that we
obtain them from the foods we consume since they can be manufactured.
However, do not misinterpret nonessential as meaning unimportant, as these
nonessential amino acids are just as metabolically important as the nine
essential amino acids, which we cannot manufacture and must be
obtained from the foods we consume (Table 3.1).

Table Essential and Nonessential Amino Acids

3.1
Nonessential Amino Acids Essential Amino Acids (Cannot be
(Synthesized by humans from synthesized by humans, so must be
carbohydrate and fragments of consumed from foods)
other amino acids)
Amino Acid Abbr Notes Amino Acid Abbr Notes
Alanine Ala Can be converted Histidine His Unlike the other
to glucose in the essential amino
liver acids, does not
(gluconeogenesis) induce a protein-
via the alanine– deficient state
glucose cycle (negative
(Glucogenic) nitrogen balance)
when removed
from the diet.
Involved in
production of
histamine
(Glucogenic)
Arginine Arg A conditionally Isoleucine Ile Branched-chain
essential amino amino acid that
acid that may may be useful for
become essential muscle recovery
under certain and the immune
metabolic system following
conditions. Used exercise
in production of (Glucogenic)
nitric oxide
(Glucogenic)
Table Essential and Nonessential Amino Acids
3.1
Nonessential Amino Acids Essential Amino Acids (Cannot be
(Synthesized by humans from synthesized by humans, so must be
carbohydrate and fragments of consumed from foods)
other amino acids)
Amino Acid Abbr Notes Amino Acid Abbr Notes
Asparagine Asn Necessary for the Leucine Leu Branched-chain
development and amino acid that
function of the may be useful for
brain and also muscle recovery
plays a role in and the immune
ammonia system following
synthesis exercise.
(Glucogenic) Stimulates
muscle protein
synthesis
(Ketogenic)
Aspartic Asp Can be converted Lysine Lys Metabolized to
acid to glucose in the form acetyl-
liver coenzyme A, the
(gluconeogenesis) intermediary
and is also product in energy
involved in metabolism. Also
neurotransmission used to help form
(Glucogenic) collagen, a
connective tissue
protein
(Glucogenic)
Cysteine Cys A conditionally Methionine Met Restriction may
essential amino lower obesity risk
acid that may and improve
become essential longevity in
under certain humans, but may
metabolic also lower
conditions production of
(Glucogenic) other amino acids
(Glucogenic)
Table Essential and Nonessential Amino Acids
3.1
Nonessential Amino Acids Essential Amino Acids (Cannot be
(Synthesized by humans from synthesized by humans, so must be
carbohydrate and fragments of consumed from foods)
other amino acids)
Amino Acid Abbr Notes Amino Acid Abbr Notes
Glutamic Glu An important Phenylalanine Phe Important for
acid neurotransmitter production of
and also used as neurotransmitters
part of a flavor norepinephrine
enhancer and epinephrine
(monosodium (Glucogenic and
glutamate) Ketogenic)
(Glucogenic)
Glutamine Gle A conditionally Threonine The Used in the
essential amino synthesis of
acid that may proteins and
become essential glycine
under certain (Glucogenic and
metabolic Ketogenic)
conditions
(Glucogenic)
Glycine Gly A building block in Tryptophan Trp Used to
protein synthesis synthesize the
and also functions neurotransmitters
as a serotonin and
neurotransmitter melatonin, and
(Glucogenic) the vitamin niacin
(Glucogenic and
Ketogenic)
Proline Pro A conditionally Valine Val Branched-chain
essential amino amino acid that
acid that may may be useful for
become essential muscle recovery
under certain and the immune
metabolic system following
conditions exercise
(Glucogenic) (Glucogenic)
Serine Ser Important for
normal neurologic
function
(Glucogenic)
Table Essential and Nonessential Amino Acids
3.1
Nonessential Amino Acids Essential Amino Acids (Cannot be
(Synthesized by humans from synthesized by humans, so must be
carbohydrate and fragments of consumed from foods)
other amino acids)
Amino Acid Abbr Notes Amino Acid Abbr Notes
Tyrosine Tyr A conditionally
essential amino
acid that may
become essential
under certain
metabolic
conditions. Used
to manufacture
dopamine,
norepinephrine,
and epinephrine
(Glucogenic and
Ketogenic)

Source: From National Academy of Sciences. Dietary Reference Intakes for Energy, Carbohydrate, Fiber,
Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (macronutrients). Washington (DC): National
Academies Press; 2005. p. 591, 593; Negro M, Giardina S, Marzani B, Marzatico F. Branched-chain
amino acid supplementation does not enhance athletic performance but affects muscle recovery and
the immune system. J Sports Med Phys Fitness. 2008;48(3):347–51; Ruzzo EK, Capo-Chichi J-M, Ben-
Zeev B, et al. Deficiency of asparagine synthetase causes congenital microcephaly and a progressive
form of encephalopathy. Neuron. 2013;80(2):429–41.

To make proteins, amino acids are held together via peptide bonds, where
the acid end of one amino acid connects with the nitrogen of another amino
acid and, in the process, water is formed (Figure 3.3). The sequence of how
these amino acids are connected determines the function of the protein. So,
although a protein may contain the same amino acids, how they are ordered
will determine what the protein will do.

Amino Acids

Organic compounds characterized by an amine group (NH2) on one end of

the molecule and a carboxyl group (COOH) on the other end of the
molecule. Amino acids are held together in different sequences to compose
polypeptides and proteins.

Polypeptide
A molecule consisting of a chain of amino acids held together by peptide
bonds. The molecule is too small to be called a protein.

Essential Amino Acids

Amino acids that humans are incapable of synthesizing from other amino
acid skeletons, making it essential that they be in consumed foods.
Essential amino acids are also referred to as indispensable amino acids.

Nonessential Amino Acids

Nonessential Amino Acids are those amino acids that humans are
capable of synthesizing from other amino acid skeletons, so it is
nonessential that they be in consumed foods. Nonessential amino acids are
also referred to as dispensable amino acids.

Glucogenic Amino Acids

Glucogenic amino acids are amino acids that can be converted to

glucose through the process of gluconeogenesis in the liver. In humans, all
amino acids with the exception of leucine and lysine are glucogenic.
Alanine is a primary glucogenic amino acid with a robust liver pathway for
converting alanine to glucose.

Ketogenic Amino Acids

Ketogenic amino acids are converted to ketones when catabolized.

Isoleucine, phenylalanine, threonine, tryptophan, and tyrosine are both
glucogenic and ketogenic, whereas leucine and lysine are only ketogenic.
FIGURE 3.3: Proteins formed by connecting individual amino acids via
peptide bonds.

Example:
(AA1+AA3+AA5+AA2+AA1+AA4)
and
(AA3+AA1+AA2+AA5+AA4+AA1)

will have different functions, although they contain the same amino acids,
because the amino acids are held together in a different sequence.

All of the necessary amino acids must be present at the same time to
build a protein, and as protein synthesis is coded by DNA, amino acid
substitutions cannot be made. It is also important to consider that protein
synthesis requires energy (calories) and is difficult to accomplish when
someone is in a severely energy-deficient state. As the human system is
highly adaptive, the synthesis of specific proteins can be stimulated through
different actions. For instance, assuming sufficient energy and amino acids
are available, an individual lifting weights that are heavier than that person is
accustomed to will encourage the synthesis of more muscle protein to enable
a more energy-efficient weight lifting.
Proteins have four structural components:

Primary structure: the sequence of the amino acids that compose the
protein and is, therefore, the main determinant of the protein’s function.
Secondary structure: the hydrogen bonds of the protein, which are
connected to the primary structure of the protein.
Tertiary structure: the protein’s shape. For instance, the double-helix
shape of DNA is part of the DNA protein tertiary structure.
Quaternary structure: the number of polypeptides and proteins that are
connected to the protein as side chains.

Protein Functions

The proteins we consume are digested into individual amino acids, and these
amino acids interact with the amino acids produced by body tissues to make
up the total pool of amino acids available to tissues. Tissues have multiple
and different amino acid/protein requirements, as they have different
functions. For instance, neurologic tissue requires neurotransmitters, which
are specialized proteins for carrying nerve impulse messages; muscles
require protein to produce and repair muscle; and so on. The main functions
of proteins include:
Protective: Proteins help to synthesize antibodies, which attack foreign
substances, including bacteria and viruses, to protect the body from
invasion and infection. An example of an important antibody is
immunoglobulin G. Proteins also provide barrier defenses against
invasion of bacteria and viruses through skin, tears (to protect the eyes),
and mucin (in saliva, to protect the gastrointestinal tract).
Tissue structure: Structural proteins provide the structure to support
cell/tissue shape, including organs, muscles, bone, skin, hair, and nails.
An example of a structural protein is collagen, which provides strength
and resilience to body tissues. The creation of structural proteins is a
necessary component of tissue growth and maintenance.
Messenger: Some proteins, including hormones, transmit messages to
specific tissues to determine and, literally, control how that tissue will
function. For instance, the hormone estrogen provides messages for the
creation and function of the uterus.
Transport: Specific proteins are carriers of molecules that are critical to
tissue function. As an example, the protein hemoglobin carries oxygen to
cells and removes carbon dioxide from cells for normal cellular
respiration. Other examples include lipoproteins, which carry lipids (fats)
in the blood; transferrin and ceruloplasmin, which carry and transfer iron
for the manufacture of hemoglobin; and protein-bound iodine, which is
used to make the hormone thyroxine.
Enzymes and hormones: These proteins control the chemical reactions
that each cell has and, in doing so, are responsible for the creation of
new molecules and tissues. Enzymes are the action arm of the genetic
information in each person’s DNA. An example of an enzyme is
pancreatic amylase, which breaks down large carbohydrate molecules
into smaller molecules that can be absorbed. Another example is
phenylalanine hydroxylase, which converts the amino acid phenylalanine
to tyrosine, another amino acid. Examples of protein-based hormones
include insulin, glucagon, and growth hormone. Amino acids also
stimulate secretion of insulin, glucagon, growth hormone, and insulin-like
growth factor-1, all of which are related to maintenance, recovery, and
enlargement of the muscle mass (79).
Fluid balance: Blood proteins are necessary for controlling fluid inside and
outside tissues through osmotic pressure. Protein-deficient states are
associated with fluid being lost from tissues and the resulting edema.
Acid–base balance: Proteins are amphoteric, as they have the capacity to
pick up and release hydrogen, and by doing so they help to control body
pH (relative acidity/alkalinity).
Nitrogen compound synthesis: Proteins are involved in the synthesis of
other small nitrogen-containing compounds, including creatine, purines,
and pyrimidines. Creatine is involved in manufacturing phosphocreatine,
the compound used for creating a large number of ATPs in extremely
high-intensity activity.
 In humans, some individual amino acids (not proteins) also have important
biologic roles. Examples of these include the following:

Glycine and glutamic acid are neurotransmitters.

Tryptophan is a precursor of the neurotransmitter serotonin.
Glycine is a precursor of heme (part of hemoglobin).
Arginine is a precursor of nitric oxide (part of the process of delivering
oxygen to cells).
Carnitine transports lipids inside a cell into the mitochondria of the cell to
derive energy.

Sources of Protein

Important Factors to Consider

Virtually every food we eat has a wide array of amino acids, but not all
foods have the essential amino acids in a ratio that allows them to be
efficiently used by tissues to fulfill all protein functions. Therefore,
athletes should make an effort to consume regular, small amounts (25–
30 g) of good-quality protein throughout the day to satisfy total tissue
needs (1.2–1.7 g/kg/day).
Although the highest sources of good-quality protein are from meats,
vegetarians can obtain good-quality protein by mixing foods in a way
that improves the distribution of essential amino acids. This strategy of
creating complementary proteins to improve protein quality has been
practiced for generations by many cultures, including mixing beans
with corn (Central and South American) and mixing beans with rice
(Mediterranean basin and Asia).

Proteins and their component amino acids are found in nearly everything
we consume that has not been processed to produce a single
substance/chemical (for instance, table sugar). Different foods, however,
have different concentrations of proteins and amino acids and different
distributions of amino acids that affect the volume and quality of the protein
consumed. The highest sources of protein (i.e., highest volume with the best
distribution of amino acids) come from animal-derived foods (i.e., meat, fish,
poultry, eggs, dairy), whereas plant-based foods provide the lowest sources
of protein (i.e., fruits and vegetables) (Table 3.2).

Table 3.2 Selected Food Sources of Protein Based on Volume

of Protein/g of Food
High source
 Meat
Beef
Lamb
Pork
Etc.
Fish and shellfish
Poultry
Eggs

Moderately high
source Dairy products
Legumes
Beans
Peas
Lentils
Soy

Moderate source
Cereal grains
Corn
Wheat
Rice
Barley
Oats
Seeds and nuts
Cashews
Peanuts/peanut butter
Sesame seeds

Low source
Fruits
Apples
Oranges
Grapes
Vegetables
Broccoli
Leafy greens
Carrots

Measuring and Evaluating Protein

Besides considering the volume of protein delivered from the foods

consumed, the distribution of amino acids in the food should also be
considered to determine the quality of the protein consumed. The higher the
protein quality, the lower the volume of protein necessary to satisfy our
biologic requirements for protein. Animal-based foods have both a high
volume and a high quality of protein, whereas nonanimal foods have both
lower volume and lower quality of protein. To a large extent, this can be
corrected by combining specific plant-based foods to enhance their quality
(i.e., the distribution of essential amino acids). Some plant-based foods are
low in a specific essential amino acid, whereas other plant-based foods are
low in another specific essential amino acid. By combining them (i.e., by
eating them at the same time), the essential amino acid mix creates
complementary proteins that improve the protein quality. Legumes, for
instance, have low levels of tryptophan and methionine, whereas grains have
low levels of lysine, isoleucine, and threonine. By combining legumes and
grains, the distribution of essential amino acids is improved to make a good-
quality protein. A common strategy for producing a good-quality protein is to
consume peanut butter, which is low in tryptophan and methionine, with
wheat bread, which is low in lysine, isoleucine, and threonine. The
combination (a peanut butter sandwich) results in a higher quality protein
(Table 3.3). The typical strategy for improving plant protein quality is to
consume legumes with grains, or legumes with nuts and seeds.

Table 3.3 Combining Nonmeat Foods to Improve

Protein Quality
Food Amino Acids That Foods That Can Improve
Are Low (Not Quality (Complementary
Missing) Foods)
Legumes (lentils, peas,
beans, peanuts) Tryptophan Grains
Methionine Nuts
Seeds

Grains (wheat, corn, oats,

rice, rye, barley) Lysine Legumes
Isoleucine Dairy
Threonine

Nuts and seeds (almonds,

sunflower seeds, cashews, Lysine Legumes
etc.) Isoleucine

Specific foods have different amino acid profiles. The amino acids listed in this table are based on
averages for the food category.
Although it takes some additional planning, it is possible to obtain good-quality protein from nonanimal
sources. It should also be considered that pure vegans (i.e., those consuming no animal products) must
also plan for other nutrients that may more easily be delivered through animal products, including iron,
zinc, and vitamin B12. With good planning, however, it is most definitely possible to consume all of the
necessary nutrients from a plant-based diet.
Source: Pennington JAT, Douglass JS. Food Values of Portions Commonly Used. 18th ed. Baltimore (MD):
Lippincott Williams & Wilkins; 2005. p. 264–314.

Protein Quality

A measure of the net utilization of the dietary protein consumed. There are
several methods for determining protein quality, but all are related to the
level of nitrogen retained compared with the level of nitrogen consumed.
Nitrogen is only derived from protein-related products, and higher nitrogen
retention means better tissue utilization and higher protein quality.

Complementary Proteins

Two or more food sources that individually do not provide high-quality

protein, but when combined they complement each other and provide a
better distribution of the essential amino acids with higher protein quality.
As an example, combining legumes and cereal in a meal (such as beans
and corn tortillas) produces a significantly higher protein quality than
eating either legumes or cereals by themselves.

The ratio of amino acids consumed at one time makes a difference in the
protein quality (i.e., what proportion of the amino acids consumed can be
efficiently used metabolically for one or more of the protein functions listed
earlier), and protein quality makes a difference in the proportion of amino
acids that are deaminated (i.e., have the nitrogen removed) so the remaining
carbon chain can be stored as fat or burned for energy. The lower the quality
of the protein consumed, the greater the proportion of nitrogen that is
removed and that must be excreted (see Figure 3.1). As a way of visualizing
this, Table 3.4 provides a worksheet for estimating how much protein will be
retained and used as protein, or lost and burned for energy or stored as fat.
The purpose of this table is to help the reader understand that a complete
protein is determined by both the presence and the ratio of essential amino
acids, which, together, help to determine protein quality and retention.
 Complete Protein

Refers to protein that contains all of the essential amino acids in a

concentration/ratio that is capable of supporting growth and preventing
deficiency if consumed in appropriate quantities.

The main considerations for determining protein quality are as follows: (i)
the characteristics of the protein and the food matrix in which it is consumed
(i.e., how available is the protein from the food that has been consumed) and
(ii) the demands of the individual consuming the food, as influenced by age
and growth phase (faster growth requires more protein), health status (illness
often increases the tissue requirements for protein), physiologic status
(activities that increase muscle breakdown require more protein for muscle
repair), and energy balance (low energy balance limits protein utilization as
humans are energy-first systems). Low energy balance results in the protein
used to satisfy energy requirements rather than it being used for the
multitude of other functions only proteins can satisfy (43). Clearly, protein
status is a much more complicated issue than just how much protein is
consumed.
The traditional methods for determining protein quality in humans involve
assessment of nitrogen retention (BV), growth (PER), and amino acid
requirements and the ability to digest them (protein digestibility–corrected
amino acid score [PDCAAS]).

Biologic Value
The BV is a measure of the protein absorbed from consumed foods that is
incorporated into total body protein (skin, hair, muscle, organs, hormones,
etc.). The proportion that is absorbed but not incorporated into body proteins
is excreted. Since only protein contains nitrogen (N), nitrogen is used as an
estimate of protein consumption, absorption, and excretion. Therefore,
nitrogen balance is a measure of nitrogen consumed versus nitrogen
excreted. The basic strategy is to have a known nitrogen content in the
consumed meal, measure the nitrogen lost in fecal matter, which represents
the amount of protein not absorbed, and measure the amount of nitrogen lost
in the urine, which represents the amount of protein absorbed but not
incorporated into body tissues. Higher quality (i.e., better essential amino
acid distribution) proteins have a higher rate of incorporation into body
tissues and a lower rate of loss in the urine. The result provides a percent
value, with a higher percent equal to a higher BV. The BV can also be
compared with a test protein (typically egg albumin, which has a BV of 94%)
to determine the quality of a protein compared with a known standard. The
basic formula for BV is as follows (45):

Nitrogen Balance

Nitrogen balance is a measure of protein adequacy, by providing a

measure of the nitrogen consumed versus the nitrogen excreted. (Protein is
the only energy substrate containing nitrogen, so measuring nitrogen
provides an indirect measure of protein.). Positive nitrogen balance
suggests incorporation of protein (which is nitrogen containing) into new
tissues/products, whereas negative nitrogen balance suggests a net loss of
protein-associated tissues/products. For example, child growth is a prime
example of positive nitrogen balance and is observed in an athlete who is
building muscle. Someone who is consuming insufficient energy will lose
tissue weight and will metabolize protein to help satisfy the energy
requirements, resulting in a negative nitrogen balance.

Protein Efficiency Ratio

PER is a measure of the weight gained by a test animal (typically a baby rat,
chick, or baby mouse) divided by the total protein consumed during a test
period. The greater the gain in body mass for any given amount of protein,
the higher the PER and, therefore, the better the quality of the protein
consumed. In simple terms, if you give 100 g of protein X to a chick and it
gains 20 g, and you give 100 g of protein Y to another chick and it gains 10 g,
then protein X is a higher quality protein. The basic formula for PER is as
follows (10):
Protein Digestibility–Corrected Amino Acid Score
PDCAAS is a method used by the United States Food and Drug Administration
(FDA) and the Food and Agricultural Organization of the United Nations/World
Health Organization (FAO/WHO). It involves the determination of protein
quality based on both the amino acid requirement and a human’s capacity to
digest it. The PDCAAS value of “1” is the highest possible value, and a value
of “0” is the lowest possible value. It is based on the amino acid requirement
of a 2- to 5-year-old child (the most protein-demanding age group per unit of
mass) and the amino acid requirements adjusted for digestibility. The
PDCAAS provides a protein quality ranking based on the amino acid profile of
a specific food protein, compared with a standard amino acid profile with the
highest possible score of “1.” So, after digesting the protein, it would provide
100% or more of the essential amino acids required. The basic formula for
PDCAAS is as follows (66):

Examples of PDCAAS values include:

Casein (milk protein) = 1

Egg white (albumin) = 1
Whey protein (milk protein) = 1
Beef = 0.92
Chickpeas = 0.78
Vegetables = 0.73
Other legumes (beans, peas, etc.) = 0.70
Peanuts = 0.52
Whole wheat = 0.42

Digestible Indispensable Amino Acid Score

Digestible indispensable amino acid score (DIAAS) is recommended as a
revised score of the PDCAAS by the FDA (15). The purpose of this score is to
account for the different digestibilities of individual amino acids that are
consumed. It is intended to be a more accurate means of assessing protein
quality. DIAAS is defined as (39):
 DIAAS can be used as follows (15):

For calculation of DIAAS in mixed diets for meeting the needs for quality
protein, as humans consume proteins from varied protein sources in
mixed diets.
To document the additional benefit of individual protein sources with
higher scores in complementing less nutritious proteins.
For regulatory purposes to classify and monitor the protein adequacy of
foods and food products sold to consumers.

An expert panel has concluded that the concept of DIAAS is a method

preferable to PDCAAS for the assessment of protein and amino acid quality,
but that the usage of DIAAS will be limited until there are good data on the
digestibility of commonly consumed foods (34).
Table 3.5 displays protein quality using biologic value (the proportion of
nitrogen retained) and the PDCAAS (the degree to which a consumed protein
compares with egg albumin) (62, 72).

Table 3.5 Nitrogen and Protein Quality

Proportion of Nitrogen Retained Protein Quality Compared With Whole Egg
Protein

Whey protein: 96% Retained Whey protein: 1.04

Whole soybean: 96% Egg protein: 1.00
Retained Cow’s milk: 0.91
Chicken egg: 94% Retained Beef: 0.80
Cow’s milk: 90% Retained Casein: 0.77
Cheese: 84% Retained Soy: 0.74
Rice: 83% Retained Wheat protein (gluten): 0.64
Fish: 76% Retained
Beef: 74.3% Retained
Soybean curd (tofu): 64%
Retained
Whole wheat flour: 64%
Retained
White flour: 41% Retained
 High-quality proteins provide all of the essential amino acids in amounts
that tissues can efficiently use. Foods of animal origin (meat, fish, dairy,
eggs) deliver high-quality protein with an excellent distribution of the
essential amino acids. Foods of plant origin have at least one limiting amino
acid that is present in an amount lower than body tissues optimally require.
However, different plant foods have different limiting amino acids, so
combining different plant foods at the same meal (i.e., legumes with cereals)
with different limiting amino acids improves the protein quality of the foods
consumed. Lower quality proteins result in a higher proportion of the amino
acids to be lost as protein, because the nitrogen is removed and the
remaining carbon chain is either stored as fat or burned as a source of
energy.
Consumption of too much protein at one time also results in removal of
nitrogen from the excess amino acids, with the remaining fragments being
stored as fat or burned as a source of energy. The removed nitrogen is
potentially toxic and so must be removed, mainly through urine with a
concomitant loss of body water. Therefore, low-quality protein consumption
or excess protein consumption in conjunction with inadequate fluid intake
exacerbates dehydration and kidney damage risk (75).

Protein Requirements

Important Factors to Consider

Protein requirements are affected by numerous factors, including the

growth phase (fast growth is associated with higher needs), gender,
pregnancy/lactation, and training intensity, duration, and type. A male
adolescent athlete in the middle of the adolescent growth spurt will,
therefore, have a far higher protein requirement (g/kg) than a young
adult male involved in the same sport.
It is important to satisfy the total energy requirement for an adequate
intake of carbohydrates and fats to ensure that the consumed protein
can be used anabolically (i.e., to build tissue and manufacture needed
enzymes and hormones) rather than to be used to satisfy the energy
requirement. Humans are “energy-first” systems and must satisfy the
need for energy before manufacturing other substances needed for
optimizing health and performance.

A number of factors influence protein requirements for physically active and

inactive people, including the following (55, 72):

Age (growth phase): An individual who is growing (childhood, adolescent

growth spurt, etc.) has a higher requirement for protein than people who
 are fully grown.
Gender (amount of muscle mass): There are gender differences in muscle
mass that influence protein requirements. Women typically have less
muscle mass than men and would, therefore, have a lower protein
requirement.
Pregnancy/lactation: Women who are pregnant and/or lactating have a
higher requirement for protein to enable fetal growth (pregnancy) and to
provide sufficient protein to the breast-feeding infant (lactation).
Length of training at time of data collection: Protein requirements are
higher at the initiation of a new training regimen, as there are greater
changes in tissues than in people who have adapted to the training.
Energy intake and exercise: Inadequate energy intake and/or exercise
that is not adequately supported with sufficient energy may result in
protein tissue (muscle, bone, and organ) to help satisfy the requirement
for energy. The subsequent necessity to repair these tissues increases
protein requirement.
Type of exercise: Some physical activity results in a greater breakdown of
protein-based tissue, either to help supply energy or as a result of the
nature of the activity, which may be tissue damaging. In either case,
more protein would be required to repair the tissue damage.

Skeletal muscle and organ mass represent the major functional deposits of
protein and constitute at least 60% of total body protein (58). Body proteins
also exist in bone, blood plasma, and skin. There is no active “pool” of protein
or amino acids for the body to draw upon when needed, so a failure to
provide sufficient energy and protein of adequate quality in a timely fashion
will cause a breakdown of existing body proteins to satisfy needs (36). This is
an intricate balance that must satisfy current metabolic needs, tissue
recovery requirements, and future goals that, for an athlete, may include an
enlargement of the muscle mass. It is clear that consuming insufficient
protein causes a failure to satisfy metabolic requirements and may
compromise the immune system, tissue development, and tissue repair (55,
58). However, having protein in excess of 2 g/kg/day may increase
dehydration risk, lower bone mineral density, increase the risk for kidney
stones, and increase the risk of kidney failure (3, 37, 57). To make matters
even more complicated, it seems clear that total daily recommendations for
protein may be misleading, as they fail to address the following important
factors:

Total daily protein requirement can be estimated based on growth phase,

activity, and physiologic goals (8).
Humans can only process a limited quantity of protein at one time (∼20–
25 g), suggesting that the amount of protein provided at each meal be
considered.
Maximally stimulating postexercise muscle recovery is best accomplished
when protein is consumed in the period immediately postexercise,
 indicating that timing of intake is an important factor.
Protein is best used metabolically when individuals are in a state of
anabolic energy balance state (i.e., they have not burned more energy
than they have consumed), so satisfying energy needs is an important
factor in allowing protein to be used anabolically rather than to satisfy
the energy requirement.
Consumption of too much total protein over time and too much protein at
a single meal can be damaging to both bones and kidneys and may result
in a state of dehydration.

Digestion, Absorption, and Metabolism of Protein

Digestion
The purpose of protein digestion is to break complex proteins down into their
component amino acids. Although the mouth has no protein-digesting
enzymes, the saliva (primarily water) helps to denature the consumed
proteins (break down some of the bonding structures of the protein) and the
protein is also “chewed” in the mouth, allowing greater access of protein-
digesting enzymes to access protein bonds later in the digestive tract. Once
in the stomach, the acidity of the stomach (reaching a pH of 1–2) helps to
further denature the protein, and the primary protein-digesting enzyme,
pepsin (also referred to as gastric protease), begins the process of breaking
down proteins into amino acids. Pepsin breaks down the consumed protein by
attacking the peptide bonds that hold amino acids together. This is a step-
wise process, with proteins first being broken down into polypeptides (smaller
protein) and then eventually into individual amino acids.
Once the stomach contents, including the partially digested proteins
(polypeptides and some amino acids), are released into the small intestine,
the pancreas releases pancreatic juice and the digestive enzymes trypsin,
chymotrypsin, and carboxypeptidase into the small intestine. The pancreatic
digestive enzymes are sometimes referred to together as pancreatic
proteases. The pancreatic juice is highly alkaline and changes the acid pH of
the stomach contents to neutral (pH = 7). The shift in pH for highly acidic to
neutral further contributes to denaturing of the protein, making the digestive
enzymes more effective (Table 3.6).

Table 3.6 Protein-Specific Digestive Enzymes

Pepsin Pepsinogen is released by the chief cells of the stomach,
and the pepsinogen is converted to pepsin when the pH
of the stomach becomes lower (from pH of 7 to 1–2)
from the release of hydrochloric acid by the parietal cells
of the stomach. The lower pH is a signal that the
stomach is in the process of digesting proteins. Pepsin is
 a primary digestive enzyme, involved in breaking down
consumed proteins to polypeptides and amino acids by
cleaving the peptide bonds that hold together the amino
acids that constitute the protein.
Trypsin A digestive enzyme produced by the pancreas and
enters the small intestine via the common pancreatic
bile duct. It breaks down proteins and polypeptides into
smaller polypeptides and individual amino acids in the
duodenum of the small intestine.
Chymotrypsin A digestive enzyme produced by the pancreas and
enters the small intestine via the common pancreatic
bile duct. It has a slower breakdown rate than trypsin,
particularly for polypeptides that contain leucine and
methionine. Chymotrypsin continues the digestive
process initiated by pepsin and trypsin, digesting
polypeptides into individual amino acids.
Carboxypeptidase A digestive enzyme produced by the pancreas and
enters the small intestine via the common pancreatic
bile duct. It specifically breaks down the acid end of
protein and/or polypeptide molecules.

Absorption
With the digestive process complete, the amino acids are absorbed into the
blood through the small intestine. Most protein absorption occurs in the
jejunum and ileum. In a healthy individual, protein digestion is highly
effective, so only a small proportion of dietary protein is typically lost in the
fecal matter. It is important to note that aging commonly results in a
reduction in gastric HCl, which makes it more difficult for some older adults to
efficiently digest all proteins. Once in the blood, most amino acids are
processed by the liver, whereas BCAAs can be processed by the liver, muscle,
and other tissues. The metabolism of amino acids involves manufacturing the
specific proteins required by the body to function.

Important Factors to Consider

It is incorrect to think that consumption of a specific protein will result

in the manufacture of more of that protein. Once the protein is digested
into its individual amino acids and delivered to tissues, the tissues
manufacture proteins based on genetic command and that are needed
for survival and health.
As an example, gelatin sold in your local grocery store often advertises
itself as being good for making healthy hair and nails. Although gelatin
is a relatively low-quality protein that is a major component of hair and
 nails, eating hair and nails (i.e., gelatin) does not mean that you will
have healthy hair and nails!

Metabolism
Proteins are digested into their component amino acids, and these amino
acids are absorbed into the blood where they are delivered to tissues to be
synthesized into new proteins or metabolized for energy. If the amino acids
delivered to tissues exceed current needs, they are deaminated (i.e., the
nitrogen is removed) and the remaining carbon chain is converted to glucose
(gluconeogenesis) or stored as fat (Figure 3.4). The removed nitrogen is
either incorporated into a new nonessential amino acid in a process referred
to as transamination (the transfer of nitrogen from one amino acid, which has
had the nitrogen removed, to a newly created nonessential amino acid) or
removed via the kidneys. The newly created nonessential amino acids are
used to synthesize new proteins.

FIGURE 3.4: Protein metabolism. ATP, adenosine triphosphate; CoA,

coenzyme A.

The deaminated amino acid can also be used to create pyruvic acid, acetyl
coenzyme A (the intermediary product in all energy metabolism), or can go
directly into the citric acid cycle, all of which are products that can go into the
electron transport chain for the creation of ATP (energy). Consider, however,
that all proteins used to create ATP must have its nitrogen removed, which
has the potential of creating kidney stress if the amounts of protein
consumed are high.

Protein Intake Recommendations

 Important Factors to Consider

The recommendations for protein intake are based on age, gender,

pregnancy/lactation, and level of activity. In each case, these
recommendations are based on the amount that should be consumed
per day and per kg mass (weight). However, it is important to
remember that the daily requirement cannot be consumed at a single
meal, because that amount of protein would exceed the body’s
capacity to metabolize it properly. Depending on body size, the total
daily protein requirement should be distributed evenly throughout the
day in 25–30 g portions to optimize tissue utilization.
It is relatively easy to consume protein at the level of the established
requirement from typically consumed foods. Protein supplements are
typically not necessary and may keep athletes from consuming foods
that can provide the energy and other nutrients needed to ensure that
the consumed protein will be used anabolically rather than to help
support the need for energy.

Protein intake recommendations for the general public in the United States
are in the range of 10%–35% of total calories for healthy adults, with slightly
less for children and adolescents (Table 3.7). This range is based on (27):

0.80 g protein/kg weight/day for adults,

0.85 g protein/kg weight/day for adolescents,
0.95 g protein/kg weight/day for preadolescents aged 4–13 years, and
1.10 g protein/kg weight/day for 1- to 3-year-olds.
The table represents recommended dietary allowances (RDAs) in bold type, adequate intakes (AIs) in
ordinary type followed by an asterisk (*). RDAs and AIs may both be used as goals for individual intake.
RDAs are set to meet the needs of almost all (97%–98%) individuals in a group. For healthy breast-fed
infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover the
needs of all individuals in the group, but lack of data prevent being able to specify with confidence the
percentage of individuals covered by this intake.
a
Based on 1.5 g/kg/d for infants, 1.1 g/kg/d for 1–3 yr, 0.95 g/kg/d for 4–13 yr, 0.85 g/kg/d for 14–18 yr,
0.8 g/kg/d for adults, and 1.1 g/kg/d for pregnant (using prepregnancy weight) and lactating women.
b
Acceptable macronutrient distribution range (AMDR) is the range of intake for a particular energy
source that is associated with reduced risk of chronic disease while providing intakes of essential
nutrients. If an individual consumed in excess of the AMDR, there is a potential of increasing the risk of
chronic diseases and insufficient intakes of essential nutrients.
c
ND = Not determinable due to lack of data of adverse effects in this age group and concern with
regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent
high levels of intake.
Source: Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate. Fiber, Fat, Fatty
Acids, Cholesterol, Protein, and Amino Acids (2002/2005). Washington, DC: The National Academies
Press; 2005. Available from: www.nap.edu. Accessed April 19, 2018.

These values differ from the recommendations of the WHO (81), which
suggests an intake of 0.83 g protein/kg weight/day of good-quality protein for
all healthy adults of both genders and at all ages. For some groups, this value
is considerably less than the upper level of the protein intake
recommendation of the U.S. Institute of Medicine (IOM) (27), corresponding to
∼8%–10% of total calories consumed. The Nordic Nutrition recommendations
are all less than the IOM recommendations, ranging from 10% to 20% of total
energy consumed, with an average of 15% of total calories from protein for
dietary planning purposes. This translates to 1.1–1.3 g protein/day for healthy
adults, and slightly more for those aged over 65 years (1.2–1.5 g protein/kg).
The protein intake recommendations for active people ranges from 1.2 to
1.7 g protein/kg weight/day, depending on type and duration of activity, age,
and gender (62, 73). Typical recommendations for endurance athletes are
1.2–1.4 g protein/kg weight/day and for strength-trained athletes from 1.6 to
1.7 g protein/kg weight/day (21, 42). These higher requirements in athletes
are based on higher lean (muscle) mass, a greater exercise-associated loss of
protein in the urine, more protein “burned” as a source of energy, and a
greater requirement for muscle repair (20, 62, 72). As demonstrated in Table
3.8, most athletes can easily consume far more protein than the upper level
of these ranges from food alone (57).

Table Protein Content of Commonly Consumed Foods, Providing

3.8 ∼2,350 Calories
Meal Food Amount Calories Protein
(g)
Breakfast Orange juice
1 cup (8 112 1.74
oz)

Whole wheat bread, toasted

2 slices 161 7.97

Almond butter
1 tbsp 98 3.35

Whole egg, hard boiled

2 large 156 12.58
eggs

Mid-AM Banana
snacks 1 109 1.20
medium

Peanuts
1 oz 166 4.84
Table Protein Content of Commonly Consumed Foods, Providing
3.8 ∼2,350 Calories
Meal Food Amount Calories Protein
(g)
Lunch Roast beef sandwich
2 oz 65 10.56
Lean roast beef 2 regular 161 7.97
Whole wheat bread slices 3 0.19
Mustard 1 tsp 2 0.02
Lettuce 1/3 cup
(shred)

Milk, 1% fat
8 oz (1 102 8.22
cup)

Strawberries, fresh
1 cup 49 1.02

Mid-PM Apple, raw

snacks 1 95 0.47
medium

Sports beveragea
16 oz 127 0.00

Dinner Chicken breast (no skin)

baked 3 oz 147 26.29

Broccoli, boiled
1 large 98 6.66
stalk

Potato, baked with melted

low-fat cheddar cheese 1 145 3.06
medium 49 6.90
potato
1 oz

Multigrain bread
1 slice 69 3.47

Frozen yogurt (vanilla)

½ cup 114 2.88
Table Protein Content of Commonly Consumed Foods, Providing
3.8 ∼2,350 Calories
Meal Food Amount Calories Protein
(g)
Evening String cheese (low fat)
snacks 1 stick (1 49 6.90
oz)

Fresh orange
1 Orange 69 0.21

Total Calories and Protein (g) 2,339 126.30

Based on the maximum recommendation of 2.0 g protein/kg/d a 120 lb (55 kg) athlete consuming
these foods would require a maximum of 110 g protein/d, and these foods provide 126.30 g protein.
a
Consumed as part of physical activity/training.

Most athletes have energy requirements that are considerably higher than
same-weight nonathletes, making it far easier to obtain the needed protein if
energy requirements are satisfied. Numerous studies have found that athlete
protein intake is often in the range of 2–2.5 g/kg/day, and as high as 3
g/kg/day, values that represent nearly double the upper end of the desirable
range. Despite the easy access of protein from foods alone, the diets of some
athlete groups should be carefully assessed to ensure an adequate intake.
These groups include (26):

Athletes who are in a growth phase and have a high energy and protein
requirement from the combined demands of growth and physical activity.
These athletes are often in school settings where getting sufficient food
during the day may present difficulties.
Athletes who restrict food consumption to achieve a lower weight. Food
restriction compromises both energy and protein consumption, making it
difficult to satisfy protein functions.
Vegetarian athletes who avoid all animal products, which are the highest
sources of protein. Although it is possible for vegetarian athletes to
obtain the protein they require, doing so requires planning.

As indicated in Chapter 2, carbohydrates have a protein-sparing effect.

That is, if sufficient carbohydrates are consumed to satisfy a sufficient
proportion of the energy (calorie) requirement, the consumed protein is not
used for energy, therefore making it available to satisfy other functions that
are specific to protein. Therefore, protein consumption adequacy can only be
viewed in the context of whether sufficient total energy has been consumed.
Using the acceptable macronutrient distribution ranges of the IOM, Phillips et
al. (57) have predicted the endurance and strength athlete macronutrient
ranges (Table 3.9).
 Table 3.9 Macronutrient Distribution Ranges for Endurance and
Strength Athletes
Macronutrient Dietary energy AMDR for Endurance AMDR for Strength
(AMDR)a (%) Athletesb (%) Athletesc (%)
Carbohydrate 45–65 55–80 30–65
Fat 20–35 10–25 15–30
Protein 10–35 10–20 20–40
a
The acceptable macronutrient distribution range (AMDR) of the Institute of Medicine represents “…a
range of intakes for a particular energy source that is associated with reduced risk of chronic diseases
while providing adequate intakes of essential nutrients.”
b
Derived based on recommendations for carbohydrate intake for optimizing performance.
c
Derived based on recommendations for protein requirements from retrospective nitrogen balance
analysis, and working upward from those estimates to include sufficient nutrients for health, as well as
the elevated energy requirements for these athletes to maintain an increased skeletal muscle mass.
Source: Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty
Acids, Cholesterol, Protein and Amino Acids. Food and Nutrition Board. Washington (DC): National
Academies Press; 2005; Phillips SM, Moore DR, Tank JE. A critical examination of dietary protein
requirements, benefits, and excesses in athletes. Int J Sport Nutr Exerc Metab. 2007;17:S58–76.

Protein and Athletic Performance

Maintaining, Building, and Repairing Muscle

Improving physical performance is a clear goal for athletes and many studies
have been conducted to assess how best to achieve this goal through dietary
modifications. It is clear that athletic performance is improved with a lean
body mass that enhances the strength-to-weight ratio (60). Studies have
found that specific nutritional compounds, when consumed at the right times
and in the right amounts, may serve to enhance athletic performance. The
essential amino acid leucine is known to be a regulator in protein
metabolism, including helping to reduce muscle protein breakdown and to
stimulate MPS (Tables 3.10–3.12).

Table Summary of Human Studies Related to Dietary Intake

3.10 of Leucine or Supplementation
Reference Population Design Findings
Alvestrand 12 Infusion with intravenous Plasma and
et al. (2) females leucine. intracellular levels of
AAs decreased, and
40% of excess leucine
was oxidized.
Bohé et al. 21 Infusion with mixed AAs MPS became saturated
(4) humans at 240% above basal at high concentrations
levels. of intramuscular EAAs.
Table Summary of Human Studies Related to Dietary Intake
3.10 of Leucine or Supplementation
Reference Population Design Findings
Rennie et al. Humans Infusion with mixed AAs Leucine stimulated MPS
(61) or leucine. to the same extent as
complete meals.
Glynn et al. 14 Consumption of EAAs or Leucine content in 10 g
(22) humans EAAs with increased EAAs is sufficient to
leucine content. maximize MPS.
Casperson Older Meals supplemented with Leucine improved MPS
et al. (9) humans leucine for 2 wk. in response to lower
protein meals.
Churchward- 24 males Completion of resistance Low doses of whey
Venne et al. exercise and supplemented with
(12) consumption of varying leucine or EAAs
doses of whey stimulated MPS to the
supplemented with same degree as larger
leucine or EAAs without doses.
leucine.
Nelson et al. 12 males Performed high-intensity The high-leucine dose
(49) endurance exercise and in the supplement
subsequently ingested saturated BCAA
leucine/protein metabolism, increased
supplement or control. leucine oxidation, and
attenuated MPB.

AAs, amino acids; BCAA, branched-chain amino acid; EAAs, essential amino acids; MPB, muscle protein
breakdown; MPS, muscle protein synthesis.

Table Summary of Human Studies Related to Timing, Dosing,

3.11 and Long-Term Effects of Leucine Supplementation
Reference Population Design Findings
Bohé et al. 6 humans Mixed AAs were infused MPS rates declined
(4) by IV. rapidly after 2 h.
Gaine et al. 7 humans Consumption of Leucine oxidation
(17) controlled diet and decreased as protein
performed aerobic utilization improved.
exercise for 4 wk.
Moore et al. 6 young Performed resistance Leucine oxidation
(44) males exercise then consumed increased after 20 g
differing amounts of protein as MPS was
protein. maximally stimulated.
Table Summary of Human Studies Related to Timing, Dosing,
3.11 and Long-Term Effects of Leucine Supplementation
Reference Population Design Findings
Churchward- 24 males Completed resistance Low doses of whey
Venne et al. exercise and consumed supplemented with
(12) varying doses of whey leucine or EAAs
supplemented with stimulated MPS to the
leucine or EAAs without same degree as larger
leucine. doses.
Nelson et al. 12 males Performed high-intensity The supplemental
(49) endurance exercise and leucine dose saturated
subsequently ingested BCAA metabolism,
leucine/protein increased leucine
supplement or control. oxidation, and
attenuated MPB.

AAs, amino acids; BCAAs, branched chain amino acids; EAAs, essential amino acids; MPB, muscle
protein breakdown; MPS, muscle protein synthesis.

Table Summary of Human Studies Related to the Effect of

3.12 Leucine Supplementation on Breakdown of Muscle
Protein
Reference Population Design Findings
Schena et 16 Trekked 21 d at high BCAA supplementation
al. (67) humans altitude and took either decreased muscle loss
BCAA or placebo during chronic hypobaric
supplements. hypoxia.
Nair et al. 6 healthy Leucine or saline infusedLeucine decreased MPB
(46) males intravenously. across several muscle
sites.
Koopman 8 elderly Consumed a control diet Coingestion of leucine did
et al. (33) males or one supplemented not attenuate MPB.
with leucine after
exercise in crossover
design.
Glynn et 14 Consumed EAAs with Leucine supplementation
al. (22) humans normal or high-leucine showed a modest decrease
content. in MPB.
Stock et 20 trained Performed resistance Leucine supplementation
al. (69) humans exercise and consumed did not attenuate MPB.
a leucine-supplemented
beverage before and
after.
Table Summary of Human Studies Related to the Effect of
3.12 Leucine Supplementation on Breakdown of Muscle
Protein
Reference Population Design Findings
Kirby et 27 males Performed drop jumps Leucine supplementation
al. (30) and consumed a did not attenuate MPB.
placebo, leucine, or
nothing.
Nelson et 12 males Performed high-intensity The high-leucine dose in
al. (49) endurance exercise and the supplement saturated
subsequently ingested BCAA metabolism,
leucine/protein increased leucine
supplement or control. oxidation, and attenuated
MPB.

BCAA, branched chain amino acids; EAAs, essential amino acids; MPB, muscle protein breakdown.

Muscle protein constantly changes through the breakdown of existing

proteins and the synthesis of new proteins (50). This process varies
dramatically over the course of a single day, but it is now known that a
prolonged period with no food consumption results in a decreased protein
synthesis of between 15% and 30% below normal levels, and this catabolic
period continues until energy (calories) and amino acids are ingested to
stimulate the process of protein synthesis (50). Skeletal muscle is highly
responsive to dietary protein and energy intake, and exercise stimulates both
MPS and muscle protein breakdown (32, 76, 77). Muscle protein acquisition
results when there is either increased MPS or decreased muscle protein
degradation, so for muscle enlargement to occur, MPS must surpass muscle
protein breakdown (13). Consumption of high-quality protein that provides
the essential amino acids is essential in encouraging postexercise MPS.
Muscle activity and the availability of nutrients strongly influence exercise-
induced adaptive changes in muscle (44, 80), and a failure to provide
sufficient energy and protein soon after an exercise bout will compromise
optimal muscle recovery and maintenance (1, 13). It has been shown that
consumption of protein/amino acids (>15 g) following resistance exercise
effectively increases MPS rates (31). It is well established that resistance
exercise results in greater protein synthesis that continues for up to 48 hours
postexercise (54). Therefore, individuals who wish to increase muscle mass
must consume protein soon after exercising to gain a positive protein balance
and capitalize on the enhanced muscle receptiveness to protein, but should
also sustain a good energy balance with well-distributed protein consumption
for the days following the resistance activity (24).

Branched-Chain Amino Acids

The three BCAAs, leucine, valine, and isoleucine, stimulate protein synthesis
and inhibit protein breakdown, particularly in skeletal muscle, possibly
because BCAAs are the only essential amino acids that are metabolized in
muscle and other tissues, but not in the liver (80). Of the three BCAAs, the
essential amino acid leucine appears to be the most potent stimulator of
protein synthesis (19). A number of studies have assessed leucine’s role in
MPS and its role in reducing muscle protein loss in states of inadequate
energy consumption (i.e., in a catabolic state) (18, 50). It also appears that
leucine regulates protein synthesis in cardiac muscle and adipose (fat) tissue
(70).
The value of BCAAs, particularly leucine, in stimulating MPS may be
misinterpreted, with athletes sometimes consuming large doses of
supplemental protein and/or amino acids with an elevated leucine content.
However, there are findings suggesting that metabolic pathway thresholds
may be overwhelmed by single bolus doses that exceed ∼20–25 g protein
and equivalent AA intake, and consuming leucine in large bolus doses greater
than these equivalents is not useful (12).
It is also possible that the onset of fatigue during exercise is attributed to
changes in concentrations of the neurotransmitters serotonin, dopamine, and
noradrenaline, which are dependent on serum amino acids being transported
through the blood–brain barrier (59). The amino acids involved in the
synthesis of these neurotransmitters use the same blood–brain barrier
transporters as the BCAAs, with the possibility that excess leucine and other
BCAAs may compete with the transporters and inhibit the production of
neurotransmitters, resulting in premature fatigue (41). Supplemental intake
of individual amino acids may cause problems, and it is important to
remember that amino acids are normally consumed as part of an entire meal
consisting of whole proteins, and that the consumed protein is associated
with a parallel increase in blood glucose and insulin release, both of which
enable leucine’s action (19, 35). Supplemental amino acids are devoid of
carbohydrates, which provide the glucose and subsequent insulin. A good
strategy for assuring optimal protein metabolism is to add high-leucine foods,
including whey protein, eggs, poultry, fish, and kidney beans, to meals during
postexercise recovery to aid MPS by increasing muscle hypertrophy,
attenuating muscle breakdown, and maintaining net positive muscle protein
(11). It has also been found that large doses of supplemental leucine are not
more effective than doses commonly ingested in a well-balanced healthy
diet. Additionally, there are mixed results on whether large doses of leucine
may induce detrimental health effects. Some studies have found that large
doses are associated with insulin resistance (40, 82), whereas other studies
have found that increasing dietary leucine had a positive effect on insulin
sensitivity (35). Despite the few lingering questions regarding a potentially
negative health impact with high-dose intakes, consumption of high-leucine
foods and leucine-enhanced foods and supplements (e.g., whey protein food
bars) postexercise has been found to enhance MPS across different
populations.
The distribution of protein consumption during the day and its intake
following exercise and periods of lower activity are also important
considerations (see Tables 3.10 and 3.11). Aging is associated with lower MPS
following ingestion of essential amino acids, but it has been found that
proteins with a slightly elevated leucine content (e.g., whey protein), when
provided in well-distributed intervals throughout the day, increase MPS in
both young and older adults (9, 14, 52) (Figure 3.5).

FIGURE 3.5: Protein distribution makes a difference in muscle development.

(From Paddon-Jones D, Sheffield-Moore M, Zhang X-J, et al. Amino acid
ingestion improves muscle protein synthesis in the young and elderly. Am J
Physiol Endocrinol Metab. 2004;286(3): E321–8.)

As noted earlier, the provision of ∼25 g of good-quality protein well

distributed in daily meals appears sufficient to obtain the desired outcomes,
assuming energy balance is sustained (51, 57). Studies have determined that
large doses of leucine are not more effective than good-quality foods and
may negatively impact health (40, 82).
From a practical standpoint, consumption of a beverage containing
approximately up to 25 g protein after heavy resistance training has the
potential of improving MPS. Combining this protein with an equal caloric load
of carbohydrate also helps to ensure better energy balance, allowing the
protein-sparing effect of carbohydrate to manifest itself (so the protein can
be used for muscle recovery rather than energy). The carbohydrate provided
at this time also aids in glycogen recovery (83). Studies have found that
chocolate milk, because of its combination of carbohydrate and high-quality
protein that contains leucine, plus electrolytes (primarily sodium, chloride,
and potassium) to help recover a hydrated state, is an effective postexercise
replenishment beverage (23, 74).

Risks of Too Much Protein

Many physically active people often consume high-protein diets, often at
levels exceeding 2.0 g protein/kg or more than 25% of total calories from
protein, primarily to enhance muscle mass and strength. There is little
scientific support for consuming protein above 2.0 g/day, and there are no
long-term data on the potential health effects of this level of regular protein
consumption (65). There is an increasing body of evidence to suggest that
chronic and excessively high intakes of protein, at levels exceeding 2.0 g/kg,
may increase the risk of renal damage. A 2-year human intervention study
assessing a relatively low-carbohydrate and relatively high-protein meat and
dairy-based diet following the basic recommendations of the well-known
Atkins Diet found that after 24 months, there were some signs of kidney
function loss (16, 68). Although this is unlikely to be a major concern for
otherwise healthy people, this would be a particular concern for individuals
who already have kidney dysfunction (38, 75). Animal studies inducing these
same high-protein, low-carbohydrate intakes have had similar findings (28).
The proposed mechanism for the kidney damage is related to the
combination of forced nitrogenous excretion, formation of kidney stones, and
hypertension associated with the sodium in animal proteins. This review
suggests that protein intakes exceeding 25% of total energy or more than 2–
3 g/kg/day are not recommended (37). Because the excreted urea and uric
acid are acidic, blood calcium is used to buffer the acidity in the kidneys. This
added calcium increases the risk for uric acid–calcium kidney stones (25, 63).
Because blood calcium levels cannot change (it is a major pH buffer in the
blood), the calcium lost to the kidneys is replaced by calcium from bones,
resulting in lower bone mineral density (3) (Figure 3.6).
FIGURE 3.6: High-protein diets and increased risk of kidney disease.
(Adapted from Marckemann P, Osther P, Pedersen AN, Jespersen B. High-
protein diets and renal health. J Ren Nutr. 2015;25(1):1–5.)

The IOM has set the protein distribution range at 10%–35% of total
calories consumed, with no upper limit on protein intake because of the lack
of clearly associated health problems (27). It is common for high-protein
intakes, often as much as 300 g/day, to be consumed without any apparent
negative health effects. However, the long-term effects of this dietary pattern
have not been adequately assessed (75). There is also concern that high-
protein intakes above 2.0 g/kg/day negatively affect the consumption of
carbohydrate, which could have an impact on performance (75).

Summary

The recommended protein intake (recommended dietary allowance) for

the general adult population is 0.8 g/kg/day, with recommendations for
active people in the range of ∼1.2–2.0 g/day. The timing of intake and the
quality of protein consumed are also important considerations for
athletes.
Resistance activity helps to stimulate the enlargement of muscle mass if
coupled with sufficient energy and protein up to 25 g consumed
immediately within 2 hours postexercise. Protein intakes above this
amount postexercise do not additionally stimulate protein synthesis but
merely result in more urea synthesis and nitrogenous excretion (5, 55).
The protein recommendation, compared with the other energy substrates
(carbohydrate and fat), is relatively small for physically active people
 (∼1.2–2.0 g protein/kg/day, compared with the 5.0–12.0 g
carbohydrate/kg/day) (73). Ideally, this amount of protein should be
evenly distributed during the day in amounts of ∼25 g/meal to obtain the
greatest benefit. It appears that an average protein intake of 1.25
g/kg/day (assuming sufficient total energy consumption) adequately
compensates for muscle protein breakdown during long resistance and
endurance exercise sessions (58).
The daily requirement of protein should be met with meals that provide a
regular distribution of high-quality protein over the course of the day and
following strenuous training (73).
Current protein recommendations are often expressed in terms of the
regular spacing of modest protein intakes (∼0.3 g/kg) following physical
activity and throughout the day. Adequate energy is required to optimize
protein utilization (73).
High-quality proteins containing the amino acid leucine, particularly when
consumed postexercise, are useful for MPS and for sustaining lean mass
(73).
There is justifiable concern that, despite unanimous recommendations for
high-carbohydrate intakes for athletes and recommendations for
relatively low intakes of protein, athletes appear to consume far in excess
of their need for protein, fail to optimally distribute protein during the
day, and consume less than they require from carbohydrates (6, 7).

Practical Application Activity

Protein intake can be analyzed as a percent of total calories consumed (%

protein), or as grams of protein/kg mass (g/kg). The preferred method is
g/kg, as this provides an adjustment for the protein consumed based on
body mass. Using % protein, it is possible for someone to have what
appears to be a desirable protein consumption (e.g., 15% of total calories),
but if insufficient calories are consumed, the protein intake will be
inadequate. You can assess your protein food intake for both % protein and
g/kg following the same instructions provided in Chapter 1, accessing the
online USDA Food Composition Database (78),
(https://ndb.nal.usda.gov/ndb/search/list), but this time create a
spreadsheet with Energy (calories) and Protein (g) and organize your foods
by meal/eating opportunities. Create subtotals for each meal, and totals for
the day, as follows:
 Note: Repeat meal format (Meal 1, Meal 2, Meal 3, etc.) above for as many eating opportunities that
you had.

1. When completed, analyze the diet to view your protein consumption,

including protein g/kg, and % energy from protein (calories from
protein/total energy)
2. Review the foods that contribute most to your protein intake.
3. Determine if your protein consumption is adequate for a nonathlete
(∼0.8 g/kg) and for an athlete (∼1.2–2.0 g/kg)
4. Assess if the intake of protein per meal is greater than ∼30 g at any
meal. On average, protein consumed in excess of 30 g/meal may not
be efficiently metabolized as protein, with a proportion of the protein
being used as energy or stored as fat rather than used anabolically to
build and repair tissues, make hormones, etc.
5. If necessary, try to make adjustments to your diet by eating different
foods and/or distributing the food consumed so that the consumed
protein will be optimally metabolized.

Chapter Questions

1. The chemical composition of proteins differs from carbohydrates or fats

because of the presence of:
a. Sodium
b. Carbon
c. Nitrogen
d. Hydrogen
2. Factors that determine protein quality:
a. Quantity and rate of intestinal absorption
b. Rate of utilization as an energy substrate
 c. Amount, type, and distribution of essential amino acids
d. Digestibility
e. a and c
3. To have a protein-sparing effect, athletes must consume sufficient:
a. nonessential amino acids
b. essential amino acids
c. carbohydrate
d. fluids
4. The anabolic potential of protein is best achieved if it is consumed in a
single large dose of between 50 and 60 g.
a. True
b. False
5. The daily protein intake recommendation for strength athletes is:
a. 0.8–1.0 g/kg
b. 1.2–1.7 g/kg
c. 2.0–3.8 g/kg
d. >3.0 g/kg
6. Chronic consumption of excess protein may negatively affect the health of
which organ?
a. Pancreas
b. Intestines
c. Kidneys
d. Brain
7. Because protein is an energy substrate, at least 20% of the total energy
requirement should be derived from protein.
a. True
b. False
8. Which of the following amino acids is associated with stimulation of MPS?
a. Leucine
b. Phenylalanine
c. Tryptophan
d. Histidine
9. Protein consumption exceeding 30 g at a single meal may result in an
increase in blood urea nitrogen, which is associated with both dehydration
and lower bone mineral density.
a. True
b. False
10. Consumption of a specific protein will result in better synthesis of that
protein. For instance, hair and nails both have a high content of the protein
“gelatin,” so consuming more gelatin in the diet will result in more healthy
hair and nails.
a. True
b. False

Answers to Chapter Questions

1. c
2. c
3. c
4. b
5. b
6. c
7. b
8. a
9. a
10. b

REFERENCES

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Spreading intake of a leucine-rich fast protein in energy-restricted
overweight rats does not improve protein mass. Nutrition.
2012;28(5):566–71.
2. Alvestrand A, Hagenfeldt L, Merli M, Oureshi A, Eriksson LS. Influence of
leucine infusion on intracellular amino acids in humans. Eur J Clin
Invest. 1990;20(3):293–8.
3. Barzel US, Massey LK. Excess dietary protein can adversely affect bone.
J Nutr. 1998;128(6):1054–7.
4. Bohé J, Low A, Wolfe RR, Rennie MJ. Human muscle protein synthesis is
modulated by extracellular, not intramuscular amino acid availability: a
dose-response study. J Physiol. 2003;552(1):315–24.
5. Burd NA, West DWD, Staples AW, et al. Low-load high volume
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CHAPTER OBJECTIVES

Recognize the different types of fatty acids, and the primary

food sources of these fatty acids.
Describe the recommended intakes of lipids for athlete and
nonathlete populations, and the best dietary sources of these
lipids.
Identify the major lipid digesting enzymes and associated
substances and their sources in the gastrointestinal (GI) tract.
Demonstrate an understanding of the major blood
lipoproteins, their sources, and how they are metabolized.
Explain the association between lipids and atherosclerosis and
heart disease, and the exercise and dietary strategies that
can be followed to lower atherosclerosis and heart disease
risks.
Discuss how trans fats are made, the foods most likely to be
high in trans-fatty acids, and the health problems these pose.
Describe how fats are metabolized to provide adenosine
triphosphate (ATP) energy to tissues, and the dietary,
hormonal, and exercise factors associated with increasing fat
metabolism.
Recognize the major functions of lipids in helping to sustain
good health.
Understand the major reactions that take place with dietary
lipids.
Know the essential fatty acids and the processes for making
nonessential fatty acids.
 Case Study

John was a talented defensive lineman on his high school

football team, getting a lot of pressure from his coach to
“. . .put on some weight!” He was not given any guidance on
what to do, so he stayed with the same training regimen as
before but started eating more — a lot more. More bacon,
more sausage, and five fried eggs instead of his usual two.
Sure enough, his weight was going up. The problem was that
the weight increase was nearly all body fat, so he had the
same amount of muscle trying to move more nonmuscle
weight, and everyone noticed he was slower off the line, and
his endurance was terrible. To make matters even worse, he
had a great deal of muscle soreness that slowed him down
even more and made it difficult for him to recover from
football practice. By the end of each week, he literally felt
lame and had terrible performances at Saturday games. So
his coach said the inevitable: “You need to lose some weight!”
So John went on self-prescribed low-calorie “diet” that was
near starvation, because he was desperate to lose that
weight. Yes, he lost weight, but almost all the weight he lost
was muscle, which made his strength-to-weight ratio even
worse (he had less muscle moving more nonmuscle weight).
His endurance was terrible, and he was pretty sure he would
have to give up football.
Finally, John’s parents made an appointment with a
registered dietitian who specialized in sports nutrition. The
dietitian showed John how to dynamically match energy
intake with expenditure, and also showed him how all those
saturated and trans fats he was consuming added to his
muscle soreness. He also spoke to a certified athletic trainer
and a strength and conditioning coach who worked together
with the dietitian to work up a diet and exercise plan that
would help John benefit from the exercise to enhance muscle
mass and lower fat mass. It worked, and John learned an
important lesson. Not all fats are the same. Some fats, such
as omega-3 fatty acids (from fish and vegetables), can reduce
muscular inflammation, while some fats, such as n-6
saturated fatty acids and trans fats (from meats and
margarine), can add to inflammation. He also found out the
hard way that too much fat will definitely make it easy to get
too many calories and will, inevitably, make it easy to become
fat.

CASE STUDY DISCUSSION QUESTIONS

1. If you were working with John, what kind of diet would you
recommend for him to help ensure he gets the energy he
needs to support his perceived need to put on weight?
2. How would you explain to John that the kind of weight he
wants to increase is an important factor in his
performance? How would you get John to think about
increasing muscle weight rather than just weight?

Introduction

Important Factors to Consider

Dietary lipids (i.e., dietary fats) have many important

functions, but the majority of populations in industrialized
nations eat too much fat, particularly of the wrong kinds
that are high in saturated fatty acids, placing them at risk
for obesity and for early development of cardiovascular
disease. Not all fats are the same in terms of their
atherogenic potential, but excess fat intake, regardless of
the source, is likely to cause problems. While reading this
chapter, think about ways to (i) improve the kinds of fats
consumed and (ii) eat to lower total fat consumption.
There is a common misunderstanding that consumption of
foods high in cholesterol (a waxy, fat-like substance that
occurs naturally in all parts of the body) is dangerous as
these foods increase heart disease risk. For instance, eggs
are high in cholesterol but relatively low in fat, but they are
often avoided because people fear that the cholesterol will
 increase heart disease risk. However, consumption of fatty
foods, even if they contain no cholesterol will also elevate
blood cholesterol because the bile used to emulsify these
dietary fats is 50% cholesterol. Therefore, the key to
lowering heart disease risk is to consume better fats (i.e.,
mono- and polyunsaturated fats associated with vegetables,
nuts, and seeds) and to lower total fat intake. Just lowering
cholesterol intake will not achieve the desired goal.

Cholesterol

A sterol molecule manufactured by animal cells with protective

cell membrane functions. (It is not found in foods of nonanimal
origin.) Bile, made by the liver to aid in dietary fat absorption, is
50% cholesterol. High blood cholesterol may occur, therefore,
from either a high level of meat consumption or a high level of
fat consumption. High blood cholesterol is associated with
higher risk of atherosclerosis and heart disease deaths.

Heart Disease

Cardiovascular disease involving reduced blood flow to the

heart and other tissues from an atherosclerotic narrowing of the
arteries, dramatically increasing the risk of a heart attack
(myocardial infarction) and stroke. High-fat diets and
inadequate exercise are associated with higher risk of
cardiovascular disease.

The term lipid is the scientific term for organic molecules that are
not soluble in water but are soluble in organic solvents (soaps,
chloroform, benzene, etc.). Lipids are commonly referred to as
fats, but traditionally the word fat refers to a lipid that is solid at
room temperature (e.g., butter), while the word oil refers to a lipid
that is liquid at room temperature (e.g., corn oil). Fats and oils are
typically also different in composition, and this can have an
impact on the health or disease potential when different fats or
oils are consumed. Some lipids, such as cholesterol, are a
common part of health assessments because the amount of
cholesterol in the blood is associated with cardiovascular disease
risk. There are many other lipids as well, including the lipid–
protein molecules that are created when dietary fats are digested
and absorbed. The degree to which these molecules are present
in the blood is also an indicator of cardiovascular disease risk, and
it provides an indication of whether more lipids are being removed
from storage to supply energy than being delivered to storage.

Lipids

Molecules that include fats, waxes, sterols, monoglycerides,

diglycerides, triglycerides, phospholipids, and fat-soluble
vitamins.

Virtually every food we consume contains lipids, including

fruits, vegetables, cereals, meats, and fish. However, different
foods contain different types and concentrations of lipids that may
either increase or decrease disease risk. For the purpose of this
book, the term lipid is used to refer to all lipids in general, and
specific fats or oils will be identified where the difference is
important for health, disease risk, or athletic performance.
In humans, lipids have a wide range of functions that are
critically important to sustaining good health. These include:

Concentrated source of energy: Lipids are an extraordinarily

efficient storage form for energy (i.e., calories). One gram of
lipid (fat or oil) provides 9 calories, while 1 g of either
carbohydrate or protein provides 4 calories. One way of
thinking about the difference in caloric density is that, for
every gram of fat removed from the diet, you can consume
twice as many grams of carbohydrate and protein and still
consume less total energy. Another way of considering the
caloric density of lipids is that eating high-fat foods (e.g., fried
foods, fatty meats) is an easy way to obtain too many calories
at a single meal.
Insulation from environmental temperature: Body fat is evenly
distributed between the fat stored subcutaneously (under the
skin) and visceral fat (the fat stored around the organs). This
fat plays dual roles that are both important, acting as a source
of energy that can be delivered to tissues in a time of need
and also acting as an insulation blanket to help sustain body
and organ temperature when exposed to environmental
temperature extremes (2).
Cushion against jarring: The subcutaneous fat layer protects
the underlying muscle, which is far more vascular (has more
blood running through it), from being bruised when struck.
Athletes of all kinds, but particularly athletes in concussive
sports (boxing, football, etc.), must be cautious of being too
lean as the direct “hits” on muscle would be damaging and
require more repair.
Prolong satiety: Consumed lipids have a delayed gastric
emptying time, and while food remains in the stomach, the
desire to eat again is delayed. This feeling of satiety, or the
feeling of fullness after eating, is considered desirable
because it helps to avoid overeating. Importantly, the delayed
gastric emptying helps to ensure that the consumed
foods/nutrients are better absorbed and enter the blood more
gradually. This graduated absorption enhances tissue
utilization of the nutrients.
Improve the flavor and palatability of foods: For anyone who
has tasted fried chicken and boiled chicken at the same meal,
it is easy to understand how higher fat foods improve food
flavor and palatability (having a more pleasant taste).
Traditionally, higher fat foods were consumed mainly on
special occasions, but many foods that are high in fat are
easily available and at low cost. The high palatability, coupled
with the low cost and easy availability, increases the risk that
excess lipids will be consumed with related higher health
risks.
Carry the fat-soluble vitamins A, D, E, and K: Some vitamins
require a lipid environment, so some lipids must be consumed
to be assured of obtaining these fat-soluble vitamins. Vitamin
E, for instance, is a vitamin commonly found in cereal oils
(i.e., corn oil), while vitamin A is found in animal sources (i.e.,
eggs, meat, dairy, liver). Avoiding all higher fat foods could
 easily result in a deficiency of one or more of these fat-soluble
vitamins.
Provide the essential fatty acids: While humans can
manufacture most of the lipids required to ensure health, we
are unable to manufacture the essential fatty acids, linoleic
acid (LA) and a-linolenic acid (ALA). Therefore, it is essential
that we consume these fatty acids from the foods we eat.
These fatty acids are available from a wide range of foods,
including fish, shellfish, leafy vegetables, walnuts, flax, and
more. Failure to consume foods with the essential fatty acids
is associated with central nervous system and cardiac
problems.

Essential Fatty Acids

The essential fatty acids, LA and ALA, are referred to as

essential because humans are unable to manufacture them.
Therefore, it is essential that we obtain these fatty acids from
consumed foods.

LA is an unsaturated omega-6 fatty acid (i.e., the double

bond is at the sixth carbon atom) and is required for normal
neurological function, the growth and maintenance of hair
and skin, and the maintenance of good bone mineral
density. There is evidence that diets relatively high in LA
also lower heart disease risk (12). Food sources of LA
include plant seed oils, including corn, sunflower, and
soybean oils. Certain nuts, including pecans, Brazil nuts,
and pine nuts, are relatively high in LA. Humans convert
consumed LA into γ-linolenic acid (GLA) and arachidonic
acid, both of which have important physiological functions.
GLA inhibits the tissue inflammation associated with
rheumatoid arthritis, diabetes, and allergies (17).
Arachidonic acid not only supports brain and muscle
function but also promotes inflammation (19).
Linolenic acid is an unsaturated omega-3 fatty acid (i.e., the
double bond is at the third carbon atom) and is necessary
for healthy cell membranes and cardiovascular function
 because of its cholesterol lowering and inflammation
lowering properties (7). The consumed form of linolenic acid
is in the form of the omega-3 fatty acid ALA, the omega-3
fatty acid eicosapentaenoic acid (EPA), and the omega-3
fatty acid docosahexaenoic acid (DHA). Common food
sources of ALA include flaxseed, soybeans, pumpkin seeds,
walnuts, and canola oil; common food sources of EPA
include fatty fish, fish oils, and marine foods (i.e., marine
algae, seaweed); common food sources of DHA include
marine foods, fatty fish, and DHA-enriched eggs (32, 48).

Types of Lipids

Important Factors to Consider

Different types of lipids have different metabolic outcomes

when consumed. Saturated lipids tend to maintain serum
lipids and cholesterol longer and are therefore more
atherogenic. Monounsaturated lipids tend to be well
tolerated and are cleared relatively quickly from the serum.
Polyunsaturated lipids tend to be cleared from the serum
quickly and have the effect of lowering blood lipids and
cholesterol. However, excess intake of all lipids may have
an atherogenic effect, so the amount consumed at a single
meal should be relatively low.
Saturated fatty acids are often used in food processing
because they are less likely to interact with the environment
and become rancid. Saturated fatty acids that are liquid,
such as those found in palm oil, tend to be even more
popular with food manufacturers because liquids are more
easily mixed with other food ingredients. Therefore, athletes
should be cautious about consuming too many
processed/packaged foods, these tending to be higher in
saturated fat . Recommendation: Read the label!
Fatty Acids
Most fatty acids consist of an even-numbered carbon chain of
12–28 carbon atoms, with hydrogen atoms attached to the
carbons, but there are also less common fatty acids with 8 and 10
carbon atoms. At one end of the carbon chain, there is a
carboxylic acid (hence the name "fatty acid"). When not attached
to other molecules, fatty acids are referred to as free fatty acids.
Typically, dietary fatty acids are attached to a glycerol molecule in
the form of a triglyceride. Some fatty acids are saturated, others
monounsaturated, and still others polyunsaturated. These
different types of lipids have different types of bonds that hold
together the carbon atoms, which make up the skeleton of the
fatty acids.

Fatty Acids

A fat molecule with a carbon chain that has a carboxylic acid

(COOH) at the terminal end. In the diet, they are typically part
of triglycerides. Fatty acids have variable carbon chain lengths,
from short chain (fewer than six carbons such as butyric acid),
medium chain (between 6 and 12 carbons), and long chain
(longer than 12 carbons). The carbon chains may be saturated,
monounsaturated, or polyunsaturated.

Saturated fatty acids have carbon atoms that are held

together entirely with single bonds, meaning that the carbon
atoms are saturated with hydrogen atoms. Single bonds are
stronger, more stable, and less chemically reactive than double
bonds. Monounsaturated fatty acids have a single (i.e., mono)
double bond in the carbon chain, meaning that the two adjoining
carbon atoms are each missing a hydrogen atom and are held
together with a weaker bonding structure, a double bond.
Polyunsaturated fatty acids contain two or more double bonds
in the carbon chain. Do not be confused by the terminology, as
double bonds are weaker and less stable than single bonds.
Because of that, the greater the number of double bonds, the
greater the opportunity for the chemical environment to react
with the fatty acid. It is this ability to react with the fatty acid that
makes the difference when it is consumed. In general, saturated
fatty acids are commonly found in highest concentration in fats of
animal origin, but they are also high in other dietary lipids,
including palm kernel oil and coconut oil (Figure 4.1).

FIGURE 4.1: (A) Saturated, (B) monounsaturated, and (C)

polyunsaturated fatty acids. (From Kraemer WJ, Fleck SJ,
Deschenes MR. Exercise Physiology. Philadelphia (PA): LWW (PE);
2012.)

Saturated Fatty Acids

These fatty acids have no double bonds between the carbon

atoms and tend to stay elevated in the blood longer, increasing
their potential for creating atherosclerosis. Common saturated
fatty acids are found not only in animal fats (i.e., stearic acid)
but also in palm oil (i.e., palmitic acid).

Monounsaturated Fatty Acids

These fatty acids have a single double bond between the carbon
atoms and are well tolerated by humans. The most common
 monounsaturated fatty acid consumed is oleic fatty acid, which
is high in olive oil and canola oil.

Polyunsaturated Fatty Acids

These fatty acids have two or more double bonds between the
carbon atoms, making them easy to digest and interact with,
enabling faster clearance from the blood and reducing
atherosclerosis potential. The omega-3 fatty acids, in particular,
are polyunsaturated fatty acids from seafood that have been
shown to lower heart disease risk.

The most common form of lipid in the human diet, whether

from fat or oil, is in the form of triglycerides, which is the
primary form of lipid (i.e., fat) storage in humans and other
mammals. Nearly all dietary lipids (∼95%) are in the form of
triglycerides. The triglyceride molecule, as the name suggests, is
composed of one glycerol molecule with three fatty acids
connected to it (Figure 4.2). Triglycerides are extremely efficient
forms of energy storage, providing 9 calories/g, compared with 4
calories/g from either proteins or carbohydrates. It takes less than
half the dietary fat to deliver the same calories as carbohydrates
and proteins, so it is easier to consume excess calories if the
foods consumed have a high proportion of fat.

FIGURE 4.2: Triglyceride molecule. (From Kraemer WJ, Fleck SJ,

Deschenes MR. Exercise Physiology. Philadelphia (PA): LWW (PE);
2012.)
 Triglycerides

A fat molecule composed of glycerol plus three fatty acids,

which is the most common form of dietary lipids consumed by
humans. Triglycerides are also the main storage form of lipids
(i.e., body fat) in humans.

The triglycerides in each food we consume can have some

saturated, some monounsaturated, and some polyunsaturated
fatty acids. The polyunsaturated fatty acids, which are highly
prevalent in sunflower oil, corn oil, and safflower oil, have a
tendency to decrease serum cholesterol, which is associated with
lower cardiovascular disease risk. The monounsaturated fatty
acids, which are highly prevalent in olive oil, and canola oil, also
tend to decrease serum cholesterol. The saturated fatty acids,
commonly found in high proportions not only in animal fats, but
also in coconut oil, palm kernel oil, and cocoa butter, tend to
increase serum cholesterol, which is associated with higher
cardiovascular disease risk. Table 4.1 shows the distribution of
saturated, monounsaturated, and polyunsaturated fatty acids in
dietary lipids.

Table Distribution of Saturated, Monounsaturated,

4.1 Polyunsaturated, and Trans-Fatty Acids in
Commonly Consumed Dietary Lipids of Plant
and Animal Origin
Food % % % %
Saturated Monounsaturated Polyunsaturated Trans-
Fatty
Acids
Fatty Acids of Plant Origin
Coconut oil 85.2 6.6 1.7 0.0
Cocoa 60.0 32.9 3.0 0.0
butter
Palm 81.5 11.4 1.6 0.0
kernel oil
Palm oil 45.3 41.6 8.3 0.0
Table Distribution of Saturated, Monounsaturated,
4.1 Polyunsaturated, and Trans-Fatty Acids in
Commonly Consumed Dietary Lipids of Plant
and Animal Origin
Food % % % %
Saturated Monounsaturated Polyunsaturated Trans-
Fatty
Acids
Fatty Acids of Plant Origin
Cottonseed 25.5 21.3 48.1 0.0
oil
Wheat 18.8 15.9 60.7 0.0
germ oil
Soybean 14.5 23.2 56.5 0.0
oil
Olive oil 14.0 69.7 11.2 0.0
Corn oil 12.7 24.7 57.8 0.0
Sunflower 11.9 20.2 63.0 0.0
oil
Safflower 10.2 12.6 72.1 0.0
oil
Hemp oil 10.0 15.0 75.0 0.0
Canola oil 5.3 64.3 24.8 0.0
Mixed 13.6 33.5 20.2 14.8
vegetable
oil — stick
margarine
Mixed 16.7 24.7 23.8 3.3
vegetable
oil — tub
margarine
Fatty Acids of Animal Origin
Butter 54.0 19.8 2.6 0.04
Duck fat 33.2 49.3 12.9 0.0
Lard 40.8 43.8 9.6 0.0
Source: From Pennington JAT, Douglass JS. Bowes & Church’s Food Values of Portions
Commonly Used. 18th ed. Baltimore (MD): Lippincott Williams & Wilkins; 2005; United
States Department of Agriculture. National nutrient database for standard reference,
Release 28 [Internet]. Available from: https://ndb.nal.usda.gov/ndb/search/list. Accessed
December 2017.

Long-chain fatty acids are the most common dietary lipids, but
other lipids also exist in nature or are manufactured and used in
the food supply. These include:

Diglycerides: 1 glycerol and 2 fatty acids

Monoglycerides: 1 glycerol and 1 fatty acid
Short-chain fatty acids: 4 or 6 carbon atoms
Medium-chain fatty acids: 8, 10, or 12 carbon atoms
Long-chain fatty acids: 14 or more carbon atoms (these are
the most common in the diet)

As indicated in Table 4.1, not all oils are high in

polyunsaturated fats (e.g., coconut oil and palm kernel oil). The
characteristics of these lipids often determine how they are used.
As an example, palm kernel oil is often used in processed foods
because it is highly saturated and therefore stable. In addition,
the fact that it is an oil makes it easier to mix with other
ingredients (Table 4.2). The common fatty acid reactions can help
in understanding how fats are used or why they behave as they
do.

Table Common Terminology for Lipids

4.2
Term Meaning
Essential Fatty acids that we are incapable of synthesizing, so
fatty acids they are essential that we consume them in the diet.
These include:

Linoleic acid
α-Linolenic acid
Table Common Terminology for Lipids
4.2
Term Meaning
Most The fatty acid that is most commonly found in the
prevalent food supply:
fatty acid
Oleic fatty acid (monounsaturated)

Simple Lipids that exist in nature include

lipids
Fatty acids
Glycerol
Triglycerides
Diglycerides
Monoglycerides
Sterols
Waxes

Compound Lipids attached to nonlipid compounds include:

lipids Phospholipids
Glycolipids
Lipoproteins
Structured Lipids manufactured from simple and/or compound
lipids lipids include:

Medium-chain triglyceride oil

Short- Fewer than six carbons

chain fatty
acids
Medium- 6–12 carbons
chain fatty
acids
Long- Greater than 12 carbons
chain fatty
acids

Common Lipid Reactions

Peroxidation
Peroxidation is defined as oxidation reactions of fatty acids and
cholesterol that contain one or more double bonds in the carbon
chain. The oxidized lipids may create free-radical peroxides that,
in foods, make the food taste rancid (spoiled). Meat fats that have
at least one double bond (see Table 4.1) are not associated with
high levels of antioxidants (vitamins E and C), so they can easily
undergo this oxidation rancidity reaction. For example, imagine
leaving raw bacon uncovered and unrefrigerated on the kitchen
counter for several hours. The fats in the bacon will become
oxidized and smell rancid. By contrast, vegetable oils, such as
olive oil and safflower oil, are high in mono- and polyunsaturated
fats, but they also have a high level of vitamin E, a powerful
antioxidant that captures oxygen and keeps the fatty acids from
becoming oxidized. Because of this, vegetable and cereal oils
have a high shelf life without becoming rancid. In humans,
antioxidant vitamins protect the fatty membranes of cells from
becoming oxidized and creating peroxide free radicals, which can
destroy the cell or can alter the DNA structure of the cell and
initiate a disease process (Example 4.1).

Example 4.1: Free Radicals

Free radicals are unstable and react in unpredictable ways as
they attempt to gain a missing electron. As a free radical, such
as peroxide, steals an electron from a compound it has come in
contact with, the compound with the stolen electron itself
becomes unstable, causing a chain reaction. When free radicals
enter a cell, they move around the cell in an unpredictable and
damaging pattern, destroying the cell or nicking the nucleus of
the cell. The nucleus contains the DNA of the cell, which can get
damaged, and if this cell reproduces, the reproduced cell will not
be normal, initiating a disease process such as cancer.
Antioxidants, such as vitamin E, help to protect cells by
capturing oxygen and avoiding the creation of peroxide and
other free radicals that can be made from oxidized fatty acids.
One of the reasons consumption of fresh fruits and vegetables is
associated with good health is that these foods are high in
protective antioxidants.
Iodination
Iodination reactions are performed in a laboratory to determine
the number of double bonds (i.e., its relative
saturation/unsaturation) that are present in a lipid (41, 42). For
instance, to determine if there is a difference in
saturation/unsaturation between olive oil from Greece and olive
oil from Italy, a laboratory could perform an iodination test. The
oils are bathed in a solution containing iodine, which has a distinct
dark brown color. The iodine attaches itself to the carbon atoms
that have double bonds, and the color of the oil is checked in a
machine (spectrophotometer) that can determine the degree of
color (Table 4.3). The darker the color, the higher the iodine value
(the more the molecule has attached iodine) and therefore the
greater the number of double bonds (15).

Table 4.3 Iodine Values of Selected Lipids

Corn oil 109–133
Grape-seed oil 124–143
Olive oil 80–88
Palm oil 44–51
Peanut oil 84–105
Soybean oil 120–136
Walnut oil 120–140

Hydrogenation
Hydrogenation reactions involve treating lipids with hydrogen,
which attaches itself to carbon atoms with double bonds, thereby
reducing the relative saturation level of the lipid (i.e., it makes the
lipid more saturated). These are common reactions for converting
oils into semisolids or solids. For instance, hydrogenation
reactions convert corn oil into corn oil margarine. Because
hydrogenation reactions reduce the number of double bonds, the
fatty acids become more saturated and therefore have a greater
disease risk potential than the oil equivalent. In addition, some
hydrogenation reactions may result in the formation of trans-
fatty acids, which are strongly implicated in increasing heart
disease risk (5). It is for this reason that many states are passing
laws that ban providing fats that contain trans fats to customers
in restaurants and shoppers in grocery stores. Trans fats are
banned for use in human food products sold in restaurants and
public kitchens in New York City and in California. In Europe, trans
fats are banned in Denmark and Switzerland. In 2015, the United
States Food and Drug Administration gave the food industry 3
years to phase trans fats out of the food supply (Figure 4.3).

FIGURE 4.3: Cis- and trans-fatty acids. (From Ferrier DR.

Biochemistry. 6th ed. Philadelphia (PA): LWW (PE); 2014.)

Trans-Fatty Acids

These unsaturated fatty acids have been hydrogenated to make

them more solid (i.e., conversion of corn oil into corn oil
margarine), and in the process, some of the hydrogen atoms are
 attached on the same side of the carbon atom (i.e., the “trans”
form) rather than on opposite sides of the carbon atom (i.e., the
“cis” form). These fats have been shown to be highly
inflammatory, causing increased risk of heart disease and heart
disease deaths.

Lipid Digestion and Absorption

Important Factors to Consider

Fats have the effect of slowing gastric emptying, delaying

the speed with which consumed foods leave the stomach
and enter the intestines for further digestion and
absorption.
Athletes typically feel uncomfortable exercising with food
still in the stomach, as it makes them feel uncomfortable,
and the delayed gastric emptying is likely to also inhibit
appropriate fluid consumption during exercise. Therefore,
the pregame meal should be relatively low in fats and
should be consumed early enough prior to exercise to
ensure that there is no longer food in the stomach.

Dietary lipids, mainly in the form of triglycerides, are physically

broken up into smaller particles through chewing, which does not
chemically digest the lipids into smaller molecular substances
(i.e., fatty acids and glycerol) but does enable more effective
digestion later in the GI tract. When the lipids enter the stomach,
the acidity of the stomach and fluids create still smaller lipid
droplets referred to as chyme. When this chyme enters the small
intestine, a chemical in the small intestine, cholecystokinin,
travels up the common bile/pancreatic duct and causes the gall
bladder to release bile into the small intestine. At the same time,
the pancreas releases its lipid digesting enzyme, pancreatic
lipase, which breaks the lipids into individual fatty acids and
glycerol, monoglycerides, and diglycerides. Bile, an effective
emulsifying agent, converts these smaller lipid molecules into
water-soluble micelles, which are then absorbed into the blood.
Once in the blood, the micelles are attached to a protein carrier to
create chylomicrons, which are relatively large lipid molecules
with a relatively small protein carrier. There are no receptors for
chylomicrons that allow the lipids to leave the blood, so the
enzyme lipoprotein lipase converts the chylomicrons into low-
density lipoproteins (LDLs), for which we do have receptors that
allow the lipids to be cleared from the blood and taken up by
tissues (Table 4.4).

Table Lipid Digestion and Absorption

4.4
Site Chemical Outcome
Action
Mouth None
There is no chemical breakdown in
the mouth, but chewing food
physically breaks down the food into
a smaller size that enables more
effective digestion later in the
digestive tract.

Esophagus None
No additional action.

Stomach Acidity
The stomach acid initiates some
breakdown of triglycerides into
diglycerides and fatty acids.
The stomach contents that enter the
small intestine are referred to as
“chyme.”
Table Lipid Digestion and Absorption
4.4
Site Chemical Outcome
Action
Small Pancreatic
intestine lipase Pancreatic lipase enters the small
(pancreas) intestine via the pancreatic duct and
Bile salt effectively breaks down diglycerides
(liver) and triglycerides into component
glycerol and fatty acids.
Bile salt enters the small intestine
via the common bile duct and
emulsifies the glycerol and fatty
acids into small and water-soluble
compounds. One end of an
emulsifying agent is fat soluble, so
can attach itself to the lipid, while
the other end of the emulsifying
agent is water soluble and wraps
itself around the lipid to make it
water soluble.
Bile is 50% cholesterol that is
manufactured by the liver, so high-
fat intakes require more bile, and
this bile-related cholesterol is
absorbed into the blood with the
consumed lipids. Therefore, high-fat
intakes, even if no cholesterol is
consumed, are associated with high
blood cholesterol.
Table Lipid Digestion and Absorption
4.4
Site Chemical Outcome
Action
Intestinal None
lining The water-soluble “micelle”
(emulsified fat) is transported into
the lining of the small intestine,
where it is reformed into a
triglyceride and formed into the
lipoprotein “chylomicron.” The
chylomicron enters the blood.

Blood Lipoprotein
lipase Chylomicrons are converted into
low-density lipoproteins (LDL) via
lipoprotein lipase (LPL), and the LDL
leaves the blood and is taken up by
tissues for utilization.

Lipoproteins
There are four major types of lipid carriers in the blood. These
lipoproteins (lipid and protein combinations) have different origins
and actions. These are chylomicrons, very-low-density lipoproteins
(VLDLs), LDLs, and high-density lipoproteins (HDLs).

Chylomicrons
Chylomicrons are the least dense of the lipoproteins, meaning
that they have the highest amount of fat attached to the protein
carrier. These molecules have a high atherogenic potential (i.e.,
may increase atherosclerosis risk, a factor in heart disease and
which is a hardening of the arteries from fatty streak formation)
because they are so high in lipid and because they must stay in
the blood until they are converted by lipoprotein lipase to LDL.
Chylomicrons are synthesized in the intestinal wall from dietary
fat, so the greater the amount of dietary fat consumed at a single
meal, the higher the level of circulating chylomicrons. Since
conversion of chylomicrons to LDL takes time, a high-fat meal will
have a higher sustained level of chylomicrons than a meal that
delivers the same calories but is lower in fat (43).

Atherosclerosis

A vascular disease characterized by a thickening and narrowing

of the artery wall, making it less able to adjust to fluctuations in
blood pressure. The narrowed artery also increases the risk of
blood clot formation, leading to a heart attack or stroke.
Maintaining high blood lipids, typically from high dietary
consumption of saturated and trans-fatty acids, increases
atherosclerosis risk.

Very-Low-Density Lipoproteins
VLDLs are made by the liver from triglycerides and cholesterol
and are converted by lipoprotein lipase to LDLs. Lowering the
liver’s production of VLDL requires a reduction in triglycerides,
which requires a loss of body fat, lower consumption of sugary
foods, lower consumption of fructose (i.e., foods with high levels
of high-fructose corn syrup are a particular problem), and a
reduction in alcohol consumption. High levels of VLDL are
associated with a higher risk of atherosclerosis and associated
higher heart disease risk.

Low-Density Lipoproteins
High levels of LDLs are a known risk factor in heart disease, as
LDLs have a high potential for creating fatty streaks in the
arteries, where they can cause blockage and a myocardial
infarct (heart attack) and/or stroke. Clearing LDLs from the blood
for delivery to tissues is time related, as the receptors for LDL are
limited, and the longer they remain at a high level in the blood,
the greater their disease potential. It is for this reason that LDL is
often referred to as the “bad” cholesterol. Lowering LDL
cholesterol requires lowering the consumption of fat (both total
and per meal) and lowering body fat level (Figure 4.4).
FIGURE 4.4: Atherosclerotic artery. (From Anatomical Chart
Company. Hypertension Anatomical Chart. 2nd ed. Philadelphia
(PA): LWW (PE); 2005.)

Myocardial Infarct

Literally meaning heart muscle death, it is another name for a

heart attack, which is a sudden failure of blood supply (i.e.,
failure to supply oxygen and nutrients) to the heart as a result
of an arterial blockage. The blockage results in damage to the
portion of the heart that is no longer receiving blood and is
associated with chest pain or radiating pain in the arm, neck,
and jaw. Heart attacks are typically the result of atherosclerosis.

High-Density Lipoproteins
HDLs are the smallest and most dense of the lipoprotein particles,
carrying the smallest proportion of lipid to a protein carrier. HDLs
are manufactured by the liver, and they are involved in removal of
lipid and cholesterol from tissues and blood. Therefore, these
molecules are often referred to as “good” cholesterol. Ideally, it is
best to have a relatively low amount of LDL and a relatively high
amount of HDL. Moderate alcohol consumption (i.e., one glass of
wine with dinner for a female; two glasses of wine with dinner for
a male) has been found to elevate HDL cholesterol, as does a
lowering of body fat through an appropriate exercise and diet
program (35).
Sources of Different Lipid Types in the Human Diet
The following are examples of lipid types that occur in the human
diet:

Monounsaturated fatty acids (MUFAs): Fatty acids that have a

single double bond and are typically liquid at room
temperature. Foods rich in MUFAs include vegetable oils (e.g.,
olive, canola, sunflower, high oleic safflower) and nuts. MUFAs
tend to lower bad blood cholesterol (LDL), while maintaining
good cholesterol (HDL).
Polyunsaturated fatty acids (PUFAs): Fatty acids that have two
or more double bonds and are typically liquid at room
temperature. The main food sources of PUFAs are vegetable
oils and some nuts and seeds. PUFAs provide the essential
fatty acids, which are n-3 (ALA, where the first double bond
occurs at the third carbon) and n-6 (LA, where the first double
bond occurs at the sixth carbon).
n-3 PUFAs: Include an essential fatty acid (ALA) with an 18-
carbon chain and three cis double bonds. Primary sources
include soybean oil, canola oil, walnuts, and flaxseed. Other n-
3 fatty acids include EPA and DHA, which have very long
carbon chains and are found in fish and shellfish. EPA and
DHA are also referred to as "omega-3" fatty acids.
n-6 PUFAs: Include an essential fatty acid (LA) with an 18-
carbon chain and two cis double bonds. Primary food sources
include nuts and liquid vegetable oils, including soybean,
corn, and safflower oils. These are also referred to as “omega-
6” fatty acids.
Saturated fatty acids: These are fatty acids with no double
bonds and are typically solid at room temperature. Common
food sources of saturated fatty acids include meats and dairy
products. Some tropical oils (liquid at room temperature) are
also high in saturated fatty acids, including coconut and palm
oils.
Trans-fatty acids: These are derived from partially
hydrogenated vegetable oils and used in desserts, microwave
popcorn, frozen pizza, some margarines, and coffee creamer.
While not as prevalent, trans fats also occur in fats from
ruminant animals, including cattle and sheep. Trans fats are
 highly inflammatory and are strongly associated with
increased risk of heart disease and cancer.

Lipid Metabolism

Deriving Energy From Lipids

Triglyceride catabolism produces more than double the ATP
energy produced from either protein or carbohydrate, but lipids
can be metabolized only aerobically (with oxygen). The by-product
of lipid catabolism through the citric acid cycle (Krebs cycle) is
carbon dioxide, water, and energy. However, the complete
oxidation of fats, via a metabolic pathway called β-oxidation,
requires carbohydrate and the vitamins B1, B2, niacin, and
pantothenic acid. It is referred to as “β” oxidation because two
carbon atoms at a time enter the metabolic sequence for
producing energy.
Without sufficient carbohydrate, ketones may be produced
when lipids are catabolized (10). Ketones are typically produced in
the liver mitochondria when blood glucose level is low and after
glycogen stores are exhausted. Blood glucose is the primary fuel
for the brain/central nervous system, but with inadequate blood
glucose, ketones are produced from fatty acids as a means of
supplying ketones to the central nervous system for energy. Fatty
acids are normally broken down via β-oxidation to form acetyl-
coenzyme A (acetyl-CoA), and this acetyl-CoA is further oxidized
in the citric acid cycle to produce energy. However, if the acetyl-
CoA generated in β-oxidation exceeds the capacity of the citric
acid cycle because of insufficient intermediates, such as
oxaloacetate, then the acetyl-CoA is used to make ketones, such
as acetone, rather than ATP (energy). Insufficient intermediate
products in the citric acid cycle are more likely with insufficient
carbohydrate availability (Figure 4.5). High levels of ketones may
result in ketoacidosis, which is a dangerous state that can be
damaging to tissues, including the kidneys. Ketoacidosis occurs in
diabetics who are not controlling blood sugar well, people who are
fasting, and in people on high-protein, high-fat, low-carbohydrate
diets that are referred to as ketogenic diets. People making high
levels of ketones typically have acetone breath (acetone is a
ketone that smells like nail polish remover), suggesting that blood
sugar is low.

FIGURE 4.5: Oxidation of lipids for energy.

Making New Lipids

Humans are effective manufacturers of lipids and are capable of
making and storing lipids from excess protein, excess
carbohydrate, and excess lipids. The ability to manufacture lipids
is important for a number of critical cellular processes, including
cell membranes and internal structure, production of lipid-based
hormones, and storage of excess energy. The fatty acids that we
can manufacture for these processes are referred to as
nonessential fatty acids (i.e., it is not essential that we consume
them because we can make them), and they are synthesized in
body cells from acetyl-CoA via an enzyme referred to as fatty acid
synthase. Following the formation of the fatty acid, the enzymes
called acetyltransferases attach three fatty acids to a glycerol
molecule to create triglycerides. Also important to this process are
insulin and the vitamins biotin, B2, niacin, and pantothenic acid.
Insulin aids new fatty acid synthesis by making glucose and fatty
acids available to cells, and any amount of glucose that exceeds
cellular requirements can be made into triglycerides and placed in
storage (i.e., the fat mass) (22, 46).

Lipid Recommendations and Food Sources

One of the key principles of the U.S. 2015–2020 Dietary

Recommendations is to limit energy consumption from saturated
fats because they tend to increase blood cholesterol and
cardiovascular disease risk. As can be seen from Table 4.5, it is
good to have a high amount of HDLs and a low amount of LDLs
(Figure 4.6).

Source: United States Department of Agriculture and United States Department of

Health and Human Services. 2015-2020 Dietary Guidelines for Americans. 8th ed.
December 2015. Available from:
http://health.gov/dietaryguidelines/2015/guidelines/.Accessed April 20, 2018.
Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat,
Fatty Acids, Cholesterol, Protein, and Amino Acids 2005. Washington, DC. The National
Academies press: https://doi.org/10.17226/10490.
AI, Adequate Intake; AMDR, Acceptable Macronutrient Distribution Range; DGA, Dietary
Guidelines for Americans, 2015-2020.
FIGURE 4.6: Reference ranges for blood lipids. (From Reference
Ranges for Blood Lipids. Understanding what your cholesterol
level means [Internet]. Available from:
http://www.cholesterolmenu.com/cholesterol-levels-chart/.
Accessed September 2017.)

The current intake of saturated fat in most people is excessive,

primarily from the consumption of animal fats (45). The Institute
of Medicine recommendation for healthy people is to have a fat
intake that constitutes between 25% and 35% of total calories
consumed. Of this, less than 10% should come from saturated
fats. This level of intake is ∼1.0 g/kg, but may be greater than this
amount depending on fitness and energy needs. For instance,
endurance athletes may require up to 2.0 g/kg to satisfy energy
requirements, but endurance athletes typically have a high
capacity to metabolize fats as a source of energy (18). Some
athletes with extraordinarily high energy requirements may have
even higher fat requirements as the only reasonable means of
satisfying the need for energy.
Lipids also deliver the essential fatty acids, with
recommendations for linoleic acid that range from 7 to 17 g/day
(depending on age) and for linolenic acid that range from 0.7 to
1.6 g/day (Table 4.5).

Linoleic Acid

An essential polyunsaturated fatty acid (i.e., it must be

consumed as humans cannot manufacture it) with the first
double bond at the sixth carbon (n-6). It is found in cell
membranes and is involved in the production of other fatty
acids and protective substances. Common dietary sources are
vegetable oils, and it is particularly high in safflower, sunflower,
corn, and soybean oils.

When required for energy, the stored subcutaneous and

visceral triglycerides are broken apart into their component fatty
acids and glycerol and transported to the tissues in the blood
plasma. The glycerol is metabolized like a carbohydrate and is
available to all tissues for energy created via aerobic or anaerobic
metabolism. Glycerol also has gluconeogenic potential, where it
can be converted into glucose and stored as liver glycogen or
used to satisfy central nervous system, organ, and muscular
energy needs as blood glucose. The fatty acids are transported to
muscle and organ tissue, where they are oxidized to create ATP
energy.
 Lipids and Health

Monounsaturated and Polyunsaturated Fatty Acids

Both MUFAs and PUFAs have been found to be protective against
the development of cardiovascular disease by lowering blood
cholesterol, but PUFAs are more vulnerable to peroxide formation
(rancidity) than are MUFAs. There is also some evidence that
MUFAs may help to sustain good cholesterol (HDL) (28). The most
commonly consumed MUFA is oleic fatty acid, which is highly
prevalent in olive oil and, possibly, one of the reasons (along with
higher fish and vegetable consumption) why the Mediterranean
Diet is recommended for reducing disease risks. As an example,
the food intake of Crete, a Greek Island, has a typical fat intake
that is high, providing about 40% of total calories, but a large
proportion of the fat consumed is from olive oil. The population of
Crete has a relatively low coronary heart disease and colon cancer
prevalence (38). The Mediterranean Diet also has a balance of
omega-3 and omega-6 fatty acids, which is important because
some omega-6 fatty acids tend to be inflammatory to tissues,
while omega-3 fatty acids tend to be anti-inflammatory. By
contrast with the Mediterranean Diet, the typical diet in the
United States may contain 14–25 times more omega-6 than
omega-3 fatty acids.
Because saturated fats are associated with an increase in
harmful LDL cholesterol, which increases cardiovascular disease
risk, the intake of saturated fatty acids should be less than 10% of
total calories. There is evidence that maintaining a relatively low
total fat consumption while replacing saturated fats with
polyunsaturated fats from vegetable oils is an effective strategy
for reducing heart disease risk.

Trans Fats
As potentially harmful as a high intake of saturated fats may be,
they are not as potentially harmful as trans fats. Trans fats are
typically found in margarine and shortening which were partially
hydrogenated to make the original oil more solid. Margarine and
shortening were commonly used in commercial cooking as deep-
fat frying oil for French fries and are used in commercial pastries
(cookies, cakes, etc.). Trans fats increase harmful LDL cholesterol
and are inflammatory to tissues, both of which are associated with
stroke, heart disease, diabetes, and cancer. Some studies have
found that even very small amounts of trans fats, as little as 2%
of consumed fat, may increase heart disease risk by over 20% (5).

Omega-3 Fatty Acids

There are three different omega-3 fatty acids, all of which are
polyunsaturated:

ALA
EPA
DHA

They are referred to as omega-3 fatty acids because the first

double bond, counting from the nonacid end of the fatty acid,
occurs at the third carbon atom. EPA and DHA are derived from
fish, and ALA (one of the essential fatty acids) is derived from
vegetables, seeds, and nuts. Flax seed is a commonly used
nonfish food used to enhance the dietary intake of ALA, which we
can use to synthesize the other omega-3 fatty acids. They have
been found in a number of studies to be profoundly important for
health:

DHA is highly concentrated in the cell membranes of the

retina of the eye, and animal studies have determined that
DHA is necessary for the development and function of the
retina (3). In several studies assessing visual function in
preterm infants, DHA added to the formula resulted in
significant improvement of visual function (25).
A study that assessed 1,822 males for 30 years found that
death from coronary heart disease was 38% lower in men who
consumed an average of 1.2 oz/day of fish than in men who
ate no fish. In addition, the men who ate fish had a mortality
rate from heart attack that was 67% lower. Fish is a primary
source of the omega-3 fatty acids ALA and EPA (23). Studies
have found that women consuming more ALA from foods have
a 54% lower risk of death from coronary heart disease than
 women consuming less food-based ALA (47). Based on these
and other studies, the American Heart Association
recommends the consumption of 1 g/day of an EPA and DHA
combination, either from food or through supplemental intake
(8).
Fish oils (EPA and DHA) have been found to significantly lower
serum triglyceride in diabetics. High circulating triglycerides is
a common serious health risk in type 2 diabetics (9).
Consumption of omega-3 fatty acids has been shown to
reduce the debilitating inflammatory effects of rheumatoid
arthritis after 12 weeks of increased consumption (24).
Several studies have found that increased consumption of EPA
and DHA reduced the inflammation associated with ulcerative
colitis, which is an inflammatory disease of the large intestine
(29).
In studies of people with psychological disorders
(schizophrenia, depression, and bipolar disorder),
consumption of EPA and DHA resulted in less depression
than in those taking a placebo (30).

However, recent studies also suggest that excess intake of

omega-3 fatty acids may have adverse affects, including higher
risks of prostate cancer, reduced immunity, and atrial fibrillation
that could result in stroke (13). Taken together, these studies
suggest that increasing the food consumption of omega-3 fatty
acids from more regular (∼2/week) fish consumption may result in
improved health without risking the health problems that could
occur from regular excess intakes through supplementation. In
simple terms, getting enough is important, but regular exposure
to too much may create health problems.

Lipids and Exercise

Stored lipids are sufficient to satisfy, theoretically, the energy

needs of even healthy and lean athletes who participate in
multiday ultra-marathons without having the need to refuel. Of
course, other nutrient limitations would cause the exercise to stop
before fat was exhausted, but this point is to demonstrate that
lipid availability is not likely to be the limiting substrate in
exercise. Typical lipid storage is between 5,500 and 11,100 g or
between 50,000 and 100,000 calories. In an average 70 kg (154
lb) man with a relatively low body fat of 15%, fat storage is about
10,311 g or 92,800 calories (27). Since the average cost of going
1.6 km (1 mile) is about 100 calories, this represents enough fuel
to go between 800 and 1,660 km (500 to 1,000 miles). In addition
to the caloric potential of subcutaneous and visceral stored lipid,
muscle tissues also store 2,000 to 3,000 calories of triglycerides,
which can become quickly available to cells as a fuel under the
right oxidative conditions.
Oxygen is required to derive energy from lipids, and lower
intensity exercise makes it easier to satisfy the oxygen
requirement for fat metabolism. As a result, lower intensity
activities are associated with a high proportion of fat metabolism
to satisfy the need for energy. As the intensity of exercise
increases, more carbohydrate is metabolized to satisfy the energy
requirement, and a lower proportion of fat is metabolized (Figure
4.7).

FIGURE 4.7: Fuel burned at different exercise intensities.

(Modified from Romijn JA, Coyle EF, Sideossis LS, Gastaldelli A,
Horowitz JF, Endert E, Wolfe RR. Regulation of endogenous fat and
carbohydrate metabolism in relation to exercise intensity and
duration. Am J Physiol. 1993;265:E380–91.)
 Many people perform low-intensity exercise (often referred to
as cardio) in the desire to burn fat as an energy substrate and
therefore lower the body fat level. However, the proportion of fat
metabolized should not be confused with the volume of fat
metabolized, because as exercise intensity increases, more
energy is burned per unit of time than in lower intensity activity
(see Example 4.2).

Example 4.2: Burning Fats for Energy

The following scenarios illustrate the potential for confusing
proportion with volume:

Scenario 1: A person is exercising for 1 hour and doing low-

intensity activity that burns about 100 calories every 15
minutes, for a total of 400 calories burned during the hour.
Of this, ∼80% of the energy is supplied by fat (320 calories
from fat), and 20% is supplied by carbohydrate (80 calories
from carbohydrate).
Scenario 2: A person is exercising for 1 hour, and doing
higher intensity activity that burns about 150 calories every
15 minutes, for a total of 600 calories burned during the
hours. Of this, ∼60% of the energy is supplied by fat (360
calories from fat), and 40% is supplied by carbohydrate (240
calories from carbohydrate).
While lower intensity exercise burned a higher proportion of
calories from fat (80%; 320 calories from fat), the higher
intensity exercise burned a higher volume of calories from
fat but at a lower proportion of fat burned for energy (60%;
360 calories from fat). When calculating the metabolism of
energy substrates to supply energy, both proportion and
volume should be considered.

Other factors in addition to the exercise intensity also play a

role in terminating the use of fat during exercise. These include
the following:

Available fat reserves in muscle: Some muscle fiber cells have

a higher capacity to store triglycerides than other cells. Type I
slow-twitch aerobic fibers have a high capacity for cellular
lipids, while Type II fast-twitch anaerobic fibers have a lower
capacity for cellular lipids. Most people have an even
distribution of Type I and Type II fibers, but some people have
a higher proportion of Type I fibers, enabling them to use
more fat to satisfy the energy requirement.
Ability to mobilize and transport lipids from adipose tissue to
working muscle: An exercise-associated increase in
sympathetic nerve activity stimulates the production of
epinephrine (i.e., adrenalin), which binds to adipose tissue
and begins the process of transporting fats to muscle cells.
Glycerol is transported to the liver for gluconeogenesis or
directly to the muscle cell for metabolism. Fatty acids are
bound to albumin to form HDL, which is actively transported
into the muscle cell for metabolism. There are several
hormones, besides adrenalin, that either stimulate or inhibit
the utilization of fat (Table 4.6).
Availability of stored glycogen: Higher carbohydrate intakes
are associated with higher glycogen storage, and the better
carbohydrate availability during exercise enhances the
capacity to completely metabolize fats as an energy
substrate. Insufficient carbohydrate availability inhibits β-
oxidation, creating incompletely burned fats (ketones) and
compromising total energy and fat expenditure.
Amount of carbohydrate consumed during exercise:
Sustaining a normal blood glucose level helps to sustain
carbohydrate availability and enhances fat metabolism in
aerobic activities.
Effect of training on fat utilization: Exercise training has
multiple effects on fat utilization, with studies indicating that
both endurance and resistance training increase
intermuscular triglyceride utilization, resulting in a lower
requirement for glycogen at the same exercise intensity. Since
glycogen storage is limited, using more fat to satisfy energy
needs “spares” glycogen, resulting in improved endurance. In
physically fit individuals who are training regularly, peak fat
oxidation occurs at a higher V.O2max (59%–65%) than in
untrained individuals (47%–52%) (36, 45). (See Figure 2.7.)
 Postexercise period: In the period immediately after exercise,
there is a high metabolic priority to resynthesize muscle
glycogen that limits carbohydrate utilization for energy. This
results in a sustained high fatty acid oxidation following an
exercise bout (20).

Table 4.6 Hormonal and Nutritional Factors That

Influence the Utilization of Lipids for
Energy (Lipolysis)
Stimulators of Inhibitors of Lipolysis
Lipolysis
Epinephrine Insulin
Norepinephrine Leptin
Dopamine Niacin/nicotinic acid
Cortisol
Growth
hormone
Thyroid-
stimulating
hormone
Calcium
Caffeine

Source: From Duncan RE, Ahmadian M, Jaworski K, Sarkadi-Nagy E, Sul HS. Regulation of
lipolysis in adipocytes. Annu Rev Nutr. 2007;27:79–101.

A good deal of attention is being given to whether increasing

total fat consumption, coupled with an exercise program, results
in an adaptation toward greater fat utilization that warrants an
increase in fat consumption. Regular endurance training does
cause skeletal muscle to adapt by enhancing the utilization of all
energy substrates, including a particularly high improvement in
the utilization of lipids (4). This is an important adaptation,
because greater lipid utilization to satisfy the energy requirement
reduces the utilization of glycogen, which has limited storage,
with the result that it takes longer to deplete glycogen and
endurance performance is enhanced.
 Some have hypothesized that increased fat consumption will
more greatly enhance the lipid metabolism adaptation and
improve endurance performance still further. However, the effect
of consuming a high-fat (60%–65% of energy consumed) diet that
is relatively low in carbohydrate (less than 20% of energy
consumed) for even short durations of less than 3 days has the
effect of lowering muscle and liver glycogen storage. The
outcome of these short-term high-fat/low-carbohydrate diets is to
reduce endurance, likely because of an insufficient amount of
time for adaptation to occur (6). Indeed, there are studies
suggesting that high-fat/low-carbohydrate diets that are coupled
with endurance activity for longer periods may improve fat
oxidation in both lower- and moderate-intensity activities,
suggesting an adaptation to the lower glycogen availability (40).
However, the ideal plan is to enhance lipid metabolism while also
maximizing glycogen storage, enabling more high-intensity bursts
of activity, even during endurance events/training. Studies have
found that a single day of high-carbohydrate intake that is
coupled with avoidance of any activity that would utilize glycogen
(typically complete rest) is enough to maximize stored glycogen in
athletes who are endurance trained (39, 49). Therefore, a higher
fat consumption, to enhance fat metabolism in endurance
training, coupled with a high-carbohydrate intake and rest on the
day prior to competition may be an important strategy for
improving endurance performance (16, 26). A word of caution,
however, since these findings appear relevant only to endurance
athletes. For those who require frequent bursts of speed (i.e.,
team sports) or are performing at the top intensity possible (i.e.,
sprinters, gymnasts), the training protocols they follow would not
allow for the appropriate adaptations, suggesting that a higher
fat/lower carbohydrate diet would not be appropriate for them.
High body fat levels are inversely associated with the amount of
time people spend in exercise training. It is possible that higher
intensity activity, because it lowers glycogen stores, can force a
higher reliance on fat oxidation for fuel and therefore compensate
for the excessively high-fat intakes of most Western cultures.
However, those wishing to lower body fat should be cautious of
consuming a higher fat diet, regardless of the exercise protocol,
because the higher energy density of fat could more easily
contribute to greater fat storage, obesity, and associated health
risks (37).

Summary

Lipids are a highly concentrated source of energy, providing

more than double the calories per gram (9 calories/g) than
either carbohydrate or protein (4 calories/g).
Lipids have many functions other than the provision of energy
— providing the essential fatty acids, providing a carrier for
the fat-soluble vitamins, improving food flavor and meal
satiety, and serving as a protective blanket to help control
body temperature in environmental extremes.
The essential fatty acids are linolenic acid and LA, which must
be consumed from foods as humans are unable to synthesize
these fatty acids.
There are many different kinds of lipids, and triglycerides
make up the majority of fats in the human diet and in the
human body. These triglycerides have one glycerol and three
fatty acids linked together in a single molecule.
There are different kinds of fatty acids. Some fatty acids are
saturated, some are monounsaturated, and some are
polyunsaturated. Each type of fatty acid has a different
function, and different kinds of fatty acids pose different
health risks or health benefits.
The general recommendation for fat intake for adults is
between 20% and 35% of total calories consumed. Of this
amount, it is generally considered more healthful to have a
higher proportion of mono- and polyunsaturated fats than
saturated fats.
When fats are consumed, they are absorbed into the blood as
chylomicrons, a very LDL that must be converted by
lipoprotein lipase into LDL to be taken up by tissues and
cleared from the blood.
Chylomicrons and LDLs are considered “bad” lipids/cholesterol
because they can increase atherosclerosis and heart disease
risks. Avoiding large meals that are high in fats helps to
reduce circulating chylomicrons and LDLs.
 When lipids are removed from storage (i.e., removed from
adipose tissue) to be metabolized for energy, HDLs are
formed. HDLs are considered “good” lipids/cholesterol
because they suggest that lipids are being metabolized for
energy.
The physical activity/training associated with sport and
exercise increases the requirement for energy. Because lipids
are highly concentrated in energy, they can help athletes
satisfy their energy requirements.

Physically active people are better able to metabolize lipids for

energy and, in doing so, are less likely to have high body fat
levels. Lipid metabolism for energy requires oxygen, and one of
the adaptations that occurs in people who exercise is to improve
the oxygen delivery system to muscle cells so they can more
efficiently burn fats for energy.

Practical Application Activity

Lipid intake can be analyzed as a percentage of total calories

consumed (% fat) or as grams of fat/kg mass (g/kg). The usual
method is to calculate the proportion of calories derived from
fats, which should be ∼25% to 35% of total calories. Cholesterol
intake should be less than 300 mg/day to help ensure that LDL
cholesterol is below 100 mg/dL. You can assess your fat and
cholesterol content of consumed foods using the same strategy
followed in earlier chapters, accessing the online USDA Food
Composition Database
(https://ndb.nal.usda.gov/ndb/search/list), but this time create a
spreadsheet with Energy (calories), Total Lipid (g), Total
Saturated Fatty Acids (g), Total Monounsaturated Fatty Acids (g),
Total Trans-Fatty Acids (g), and Cholesterol (mg).

1. Enter the foods/beverages with amounts consumed for an

entire day, and create totals for Energy (calories) and each
lipid component.
2. Calculate percentage of total calories from fat (Total Fat
Grams × 9/Total Energy).
 3. Calculate grams of fat/kg mass (Total Fat Grams/Your Weight
in kg).
4. Determine if total fat intake as percentage of total calories
is within the acceptable range (20%–35% of total calories).
If above 35% of total calories, what dietary changes would
you make to lower total fat consumption?
5. Determine if your cholesterol is above the dietary guidelines
recommended limit of 100–300 mg/day for various calorie
levels. If above 300 mg/day, what dietary changes would
you make to lower dietary cholesterol intake?
6. Determine if your saturated fat intake is below the
recommended intake limit (<10% of total calories/day). If
so, what changes would you make to replace saturated fat
with healthier monounsaturated and polyunsaturated fats?
7. It is generally recommended that trans fats be avoided
because they are highly inflammatory and may significantly
increase the risk of heart disease. Assess your trans fat
intake, and determine what dietary changes would be
needed to avoid trans fat consumption.

Chapter Questions

1. The fat that contains only one double bond between carbons is:
a. Saturated fat
b. Monounsaturated fat
c. Polyunsaturated fat
d. Cholesterol
2. An example of a food containing predominantly saturated fat is:
a. Skim milk
b. Corn oil
c. Margarine
d. Butter
3. An example of a food containing predominantly
monounsaturated fat is:
a. Olive oil
b. Corn oil
c. Hamburger
 d. Butter
4. Cholesterol is found in which food categories?
a. Fruits, vegetables, and grains
b. Meats and poultry
c. Fish and shellfish
d. All the above
e. B and C only
5. The type of fat that is inflammatory and has the highest risk of
increasing the risk of heart disease is:
a. Monounsaturated fat
b. Omega-3 fatty acids
c. Omega-6 fatty acids
d. Trans-fatty acids
6. What happens to vegetable and cereal oils when they are
hydrogenated?
a. The carbon chains become longer
b. The fatty acids become solid and more saturated
c. They taste less rancid but can spoil more quickly
d. They are more easily digested
7. With the onset of moderate-intensity, steady-state exercise,
about how long does it take for the oxidation of fat to reach its
maximal rate?
a. 1.5 minutes
b. 10–20 minutes
c. 30–45 minutes
d. A minimum of 60 minutes, with 90 minutes being the average
8. Good food sources of omega-3 fatty acids include:
a. Whole wheat bread and corn oil
b. Olive oil and fish
c. Fresh vegetables and fresh fruits
d. Rice and rice oil
9. Trans-fatty acids are created when:
a. Saturated fatty acids are hydrogenated
b. Unsaturated fatty acids are hydrogenated
c. Soft margarine is heated during normal cooking
d. The solid fatty acids in margarine and butter are turned to
liquid oil during cooking
10. Good lipoproteins are ______, and bad lipoproteins are ______.
a. Chylomicrons and HDL
 b. LDL and HDL
c. VLDL and HDL
d. HDL and LDL

Answers to Chapter Questions

1. b
2. d
3. a
4. e
5. d
6. b
7. c
8. b
9. b
10. d

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CHAPTER OBJECTIVES
Identify the established guidelines for recommended daily
intakes of vitamins and how to best interpret these guides.
Recall the common name(s) for each vitamin, the common
foods that are good sources for each vitamin, and the primary
functions for each vitamin.
Analyze the vitamins that athletes may be at highest risk of
deficiency for, based on the sport, common training protocols,
and traditional eating behaviors.
Discuss the theories behind why there are common beliefs
that higher intake levels of specific vitamins may improve
athletic performance.
Identify the specific water- and fat-soluble vitamins and the
potential risks of deficiency and toxicity for each.
Explain the potential health risks and benefits associated with
vitamin supplementation.

Case Study

Leah finally made it big. She got an invitation to the trials to

compete for a spot on the national team as a 200 m freestyle
swimmer, and she was finally going to the Olympic Training
Center for a meeting before the trials with the national team
coaches and sports medicine staff. Getting to this point was
definitely not easy, with before-school drives to the pool at
5:00 AM, after-school practices, always feeling hungry and
thirsty but somehow managing to stay healthy — all with the
hard work of her parents who saw to it that she got plenty of
good food to eat and enough rest to keep from getting overly
tired and sick. But now, just 6 months after graduating from
high school as an 18-year-old and starting her new life as a
college student, she has a chance to make the national swim
team. Life was exciting and good, but also more complicated
than ever.
Leah often found herself wondering where she was going
to get her next meal. Although her mother always made sure
she had something to eat before her early morning practices,
her life in college was too hectic to figure out where and what
to eat before practice. She noticed she was getting fatigued a
bit earlier than before, but no problem — she figured that she
could get some vitamin and mineral supplements to keep her
going. That was her first big mistake. Contrary to the
advertisements, vitamin supplements do not give you energy.
Some vitamin supplements might be useful for someone on a
low-quality diet and who has a specific nutrient deficiency,
but broad-spectrum nutrient supplements do not help give an
athlete who is not eating enough at the right time more
energy. Leah bought the come-on hook, line, and sinker, and
started taking a huge array of vitamin supplements before
practice as an easy meal substitute to make sure she had the
energy to swim fast. The supplements cost a huge amount,
but did not care because she believed it was a logical solution
to giving her body what she needed. She was wrong.
Leah was now at the National Training Center and it was
her turn to meet with the sports medicine staff. The first
question they asked was about her eating pattern. She
indicated that it was fine while she was at home, but that
when she went to live at college it was difficult — but no
problem because she found these amazing supplements. The
look of disbelief on the faces of the sports medicine staff
made Leah think she had said something wrong and then
when the head of sports medicine spoke she began to realize
that she did. He said, “Look, Leah; we are not about to invest
in an athlete who is going to make herself sick from not
eating enough and who is likely taking supplements that
contain banned substances (a large number of supplements
targeting athletes have been found to contain banned
substances that are not listed on the label), so even if you do
swim well, we are not going to invest in you until we are sure
that you are eating food.” He also asked Leah three
questions:

What are these vitamins supposed to work on if you are

not eating enough food?
Are you concerned that having 1,000 times the
recommended intake level on a daily basis is a bit much?
What will you do if you are found to have consumed
banned substances?

She could not answer any of these questions, and realized

all too quickly that she was playing a bad chemistry game
with her body. But, she was not about to give up on having a
chance to make it on the team, so she asked an important
question: “Can someone guide me on what and when to eat
to optimize my performance?” The dietitian looked at Leah
and said, “OK, you have just asked the right question. Let us
see if we can get you ready for next week’s competition. You
are too good a swimmer to not have a shot at this.”
After some time, Leah was back to form and was doing
well, eating properly, and realizing that there is no easy
alternative to eating. For many reasons, good food is the best
way to get what you need. It gives you the vitamins, minerals,
and energy to keep you performing at your best.

CASE STUDY DISCUSSION QUESTIONS

1. Look at a magazine that targets athletes and look at the

nutrition-related advertisements in the magazine to see
what vitamin supplements the advertisements are
encouraging athletes to consume.
2. Make a list of the recommended supplements, then look
up each supplement in the National Institutes of Health
Office of Dietary Supplements Web site for a state-of-the-
 art listing of what the potential benefits or problems are
with each of the supplements (Go to Dietary Supplement
Fact Sheets Web site — https://ods.od.nih.gov) (102).
3. Find the weaknesses in the advertisements.

Introduction

Important Factors to Consider

There is a common belief that the recommended intake of

vitamins represents the minimum level needed to sustain
good health and that having more than this level is always
better. It is also believed that if too much of any given
vitamin is consumed, then the excess will simply be
urinated away without difficulty.
In fact, the recommended intake level (the dietary reference
intakes [DRI]) is two standard deviations higher than the
average amount needed to sustain good health. Also, even
water-soluble vitamins are potentially toxic when too much
is consumed chronically.
The simple rule in nutrition, including for vitamins, that
should be followed is: More than enough is not better than
enough (Figure 5.1).
 FIGURE 5.1: Belief-based versus science-based nutrition.
Nutrient supplements are often viewed as the ultimate
“back-up system” for athletes, but when taken without
cause, not only do they not work, they often make matters
worse. Real foods are the best way to obtain needed
nutrients. (From Anatomical Chart Company. Keys to
Healthy Eating. Philadelphia [PA]: LWW; 2011.)

Vitamins are substances needed by cells to encourage

specific chemical reactions that take place in the cell. Some
vitamins (particularly B-vitamins) are involved in energy reactions
that enable cells to derive energy from carbohydrate, protein, and
fat. Because athletes require a higher level of energy than
nonathletes, these vitamins are of particular interest here. Other
vitamins are involved in maintaining mineral balance and are also
important for athletes to ensure adequate iron and calcium
status. Female athletes, for instance, are at high risk of iron
deficiency. Vitamin C has a unique characteristic that can improve
the bioavailability of iron in vegetables, which enhances iron
absorption from these foods. Vitamin D, which we can derive from
both sunlight and food, encourages the cells in a specific part of
the small intestine to allow more calcium and phosphorus to be
absorbed from food into the blood, helping to sustain and/or
improve bone mineral density. Importantly, vitamins work
together, making food consumption, which simultaneously
delivers a wide array of vitamins, a far better strategy for good
health than single-vitamin supplementation. For instance, both
vitamin E and vitamin C have antioxidant properties, with vitamin
E in the cell membrane and vitamin C in the blood. When vitamin
E captures a potentially damaging oxidative free radical and
protects the cell, it can hand off the free radical to vitamin C so
that it is free to capture another free radical and continue its cell
membrane–protective function.

Vitamin

An organic compound/nutrient that is necessary for sustaining

human health and that cannot be synthesized by tissues,
therefore mandating that it be consumed. Vitamins have a
variety of functions, including tissue growth, tissue
development, tissue repair, tissue protection, red blood cell
(RBC) development, energy metabolism, immune function, and
bone development.

Vitamins are organized into fat- and water-soluble categories.

The fat-soluble vitamins literally require a fat-based
environment in which to be transported and function, whereas the
water-soluble vitamins require a water-based environment.
Contrary to popular belief, we have the capacity to store all
vitamins and, therefore, have a backup supply of all vitamins.
That is to say, if a meal were consumed 2 days ago that had a
large amount of vitamin C and the foods consumed the following
day had no vitamin C, we would not expect to suffer from
symptoms of vitamin C deficiency today. Cells that require or
deliver vitamin C have a capacity to store slightly more than they
need. However, in the case of water-soluble vitamins such as
vitamin C, there are no clear storage depots where large amounts
of the vitamin can be stored. Fat-soluble vitamins, however, do
have a large storage capacity, allowing for high-level seasonal
consumption of certain vitamins. As an example, β-carotene (the
precursor of retinol, the active form of vitamin A) is particularly
highly concentrated in orange- and yellow-colored vegetables that
are harvested in autumn. Eating the pumpkin and squash that
provide high levels of β-carotene when seasonally available
enables a high-level storage that could prevent a deficiency for
the remainder of the year.

Fat-Soluble Vitamins

These are vitamins that are soluble in fat and are in the fat-
based portion of the foods we consume. They include vitamins
A, D, E, and K.

Water-Soluble Vitamins

These are vitamins that are soluble in water and are in the
water-based portion of the foods we consume. They include the
B-vitamins and vitamin C.

Doing the math will help illustrate this. A typical body can hold
onto about 1,500 mg of vitamin C at a time. The typical rate of
utilization of vitamin C in a healthy person is ∼15 mg/day. So, the
typical healthy person has about a 100-day supply of the vitamin
before the vitamin C deficiency disease would occur (1,500/15 =
100). In the 1850s, it was discovered that British sailors who were
on long voyages and eating foods not containing vitamin C would
start to show signs of scurvy, the deficiency disease of vitamin C,
after about 3 months (∼90 days) at sea. It was discovered,
however, that if these sailors were given lime juice periodically
during these long voyages, no scurvy would occur. A British sailor
is still now called “limey” because of the common introduction of
lime juice in the diet.
 Important Factors to Consider

There are many risks to health that can be found all around
our environment. For instance, a person with pink eye who
rubs his eyes and then touches a table surface places
everyone who touches that surface at risk of contracting
pink eye, which is highly contagious. The public is now well
informed that smoking increases the risk of developing
cancer. A smoker is not assured of getting cancer, and the
person touching a table surface that had been touched by
someone with pink eye is not assured of getting pink eye,
but exposure to smoking or a contagious disease increases
the risk of getting sick.
In simple terms, health risk represents the likelihood that
something (an act, an exposure, no exercise, poor eating
habits, etc.) may have a negative impact on a person’s
health. A 20% increase in health risk means that if five
people are equally exposed to a factor that can affect
health, one in five (20%) are actually likely to get sick from
exposure to that factor. The higher the health risk, the
greater the likelihood that a higher proportion of those
exposed to the risk will actually get sick. Mortality risk is
similar to health risk, except the risk of exposure is
expressed as the risk of dying (i.e., mortality) from the
exposure.
Typically, an individual’s health/mortality risk is comprised
of multiple factors that include age, gender, disease history
of close family members, activity patterns, food intake, and
genetic predisposition to disease. Some factors are within
an individual’s control (e.g., diet, physical activity), whereas
other health/mortality risk factors are not within an
individual’s control (e.g., the level of air pollution, genes,
sex).
Source: United States Department of Health and Human Services, National Institutes
of Health. NIH News in Health. Understanding Health Risks. Bethesda (MD): USDHHS;
2016. Available from: https://newsinhealth.nih.gov/2016/10/understanding-health-
risks. Accessed April 23, 2018.
 It is a myth to believe that consumption of excessively high
levels of any vitamin, including the water-soluble vitamins, is
without problems. Many people wrongly believe that the excess
vitamin consumption will simply and benignly be excreted in the
urine. Excess intake of some vitamins, particularly preformed
vitamin A (retinol), can produce severe vitamin toxicity, and
even taking excess water-soluble vitamins creates no difficulties.
An example of this is the neurologic problem (peripheral
neuropathy — loss of feeling in the fingers) created with excess
intake of vitamin B6 (500 mg/day over time) that will create
permanent damage (84). The problem of having too many
vitamins at once, typically with high-dose supplements, is clearly
illustrated in Table 5.1. In this study, it was found that older
women (N = 38,772) who regularly consumed commonly
available dietary vitamin and mineral supplements were at
increased mortality risk. Calcium supplementation was the only
supplement associated with decreased risk. It was noted that in
1986, 66% of women studied took supplements; and in 2004 that
increased to 85% of women (75).

Table 5.1 Dietary Supplements and Mortality Rate in

Older Women
Dietary Mortality Rate in Older Women
Supplement
Multivitamins 2.4% increased risk
Vitamin B6 4.1% increased risk
Folic acid 5.9% increased risk
Iron 3.9% increased risk
Magnesium 3.6% increased risk
Zinc 3.0% increased risk
Copper 18.0% increased risk
Calcium 3.8% decreased risk

Source: From Mursu J, Robien K, Harnack LJ, Park K, Jacobs DR. Dietary supplements and
mortality rate in older women: The Iowa Women’s Health Study. Arch Intern Med.
2011;171(18):1625–33.
 Vitamin Toxicity

Also referred to as hypervitaminosis, toxicity is the result of

consuming a vitamin in amounts that exceed the body’s
capacity to neutralize or excrete the excess. Typically, vitamin
toxicities occur when individuals chronically take a high-dose
supplement of a vitamin. Some vitamins are more potentially
toxic than others, with vitamin A (retinol) known to have high
potential toxicity with excess consumption. Water-soluble
vitamins are also potentially toxic. As an example, vitamin B6 is
known to cause permanent peripheral neuropathy (loss of
feeling in fingers and toes) with chronically high-intake doses.
The likelihood of developing vitamin toxicity from the
consumption of food alone is highly unlikely.

Consumption of vitamin supplements by athletes is high, with

studies finding that up to 81% of studied athletes are regular
supplement users (50). The primary reason provided by the
athletes for taking supplements was their desire to prevent
possible nutritional deficiencies, with some athletes saying that
they consumed supplements to enhance recovery from exercise.
However, only a small proportion of supplement-taking athletes
actually consulted with health professionals, indicating that these
supplements were self-prescribed (51). As noted earlier, the
supplement consumption by athletes carries risk, as many
supplements have been found to contain banned substances not
listed on the label, and chronic supplementation may create a risk
of toxicity (33). Athletes are, of course, the target of marketing
efforts by supplement companies, but there is scant evidence
that nutrient supplements trump the regular consumption of good
food in getting the desired performance outcomes. To illustrate
this point, a study of competitive triathletes found that providing
800 IU of vitamin E for 2 months prior to a triathlon, compared
with taking a placebo, actually promoted more lipid peroxidation
and inflammation during the race (79). This is precisely the
opposite effect that would have been expected from the
consumption of an antioxidant vitamin (vitamin E). But if amounts
consumed are chronically too high, the tissues develop a
resistance to the vitamin and the opposite effect occurs.
Strenuous physical activity is known to be associated with
depressed immune cell function, making athletes at higher risk of
illness. This is made worse in athletes who have poor intakes of
certain nutrients, including protein, iron, zinc, and vitamins A, E,
B6, and B12. However, it has been found that excess consumption
of these nutrients, often through supplements, also impairs the
immune function, and there is no evidence suggesting that so-
called immune-boosting supplements actually work (44). Other
studies have also found that multivitamin and mineral
supplementation resulted in no performance enhancement,
suggesting that supplementation was not needed in athletes
consuming a normal diet (107). Clearly, the best way to obtain
the needed nutrients, including vitamins, is to have a regular
consumption of good foods that meet the requirements for
energy.

Vitamin Enrichment and Fortification

Many vitamins and minerals are added to foods in processes
referred to as food enrichment and food fortification. The
process of enrichment is to return vitamins and minerals to foods
that were lost during food processing, and the process of
fortification is to add selected vitamins and minerals to foods for
the purpose of reducing the risk of developing a nutrient and/or
vitamin deficiency and associated health problems.

Enrichment

This represents the addition of nutrients that were originally

present in the food, but were removed during food processing.
For example, the processing of wheat grain has the effect of
removing many of the B-vitamins that are present in the bran
and germ of the grain, and enrichment puts back these same
vitamins as a means of restoring the original nutrient
composition of the grain.
 Fortification

Food fortification adds key vitamins and minerals to commonly

consumed foods to enhance the food’s nutritional content and
reduce the potential of specific nutrient deficiencies in a
population. Iodine added to salt (i.e., iodized salt) is an early
example of food fortification for the purpose of reducing the
chance of developing goiter (enlarged thyroid gland). Vitamins
A and D have been fortified in milk for many years to lower the
risk of rickets, and more recently in the United States folic acid
has been added to grains to ensure that women who become
pregnant have a normal folic acid status to reduce the risk that
their offspring will have spina bifida or anencephaly.

Vitamin Deficiency

Also referred to as avitaminosis or hypovitaminosis, a vitamin

deficiency results when the tissues have become depleted of a
needed vitamin. For example, a vitamin D deficiency may result
in rickets or osteoporosis, a vitamin C deficiency may result in
scurvy, and a riboflavin (vitamin B2) deficiency may result in
glossitis and photophobia and poor energy metabolism. The
deficiency may be the result of poor diet, or a diet that does not
adequately satisfy lifestyle-related needs. For instance, smokers
require more vitamin C than nonsmokers.

Important Factors to Consider

Enrichment

Nutrients that were lost during food processing have been

added back. For example, refining wheat to make white
flour removes several B-complex vitamins and iron that are
contained in the part of the grain that is removed during
processing. Flour can be called enriched when the removed
nutrients are added back to the food before packaging.
The US Food and Drug Administration (FDA) has rules that
food manufacturers must follow to claim that a food is
 enriched. According to the FDA, a food can claim to be
enriched if it contains at least 10% more of a specified lost
nutrient than a food of the same type that has not been
enriched (100).
In addition, foods can be labeled as enriched when they
meet the FDA’s definition for a type of food with a name
that includes that term, including enriched bread or
enriched rice. Processed flour can only be labeled as
enriched flour if it contains specified amounts of vitamins
B1, B2, niacin, and iron. Examples of enriched foods include:
Bread
Pasta
Breakfast cereal
Rice products
Corn products
Wheat products

Fortification

Nutrients have been added to a food that were not

originally in the food. The World Health Organization (WHO)
and the Food and Agriculture Organization of the United
Nations (FAO) define fortification as “the practice of
deliberately increasing the content of an essential
micronutrient, i.e. vitamins and minerals (including trace
elements) in a food irrespective of whether the nutrients
were originally in the food before processing or not, so as to
improve the nutritional quality of the food supply and to
provide a public health benefit with minimal risk to health.”
The primary goal of fortification, therefore, is to identify
nutrients that are not easily obtained in foods commonly
consumed, and adding those nutrients with the hope of
reducing disease associated with specific nutrient
deficiency.
A prime example of fortification that has been practiced for
a long time is fortifying milk products with vitamins A and D,
and more recently adding (i.e., fortifying) vitamin D to
orange juice. Folic acid has been more recently added to
 (i.e., fortified) cereal grains to lower the risk of women
having babies with spina bifida and anencephaly.
Examples of foods that have been fortified include:
Cereals and cereal-based products
Milk and milk products
Fats and oils
Beverages
Infant formulas
Sources: Academy of Nutrition and Dietetics. Enriched, Fortified: What’s the
Difference? http://www.eatright.org/cps/rde/xchg/SID-5303FFEA-
D13B3A75/ada/hs.xsl/home_8388_ENU_HTML.htm. Accessed February 12, 2008;
United States Department of Agriculture, Food and Drug Administration. Are foods
that contain added nutrients considered “enriched”? Available from:
https://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInform
ation/ucm470756.htm. Accessed June 4, 2018.

Water-Soluble Vitamins

Vitamin B1 (Thiamin)
Vitamin B1, also referred to as thiamin, is present in a variety of
foods, including whole grains, nuts, beans, dried peas, and pork. It
works together with other B-vitamins in metabolic processes
involving conversion of the potential energy in consumed foods to
muscular energy (Box 5.1). Thiamin does this through its
involvement in the removal of carbon dioxide in energy reactions
with its active coenzyme, called thiamine pyrophosphate (TPP).
TPP is particularly important in deriving energy from
carbohydrates. Thiamin deficiency in athletes has not been
reported in the literature, but in groups of people consuming a
low-quality diet of unenriched polished rice or other processed
and unenriched grains, thiamin deficiency has been reported. It
has also been reported in clients with anorexia nervosa, as a
result of a severe underconsumption of all foods, including foods
containing thiamin (114).

Box 5.1 Vitamin B1 (Thiamin) Basic Information

 DRI
Adult males: 1.2 mg/d
Adult females: 1.1 mg/d
Recommended intake for athletes: 1.5–3.0 mg/d,
depending on total calories consumed (high calories =
more)
Functions: (active coenzyme: TPP)
Carbohydrate, fat, and branched-chain amino acid
metabolism
Nervous system function
Good food sources
Whole-grain cereals
Beans
Pork
Enriched grains
Deficiency
Confusion
Anorexia
Weakness
Calf pain
Heart disease
Deficiency disease: Beriberi
Toxicity: None known (no safe upper limit [UL] established)

Coenzyme

Coenzymes are small molecules that are often the active result
of vitamin consumption and are involved in encouraging
enzymes to fulfill their chemical functions. For instance, the
active coenzyme for thiamin (vitamin B1) is TPP; and the active
coenzymes for niacin are niacin adenine dinucleotide (NAD) and
niacin adenine dinucleotide phosphate (NADP). TPP, NAD, and
NADP are all involved in energy metabolic processes that would
not occur without the encouragement of these coenzymes.
 The primary thiamin-deficiency disease, called beriberi,
involves nervous system malfunction (especially in the hands and
legs, as well as in balance) and heart failure. A study has found
that up to one-third of hospitalized congestive heart failure
patients were diagnosed with thiamin deficiency and that, in this
population, increasing thiamin availability through food and/or
thiamin supplementation improved thiamin status (48). One form
of beriberi also causes edema (water retention), which would be a
contributor to congestive heart failure. As expected for a vitamin
involved in energy reactions, early thiamin deficiency is
characterized by muscle fatigue, which progresses to muscular
weakness as the deficiency becomes more severe. Other
symptoms of thiamin deficiency include loss of appetite, nausea,
constipation, irritability, depression, loss of coordination, and
confusion. A deficiency of thiamin is not likely to occur in US
athletes. However, because alcohol inhibits normal thiamin
metabolism, it is possible that thiamin-deficiency symptoms may
occur in athletes who frequently consume alcoholic beverages.
Athletes have a high requirement for energy, but because the
thiamin requirement is based on 0.5 mg of thiamin for each 1,000
calories consumed, this level should satisfy athlete needs even
where energy intakes are high.
Adequate intake (AI) of thiamin is important for energy
metabolism, muscle protein synthesis, and muscle repair (81, 96).
Athletes commonly consume high-carbohydrate foods that,
because of enrichment, are good sources of thiamin that help to
ensure that athletes who meet energy requirements also satisfy
the physiologic needs for thiamin. A study of collegiate swimmers
found that higher-intensity training was associated with lower
circulating thiamin levels in the blood than lower-intensity
training, suggesting that dietary intakes should be adjusted to
dynamically match the energy requirements of the activity (83).
Consumption of more food with higher-intensity activity should
adequately provide the thiamin needed for the additional energy
metabolic needs.
Thiamin is present in a variety of food sources, including whole
grains, nuts, legumes (beans and dried peas), and pork. It works
in unison with other B-vitamins to convert the energy in the foods
we consume to muscular energy and heat.
Vitamin B2 (Riboflavin)
Riboflavin is involved in energy production and normal cellular
function through its coenzymes flavin adenine dinucleotide (FAD)
and flavin mononucleotide (FMN), both of which are involved in
producing energy from consumed carbohydrates, proteins, and
fats (Box 5.2). Food sources of riboflavin include dairy products
(e.g., milk, yogurt, cottage cheese), dark leafy green vegetables
(e.g., spinach, chard, mustard greens, broccoli, green peppers),
whole-grain foods, and enriched grain foods.

Box 5.2 Vitamin B2 (Riboflavin) Basic Information

DRI
Adult males: 1.3 mg/d
Adult females: 1.1 mg/d
Recommended intake for athletes: 1.1 mg/1,000
calories
Functions: (active coenzymes: FMN and FAD)
Energy metabolism (electron transfer reactions)
Protein metabolism
Hormone production
Skin health
Eye health
Good food sources
Fresh milk and other dairy products
Eggs
Dark green leafy vegetables
Whole-grain cereals
Enriched grains
Deficiency
Inflamed tongue
Cracked, dry skin at corners of mouth, nose, and eyes
Bright light sensitivity
Weakness
Fatigue
Deficiency diseases: cheilosis and photophobia
Toxicity: None known (no safe UL established)
 No studies suggest that riboflavin-deficiency symptoms
commonly occur in athletes, possibly because riboflavin is
reabsorbed by the kidneys when blood levels are low (83, 107,
115). Also, no apparent toxicity symptoms occur from consuming
more than the DRI. Several studies have suggested that athletes
may have higher requirements than the DRI, which is based on
consumption of 0.6 mg riboflavin per 1,000 calories. In a series of
studies performed on exercising women and women seeking to
lose weight, the riboflavin requirement was found to range
between 0.63 and 1.40 mg/1,000 calories (6–8). There is some
evidence that physical activity increases the requirement to a
level slightly higher than 0.6 mg/1,000 calories, but not more
than 1.6 mg/1,000 calories (99). However, even with this
apparently higher requirement for athletes, no studies clearly
demonstrate an improvement in athletic performance with dietary
intakes that exceed the established DRI. Vegetarian athletes may
be at higher risk of riboflavin deficiency, particularly if they avoid
consuming foods high in riboflavin, including soy and dairy
products (16). Vegetarian athletes who increase exercise intensity
would also be considered at higher risk, particularly if the regular
food intake does not provide the needed energy with greater
consumption of plant sources of riboflavin, which includes whole
grain and enriched cereals, soy products, almonds, asparagus,
bananas, sweet potatoes, and wheat germ (65).
It is never easy to make a determination about what level of
intake is appropriate for athletes because there are many factors
to consider. For riboflavin, understanding the requirement is made
even more complex because riboflavin is easily destroyed by
ultraviolet light (the reason behind opaque milk bottles in the
grocery store, which serve to inhibit ultraviolet insertion through
the milk). The delivered riboflavin content in fresh dairy products
is not the same, therefore, as in older products that had more
opportunities for multiple light exposures. This makes it difficult to
understand the actual amount of riboflavin that is commonly
delivered by food, and whether any earlier risks that may have
been found are no longer present. Although physical activity may
increase the requirement for riboflavin, there are no studies
demonstrating an improvement in athletic performance with
riboflavin intakes that exceed the DRI.

Niacin (Niacinamide, Nicotinic Acid, Nicotinamide, or

Vitamin B3)
Niacin is involved in energy production from carbohydrate,
protein, and fat, glycogen synthesis, and normal cellular
metabolism through its active coenzymes (Box 5.3). These
enzymes, nicotinamide adenine dinucleotide (NAD) and
nicotinamide adenine dinucleotide phosphate (NADP), are
essential for normal muscle function. Although niacin deficiency is
well documented in human populations suffering from famine or
monotonous intakes of unenriched grain products, there is no
evidence that athletes are at risk of niacin deficiency.

Box 5.3 Vitamin B3 (Niacin) Basic Information

DRI
Adult males: 16 mg/d
Adult females: 14 mg/d
Recommended intake for athletes: 14–20 mg/d (higher
levels based on expected higher energy intakes)
Functions: (active coenzymes: NAD, which is
phosphorylated to NADP and reduced to nicotinamide
adenine dinucleotide hydride)
Energy metabolism
Glycolysis
Fat synthesis
Good food sources
Foods high in tryptophan (an amino acid that can be
converted to niacin):
Milk
Eggs
Turkey
Chicken
Foods high in niacin:
Whole grains
 Lean meat
Fish
Poultry
Enriched grains
Deficiency
Anorexia
Skin rash
Dementia
Weakness
Lethargy
Deficiency disease: Pellagra
Toxicity
Tolerable ULs:
10–15 mg/d for young children (age 1–8 yr)
20–35 mg/d for children and adults (age 9–70+ yr)
Toxicity symptoms:
Flushing
Burning and tingling sensations of extremities
Hepatitis
Gastric ulcers

Niacin is found in meat, whole or enriched grains, seeds, nuts,

and legumes, and body cells have the capacity to synthesize
niacin from the amino acid tryptophan (60 mg of tryptophan
yields 1 mg of niacin), which is found in all high-quality protein
foods (e.g., meat, fish, poultry). Given the broad spectrum of
foods that contain niacin, it is relatively easy for people to
consume the DRI of 12–14 mg/day, or 6.6 niacin equivalents (NEs)
per 1,000 calories. NEs are equal to 1 mg of niacin or 60 mg of
dietary tryptophan. Niacin can be obtained directly from food or
indirectly by consuming the amino acid tryptophan. The NE unit of
measure takes both sources into account.
Niacin deficiency results in muscular weakness, loss of
appetite, indigestion, and skin rash, with an extreme deficiency
leading to the deficiency disease pellagra. Symptoms of pellagra
include diarrhea, dementia, dermatitis, and, if left untreated,
results in death. An excess intake of niacin may result in toxicity
symptoms, including gastrointestinal (GI) distress and feeling hot
(becoming red faced or flushed). It may also result in a tingling
feeling around the neck, face, and fingers. These symptoms are
commonly reported in people taking large doses of niacin to lower
blood lipids, suggesting that niacin supplementation should only
occur with medical supervision. Animal studies have found that
supplementation with niacin may increase muscle mitochondrial
biogenesis, resulting in an increased potential for fat metabolism.
However, there are no studies on humans that have assessed the
impact of supplemental niacin on mitochondrial adaptation (28).
In fact, early studies that have evaluated the performance effects
of niacin supplementation found that endurance was reduced
because the excess niacin resulted in lowered fat metabolism (11,
24, 54). Lower fat metabolism leads to a greater reliance on
carbohydrate fuels (glucose and glycogen) to support physical
activity, but glycogen storage is limited resulting in lower
endurance. To date, there is no evidence that the requirement for
niacin is increased beyond the DRI with physical activity.

Vitamin B6 (Pyridoxine, Pyridoxal, and Pyridoxamine)

Vitamin B6 refers to six compounds (pyridoxine, pyridoxal,
pyridoxamine, pyridoxine-5-phosphate, pyridoxal-5-phosphate
[PLP], and pyridoxamine-5-phosphate [PMP]) that display similar
metabolic activity (Box 5.4). It is found in highest quantity in
meats (especially liver) and is also available in wheat germ, fish,
poultry, legumes, bananas, brown rice, whole-grain cereals, and
vegetables. The function of this vitamin is closely linked to protein
and amino acid metabolism, and so the requirements are also
linked to protein intake (higher protein intakes require higher
vitamin intakes). Because high-protein foods are also typically
high in vitamin B6, those consuming protein from food are most
likely to have adequate B6 levels as well. However, many athletes
consume additional protein in purified, supplemental forms
(protein powders, amino acid powders, etc.) that are devoid of
vitamin B6, suggesting that it is conceivable that athletes with
high supplemental protein intakes will have an inadequate B6
intake. The adult requirement is based on 0.016 mg of B6 per
gram of protein consumed each day and is adequate for those
consuming typical protein intakes (57). Except in alcoholism,
which affects B6 intake and impairs B6 metabolism, severe
deficiency of B6 is uncommon. The estimated deficiency
prevalence of vitamin B6 in the general population is 10.6% (91).
When deficiency occurs, it is most associated with neurologic
symptoms (irritability, depression, and confusion) and
inflammation of the tongue and mouth (19, 46).

Box 5.4 Vitamin B6 (Pyridoxine, Pyridoxal, and

Pyridoxamine) Basic Information

DRI
Adult males: 1.3–1.7 mg/d
Adult females: 1.3–1.5 mg/d
Recommended intake for athletes: 1.5–2.0 mg/d
Functions: (active coenzymes: PLP and PMP)
Metabolism of protein, including protein synthesis
Metabolism of fat
Metabolism of carbohydrate
Neurotransmitter formation
Glycolysis
Antioxidant
Good food sources
Meats
Whole grain and enriched cereals
Eggs
Deficiency
Nausea
Mouth sores
Muscle weakness
Depression
Convulsions
Impaired immune system
Toxicity
Tolerable ULs:
30–40 mg/d for young children (age 1–8 yr)
 60–100 mg/d for children and adults (age 9–70+ yr)
Toxicity symptoms:
Loss of limb sensation and loss of coordination

Vitamin B6 functions in reactions related to protein synthesis

by aiding in the creation of amino acids and proteins
(transamination reactions) and is also involved in protein
catabolism through involvement in reactions that break down
amino acids and proteins (deamination reactions). It is involved,
therefore, in manufacturing muscle, hemoglobin, and other
proteins critical to athletic performance. The major enzyme of
vitamin B6, pyridoxal phosphate, is also involved in the
breakdown of muscle glycogen for energy through the enzyme
glycogen phosphorylase.
A deficiency of vitamin B6 will lead to symptoms of peripheral
neuritis (loss of nerve function in the hands, feet, arms, and legs),
ataxia (loss of balance), irritability, depression, and convulsions.
An excess intake of vitamin B6 does lead to toxic symptoms that
have been documented in humans. These symptoms are similar
to those seen in B6 deficiency and include ataxia and severe
sensory neuropathy (loss of sensation in the fingers). The toxicity
symptoms were found in women taking doses that, on average,
equal 119 mg/day for the purpose of treating premenstrual
syndrome and several types of mental disorders (32, 84).
There is a theoretical basis for investigating vitamin B6 and
athletic performance. B6 is involved in the breakdown of amino
acids in muscle as a means of obtaining needed energy and in
converting lactic acid to glucose in the liver (67). Vitamin B6 is
also involved in the breakdown of muscle glycogen to derive
energy. Other functions of vitamin B6 that may be related to
athletic performance include the formation of serotonin and the
synthesis of carnitine from lysine. There is evidence that some
athletes may be at risk for inadequate vitamin B6 status (41, 45,
95). Poor B6 status also reduces athletic performance (92). It has
also been proposed that lower antioxidant capacity in athletes
may result from vitamin B6 deficiency (26).
Because many athletes are always looking for that extra edge,
there is an understandable attractiveness to the consumption of
natural substances that are legal. Vitamin B6 is sometimes
marketed as one of those natural (and legal) substances because,
besides its importance in energy metabolism, it is linked with the
production of growth hormone, which can help to increase muscle
mass (34). It appears as if the combined effect of exercise and
vitamin B6 on growth hormone production is greater than either of
these factors individually (37, 72). Given the importance of this
vitamin to athletic performance, it is easy to see why athletes
may rush to obtain more. However, these factors should be
considered (67):

Most athletes have adequate vitamin B6 intakes and adequate

vitamin B6 status.
Those athletes with poor vitamin B6 status are generally those
with inadequate energy intakes.
A greater proportion of female athletes and athletes
participating in sports that emphasize low weights
(gymnastics, wrestling, skating, etc.) are likely to have
inadequate energy intakes and, therefore, inadequate vitamin
B6 intakes.
High doses of vitamin B6 have been shown to have toxic
effects.
There is no good evidence that having more than the
recommended intake has a beneficial effect on athletic
performance (36).
Vitamin B6 supplementation does not appear necessary to
enhance athletic performance if a balanced diet, with
adequate energy intake, is consumed (82).

Taken together, these factors should encourage athletes to

consume an AI of energy before they consider taking supplements
of vitamin B6.
Vitamin B12 (Cobalamin)
Vitamin B12 is perhaps the most chemically complex of all the
vitamins. It contains the mineral cobalt (hence the name
cobalamin) and has a major involvement in RBC formation, folic
acid metabolism, deoxyribonucleic acid (DNA) synthesis,
synthesis of succinyl-coenzyme A (CoA; an intermediary product
of the citric acid cycle), and nerve development, but it is essential
for the function of all cells (Box 5.5).

Box 5.5 Vitamin B12 (Cobalamin) Basic Information

DRI
Adult males: 2.4 mcg/d
Adult females: 2.4 mcg/d
Recommended intake for athletes: 2.4–2.5 mcg/d
Functions
Protein metabolism, including protein synthesis
Metabolism of fat
Metabolism of carbohydrate
Neurotransmitter formation
Glycolysis
RBC formation
Good food sources
Foods of animal origin (meat, fish, poultry, eggs, milk,
cheese)
Fortified cereals
Deficiency
Disease: Pernicious anemia (more likely caused by
malabsorption of the vitamin than by dietary
inadequacy, although vegans are at higher risk of
deficient intakes)
Deficiency disease symptoms: Weakness, easy fatigue,
neurologic disorders
Toxicity: Tolerable ULs not established; the daily value (DV)
is 6 mcg/d
 Dietary sources of this vitamin are mainly foods of animal
origin (meats, eggs, dairy products), and it is essentially absent
from plant foods. There may also be some very small amount of
absorbable vitamin B12 that is produced by gut bacteria (2). It
should be clear from this that vegetarian athletes who avoid all
foods of animal origin (i.e., they do not eat meat, nor do they
consume eggs or dairy products) would be at risk for vitamin B12
deficiency.
The primary disease associated with vitamin B12 deficiency is
pernicious anemia, but inadequate intake is also associated with
higher risk of neural tube defects (i.e., spina bifida and
anencephaly), lower synthesis of neurotransmitters, reduced
mental function, and elevated levels of homocysteine (a risk
factor in heart disease). Pernicious anemia most commonly occurs
in older adults who have experienced a reduction in normal
stomach function. The stomach produces a substance called
intrinsic factor that is required for vitamin B12 absorption. Without
intrinsic factor, a person can consume an adequate level of B12
but still develop a deficiency because of poor absorption.
Symptoms of deficiency include fatigue, poor muscular
coordination (possibly leading to paralysis), and dementia.
There is a long history of vitamin B12 abuse by athletes. It was
(and continues to be) common for many athletes to be injected
with large amounts of vitamin B12 (often 1,000 mg) before
competitions (42, 103). However, the athletic performance
benefits of vitamin B12 injections and supplementation have not
been established for athletes consuming unrestricted diets (65,
80, 98, 104).
It certainly makes sense that athletes consume foods that will
avoid deficiencies of any kind, including the avoidance of B12
deficiency. The resulting anemia would clearly have an impact on
performance by producing a reduction in endurance and,
potentially, a lowering of muscular coordination. However, there
is no logical basis or proven benefits for consumption or injections
of such large doses as has been reported in the literature for
vitamin B12. Without a genetic predisposition to B12
malabsorption (typically because of an inadequate production of
intrinsic factor), there is no basis for taking supplements if a
balanced mixed-food diet is consumed. Pure vegetarian athletes
(i.e., those who avoid the consumption of all foods of animal
origin), on the other hand, may have a good reason to be
concerned about vitamin B12 status. A supplement that provides,
on average, the daily requirement (2.4 mcg) makes good sense,
as does the consumption of foods that are fortified with vitamin
B12 (such as some soy milk products). Vegan food sources of
vitamin B12 include:

B12-fortified almond milk

B12-fortified coconut milk
Nutritional yeast
B12-fortified soymilk
Tempeh or tofu
B12-fortified cereal

Folic Acid (Folate)

Folic acid is widespread in the food supply, but is present in the
highest concentrations in liver, yeast, leafy vegetables, fruits, and
legumes. It is easily destroyed through common household food
preparation techniques and long storage times, so it is most
commonly associated with fresh foods. Folate functions in amino
acid metabolism and nucleic acid synthesis (ribonucleic acid and
DNA), so a deficiency leads to alterations in protein synthesis (Box
5.6) (57). Tissues that have a rapid turnover are particularly
sensitive to folic acid. This includes RBC and white blood cells, as
well as tissues of the GI tract and the uterus. More recently,
adequate folate intake during pregnancy has been associated
with the elimination of fetal neural tube defects (most notably
spina bifida) (111). The average US folate intake exceeds the
requirement of between 180 and 200 mcg/day by between 25%
and 50%, but its importance in RBC formation and in preventing
neural tube defects has led to the supplementation with folic acid
during pregnancy. The recommended intake of folate during
pregnancy (400 mcg) is double that of the adult requirement. A
deficiency of folate leads to anemia, GI problems (diarrhea,
malabsorption, pain), and a swollen, red tongue. Because folate
works with vitamin B12 in forming healthy new RBCs, a chronic
deficiency leads to megaloblastic anemia. Excess folic acid intake
may mask vitamin B12 deficiency and may also increase cancer
risk (39, 69, 116).

Box 5.6 Folic Acid (Folate) Basic Information

DRI
Adult males: 400 mcg/d
Adult females: 400 mcg/d
Recommended intake for athletes: 400 mcg/d
Functions
Methionine (essential amino acid) metabolism
Formation of DNA
Formation of RBCs
Normal fetal development
Good food sources
Dark green leafy vegetables
Enriched and fortified grains and cereals
Beans
Whole-grain cereals
Oranges
Bananas
Deficiency
Megaloblastic (macrocytic) anemia
Neural tube defects (as a result of poor folate status at
initiation of pregnancy)
Symptoms
Weakness
Easy fatigue
Neurologic disorders
Toxicity
Tolerable ULs:
300–400 mcg/day for young children (age 1–8 yr)
600–1,000 mcg/day for children and adults (age 9–
70+ yr)
Folate naturally occurs in foods; folic acid is the synthetic form of folate.
 No studies have reported on the relationship between folic acid
and athletic performance. However, because athletes have an
above-normal tissue turnover because of the pounding the body
takes in various sports, and with evidence that RBC turnover is
faster in athletes than in nonathletes, there is a good reason for
athletes to be certain that adequate folic acid intake is satisfied
(70, 107). The prudent approach is through the regular
consumption of foods, including whole grains (now fortified with
folic acid), fresh fruits, and vegetables.

Biotin (Vitamin H)
Biotin works with magnesium and adenosine triphosphate (ATP) in
carbon dioxide metabolism, new glucose production
(gluconeogenesis), carbohydrate metabolism, and fatty acid
synthesis (Box 5.7) (57). Food sources of biotin include egg yolk,
soy flour, liver, sardines, walnuts, pecans, peanuts, and yeast.
Fruits and meats are, however, poor dietary sources of the
vitamin. Biotin is also synthesized by bacteria in the intestines. A
deficiency of this vitamin is rare but can be induced through the
intake of large amounts of raw egg whites (from about 20 eggs),
which contain the protein avidin (56). This protein binds to biotin,
making it unavailable for absorption. When a deficiency of biotin
occurs, symptoms include hair loss; scaly red rash around eyes,
nose, and mount; loss of appetite; vomiting; and depression.
However, because there are not many people who consume large
quantities of raw egg white, deficiencies of this vitamin are rare.
Athletes should be cautious of consuming large amount of raw
egg whites as a strategy for increasing protein intake. There is no
evidence, however, that athletes are at risk for biotin deficiency,
and no information on the relationship between biotin and athletic
performance.

Box 5.7 Biotin (Vitamin H) Basic Information

DRI
Adult males: 30 mcg/d
 Adult females: 30 mcg/d
Recommended intake for athletes: 30 mcg/d
Functions
Glucose synthesis (gluconeogenesis)
Fatty acid synthesis
Gene expression regulator
Good food sources
Egg yolks
Legumes, dark
Green leafy vegetables
Note: Also produced by intestinal bacteria
Deficiency
Rare; if it occurs, due to high egg white intake
Deficiency symptoms: anorexia, depression, muscle
pain, dermatitis
Toxicity: Tolerable ULs not established

Pantothenic Acid (Vitamin B5)

Pantothenic acid is a structural part of CoA, which is the
intermediary product of all energy metabolic processes (Box 5.8).
Through CoA, pantothenic acid is involved in carbohydrate,
protein, and fat metabolism. Because pantothenic acid is widely
distributed in the food supply, it is unlikely that an athlete would
suffer from a deficiency, particularly if sufficient total energy is
consumed. The highest concentrations of pantothenic acid are
found in meat, whole-grain foods, beans, and peas. If a rare
deficiency does occur, symptoms include easy fatigue, weakness,
and insomnia. Supplemental doses of the vitamin are typically 10
mg/day or higher (double the DRI) and, at this level, have not
been shown to produce toxic effects.

Box 5.8 Pantothenic Acid (Vitamin B5) Basic

Information

DRI
Adult males: 5 mg/d
 Adult females: 5 mg/d
Recommended intake for athletes: 4–5 mg/d
Functions
Energy metabolism as part of acetyl-CoA
Gluconeogenesis
Synthesis of acetylcholine
Good food sources
Widely present in all foods, with the exception of highly
processed and refined foods
Deficiency
Unknown in humans
Toxicity
Tolerable ULs not established; DV is 10 mg

There are human studies suggesting that pantothenic acid may

aid in the wound healing of skin (108, 110). Early studies on
animals also suggest that pantothenic acid supplementation is
effective in improving time to exhaustion (13, 90). However,
human studies do not agree on the potential benefits of
pantothenic acid supplementation. In one study using a double-
blind protocol, there was no difference in time to exhaustion in
conditioned runners given either a pantothenic acid supplement
or a placebo (78). However, in another study that used a double-
blind protocol, there was a lowering of lactate (−16.7%) and an
increase in oxygen consumption (+8.4%) in subjects given a
pantothenate supplement versus those given a placebo prior to
riding a cycle ergometer to exhaustion (64).
Although a possible relationship between increasing the intake
of pantothenic acid and exercise performance may exist, more
information is needed before a sound recommendation can be
made on pantothenate intake for athletes. In studies that have
experimented with pantothenic acid supplements to determine a
requirement level, the typical dosage has been 10 mg/day. When
this level is provided, 5–7 mg/day is excreted in the urine (57).
Therefore, it appears that taking supplements at or above this
level is excessive.
Vitamin C (Ascorbic acid, Ascorbate, Dehydroascorbate, l-
Ascorbate)
Fresh fruits and vegetables are the best sources of vitamin C.
Cereal grains contain no vitamin C (unless fortified with vitamin
C), and meats and dairy products are low in vitamin C. Vitamin C
is easily destroyed by cooking (heat) and exposure to air
(oxygen). It is also highly water soluble, which means it is easily
removed from foods by water. The vitamin C deficiency disease,
scurvy, is caused by a long-term dietary deficiency of the vitamin.
For a variety of reasons (fresh food availability, supplement
intake, use of vitamin C as an antioxidant in packaged foods),
scurvy is almost nonexistent now. Toxicity from high, regular
supplemental intakes of the vitamin is rare, but may include a
predisposition to developing kidney stones and a reduced tissue
sensitivity to the vitamin. Doses of 100–200 mg/day will saturate
the body with vitamin C, yet many people take supplemental
doses of 1,000–2,000 mg/day (57). This level of supplemental
vitamin C intake represents doses that are many times higher
than the DRI of 75–90 mg/day (Box 5.9).

Box 5.9 Vitamin C (Ascorbic acid, Ascorbate,

Dehydroascorbate, l-Ascorbate) Basic Information

DRI
Adult males: 90 mg/d
Adult females: 75 mg/d
Recommended intake for athletes: 100–200 mg/d
Functions
Antioxidant
Synthesis of carnitine (a transport molecule that carries
fatty acids into mitochondria for energy metabolism)
Production of epinephrine and norepinephrine
(neurotransmitters that rapidly degrade glycogen to
make glucose available to working muscles)
Facilitates absorption of nonheme iron from fruits and
vegetables
Synthesis of cortisol, a powerful catabolic hormone
 Resynthesis of vitamin E to its active antioxidant state
Collagen formation (a connective tissue protein)
Good food sources
Fresh fruits (particularly citrus and cherries)
Fresh vegetables
Deficiency
Rare
Disease: Scurvy
Deficiency symptoms: bleeding gums, deterioration of
muscles and tendons, sudden death
Toxicity
Tolerable ULs:
400–650 mg/d for young children (age 1–8 yr)
1.2–2.0 g/d for children and adults (age 9–70+ yr)
Increased risk of kidney stone formation with
chronic intake of 1 g/d (1,000 mg) or more
Source: Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes
(DRIs): Recommended Intakes for Individuals. Washington (DC): National Academy
Press; 2004.

A number of studies have evaluated the relationship between

vitamin C intake and athletic performance, and the results from
these studies are inconsistent. Part of the problem with many of
the studies performed on vitamin C is a lack of standardization
between subjects and a general lack of comparative controls.
Nevertheless, according to reviews of studies that used controls
and provided vitamin C supplements at or below 500 mg/day (a
level that is 5× the DRI), there was no measurable benefit in
athletic performance (27, 53). One study noted that when a 500-
mg dose of vitamin C was provided shortly (4 hours) before
testing, athletes experienced a significant improvement in
strength and a significant reduction in maximal oxygen
consumption (VO2max) — which is a good thing — but there was
no impact on muscular endurance (18). (VO2max is the maximum
volume of oxygen that the lungs can bring into the system.
Working at a lower level of VO2max means the person is not
working as hard as maximal aerobic capacity.) However, when
participants were provided with the same amount for 7 days,
there was an improvement in strength with a decrease in
endurance. When these same subjects were provided with 2,000
mg each day for 7 days, there was only a lowering of VO2max, but
no change in endurance performance. There may be a benefit in
consuming a slightly higher level of vitamin C for athletes
involved in concussive sports where muscle soreness occurs or
there is an injury. Studies on animals generally indicate that
having more vitamin C improves the healing process and that
inadequate vitamin C inhibits healing (86). Although there is some
evidence that muscle soreness may be more rapidly relieved with
consumption of moderate supplemental doses of vitamin C and
other antioxidants, it should be noted that the current scientific
evidence to support the use of supplemental doses of antioxidant
vitamins, including vitamin C, to enhance tendon and muscle
healing in athletes is limited (58, 93).
Given these inconsistent results, it is difficult to make a
rational recommendation on vitamin C and athletic performance.
However, slightly increasing vitamin C intake may reduce muscle
soreness faster and may also improve healing. The question is:
How much is just right? Unfortunately, it is impossible to know the
correct answer for every person. Because studies demonstrate
that high doses may cause endurance problems, it is important to
keep the level of intake below one that may result in performance
deficits. An early study reported on three deaths that were due to
iron overload. Vitamin C is known to enhance iron absorption, and
the people who died were taking large daily doses of vitamin C
(52). Also consider that athletes already typically consume more
than 250 mg of vitamin C each day from food alone because of
the high intake of fresh fruits and vegetables. A reasonable
recommendation is to consume an abundant amount of fresh
fruits and vegetables (wonderful sources of carbohydrates and
many other nutrients besides vitamin C). It has been found that
vitamin C supplementation is popular with athletes, with up to
77% of assessed athletes reportedly taking multivitamins
containing vitamin C or vitamin C. Recommendations for
consuming these supplements, however, did not come from
health professionals, and over 80% reported being unaware that
supplemental intake could negatively affect performance (97).
Choline
Although not officially a vitamin, choline has water-soluble
vitamin-like characteristics, mainly related to the formation of the
neurotransmitter acetylcholine (Box 5.10). It is often grouped
together with B-complex vitamins. Some animal species require
choline to sustain health, but humans can manufacture choline
through a metabolic pathway that involves the amino acid
methionine and the vitamin folate. Therefore, periodic
consumption of high-protein foods that are excellent contributors
of the amino acid methionine is a way to ensure adequate choline
availability. In 1998, choline was determined to be an essential
nutrient by the Institute of Medicine (117, 118). It is present in
many foods and is particularly high in beef liver, eggs, human
breast milk, and cruciferous vegetables (cauliflower, broccoli,
etc.). Lecithin, an emulsifying agent (causes fats to mix in water,
as in creamy Italian dressing vs. regular oil and vinegar dressing
with the oil rising to the top), may contain anywhere from 20% to
90% choline, depending on its source (soybean, sunflower,
rapeseed, etc.). Although the lecithin content of processed foods
is small, consumption of lecithin-containing foods may increase
the choline intake in an average adult by only 1.5 mg/kg (56).

Box 5.10 Choline Basic Information

There is no DRI, only an AI level.

AI adult males: 550 mg/d
AI adult females: 425 mg/d
Recommended intake for athletes: Unknown
Functions
Structure of cell membranes
Signaling for cell membranes
Acetylcholine synthesis and neurotransmission
Methyl-group donor for protein synthesis
Good food sources
Beef liver
Egg
Fish
 Cauliflower, broccoli, and other cruciferous vegetables
Deficiency
Fatty liver disease
Kidney disease
Easy fatigue
Toxicity
Toxicity symptoms (seen with daily high doses of
10,000–16,000 mg/d):
Fishy body odor from excess production of
trimethylamine (a choline metabolite)
May result in low blood pressure and fainting
Tolerable ULs
1,000 mg/d for children 1–8 yr
2,000 mg/d for children 9–13 yr
3,000 mg/d for adolescents 14–18 yr
3, 500 mg/d for males and females 19 yr and older
Sources: Busby MG, Fischer L, da Costa KA, Thompson D, Mar MH, Zeisel SH. Choline-
and betaine-defined diets for use in clinical research and for the management of
trimethylaminuria. J Am Dietet Assoc. 2004;104(12):1836–45; Institute of Medicine,
Food and Nutrition Board. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin,
Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington
(DC): National Academy Press; 1998. p. 390–422.

Choline is needed for the manufacture of the neurotransmitter

acetylcholine, which is involved in multiple neurologic functions
that include memory and muscle control. Although it is still being
assessed, there are early studies suggesting that endurance
athletes and people who heavily consume alcohol may benefit
from higher choline intakes (61, 105). However, a more recent
study on army rangers found no benefit of choline
supplementation on endurance, injury rates, or shooting accuracy
(4).
Even moderately high levels of homocysteine in the blood may
increase cardiovascular disease risk, and there is evidence that
choline deficiency may be a factor in higher homocysteine levels
(63, 119). One of the clinical problems seen with inadequate
choline intake is nonalcoholic fatty liver disease. Choline is
needed for the manufacture of the liver protein that carries liver-
derived fat to the blood, called very-low-density lipoproteins.
Without sufficient choline, the protein carrier cannot be
manufactured and the fat in the liver cannot be removed. A study
of postmenopausal women with low estrogen found that they
developed liver and/or muscular damage if provided a choline-
deficient diet (40). Common clinical signs of severe choline
deficiency include liver, heart, and kidney disease (66, 118).

Fat-Soluble Vitamins

Fat-soluble vitamins are delivered in a fat solute and represent

one of the important reasons why athletes should not attempt
placing themselves on a diet that is excessively low in fat. (Going
below 10% of total calories from fat is dangerous, whereas
athletes do very well when fat intake is between 20% and 35% of
total calories.) There are four fat-soluble vitamins, including
vitamins A, D, E, and K, which can be efficiently stored for later
use, so the intake of fat-soluble vitamins can be more periodic to
satisfy needs. However, the storage capacity for these vitamins
does have limitations, and providing a level of these vitamins that
exceeds the storage capacity may quickly lead to symptoms of
toxicity and, in extreme cases, death. The most potentially toxic
substance in human nutrition is vitamin A. Achieving toxic-level
doses of this vitamin is difficult if consuming typically consumed
foods, but toxic doses may be easily achieved if supplemental
intakes exceed recommended doses. In general, the storage
capabilities we have for these vitamins eliminate the need for
supplemental intake in most circumstances.

Vitamin A (Retinol or a-Carotene)

The active form of vitamin A is retinol (Box 5.11). We obtain the
active form from foods of animal origin, including liver, egg yolks,
dairy products that have been fortified with vitamin A (e.g.,
vitamin A and D milk), margarine, and fish oil. The DRI ranges
between 700 retinol activity equivalents (RAE) for women and 900
RAE for men. One RAE equals:

1 mcg of retinol
 12 mcg of β-carotene
24 mcg of α-carotene
24 mcg of β-cryptoxanthin

Vitamin A has a well-established relationship to normal vision;

helps keep bones, skin, and RBCs healthy; and is needed for the
immune system to function normally. There is no evidence that
taking extra vitamin A aids athletic performance. In an early study
performed in the 1940s, supplementation of vitamin A produced
no improvement in endurance (106). In the same study, subjects
provided with a diet deficient in vitamin A noted no decrease in
performance, probably because a deficit state of the vitamin was
not reached because of ample vitamin storage. Inadequate levels
of vitamin A intakes have been reported in a small proportion of
adolescent athletes, and given that the adolescent period is
important for bone development/growth, some attention should
be given to adolescent athletes to ensure the intake of vitamin A
is adequate (43, 68).

Box 5.11 Vitamin A (Active Form: Retinol; Precursor

Form: β-carotene) Basic Information

DRI
Adult males: 900 mcg/d
Adult females: 700 mcg/d
Recommended intake for athletes: 700–900 mcg/d
Functions
Maintaining healthy epithelial (surface) cells
Eye health
Immune system health
Good food sources
Retinol:
Liver
Butter
Cheese
Egg yolks
Fish liver oils
β-carotene:
 Dark green and brightly pigmented fruits and
vegetables
Deficiency
Dry skin
Headache
Irritability
Vomiting
Bone pain
Night blindness
Increased risk of infection
Blindness
Toxicity (high toxicity potential)
Tolerable ULs:
600–900 mcg/d for young children (age 1–8 yr)
1.7–3.0 mg/d for children and adults (age 9–70+ yr)
Toxicity symptoms: liver damage, bone
malformations, death

Because the vitamin has clearly toxic side effects when

chronically taken in excess of the DRI, athletes should be
cautioned against taking supplemental doses of this vitamin.
Toxicity of vitamin A manifests itself in several ways, including dry
skin, headache, irritability, vomiting, bone pain, and vision
problems. Excess vitamin A intake during pregnancy is also
associated with an increase in birth defects (57).
A precursor to vitamin A is β-carotene. A precursor is a
substance that, under the proper conditions, is converted to the
active form of the vitamin. Therefore, consuming foods with β-
carotene is an indirect way of obtaining vitamin A. β-Carotene is
found in all red-, orange-, yellow-, and dark green–colored fruits
and vegetables (carrots, sweet potatoes, spinach, apricots,
cantaloupes, tomatoes, etc.). It is a powerful antioxidant,
protecting cells from oxidative damage and, of course, can be
converted to vitamin A as it is needed. Unlike preformed vitamin
A (retinol), β-carotene has not been found to exhibit the same
clear toxic effects if excess doses are consumed. However, a
consistently high intake of carrots, sweet potatoes, and other
foods high in β-carotene may cause a person to develop a
yellowish skin tone. It should be noted that two research trials in
smokers and former asbestos workers found that β-carotene
supplementation for 4–6 years increased lung cancer risk by 16%–
28% when compared with a placebo (73). These trials suggest
that, although there is no current evidence of higher disease risk
in nonsmokers, reasonable intakes that do not breach the all-
important nutrient balance rule should be warranted.
Athlete surveys suggest that different sports have different
vitamin A/β-carotene intake risks. Young wrestlers, gymnasts,
combat sport athletes, and ballet dancers had average intakes
that were below 60%–70% of the recommended intake, whereas
other male and female athletes appear to have typical intakes
that meet the recommended level (10, 29, 60, 76, 109). The
difference may be the food restriction common in the sports with
lower intakes.
It is conceivable that β-carotene may, as an antioxidant, prove
to be effective in reducing postexercise muscle soreness and may
aid in postexercise recovery. However, this is a theoretical
connection only; no study makes a direct link between β-carotene
intake and reduced soreness and improved recovery. One study
has found that β-carotene reduced exercise-induced asthma, and
another found that it was a useful antioxidant for reducing DNA
damage in humans (59, 74, 77).

Vitamin D (Cholecalciferol)
There has been a great deal of work and rethinking about the role
of vitamin D in human health. It is the most potentially toxic
vitamin in human nutrition, with an UL of 50 mcg/day (Box 5.12)
(55). We can obtain the vitamin in an inactive form from food and
sunlight exposure. Ultraviolet radiation (sunlight) exposure of the
skin alters a cholesterol derivative (7-dehydrocholesterol) to an
inactive form of vitamin D called cholecalciferol. To be functional,
this inactive form of vitamin D must be activated by the kidneys.
Therefore, kidney disease may be the cause of vitamin D–related
disorders. Dietary sources of vitamin D include eggs, vitamin D–
fortified milk, liver, butter, and margarine. Cod liver oil, which was
once given commonly as a supplement, is a concentrated source
of the vitamin. The adult DRI for vitamin D is 15 mcg/day of
cholecalciferol or 600 IU of vitamin D. The UL for vitamin D was
set at a level that was intended to avoid calcium infusion and
excess mineralization of soft (i.e., muscle and organ) tissues.
Because the current knowledge of vitamin D has increased, many
scientists and qualified practitioners now recommend an intake
that is at least 1,000–2,000 IU/day, or three to five times higher
than the currently recommended intake level (71).

Box 5.12 Vitamin D (Cholecalciferol) Basic

Information

DRI
Adult males: 15 mcg/d
Adult females: 15 mcg/d
Recommended intake for athletes: 15–20 mcg/d
Functions
Absorption of calcium
Absorption of phosphorus
Healthy skin
Good sources
Ultraviolet light exposure
Fish liver oil
Lesser amounts in:
Eggs
Canned fish
Fortified milk
Fortified margarine
Deficiency
Disease: Rickets (children)
Disease: Osteomalacia (adults)
Increased risk of stress fractures
Increased risk of osteoporosis
Toxicity (high toxicity potential)
Tolerable ULs:
50 mcg/d for all age groups
Symptoms:
Nausea
Diarrhea
 Loss of muscle function
Organ damage
Skeletal damage

There is a great deal of current science suggesting that the

vitamin D promotes growth and mineralizes bones and teeth by
increasing the absorption of calcium and phosphorus. But vitamin
D also has other important characteristics that may influence
both health and athletic performance. Vitamin D activity includes
(23, 47, 85, 112, 113):

Bone health (through regulation of calcium and phosphorus

absorption)
Muscle contraction (through activation of enzymes for muscle
stimulation)
Intestinal absorption (through facilitation of calcium
absorption in the intestines)
Muscle protein anabolism (through both an increase in muscle
mass and a decrease in muscle breakdown; muscle increase
is for type II — power muscle fibers)
Improved immune function (through accumulation of fluid and
immune cells in injured and inflamed tissues and through
release of antimicrobial peptides. Outcome is reduced risk of
cancer, intestinal disease, cardiovascular disease, muscle
soreness)
Improved anti-inflammatory action (through increase
production of anti-inflammatory cytokines and interleukin-4
and decreased production of inflammatory agents interleukin-
6, interferon-γ, and interleukin-2)

Vitamin D functions to promote growth and mineralize bone

and teeth by increasing the absorption of calcium and
phosphorus. A diet with an AI of calcium and phosphorus, but
without adequate vitamin D, will thus lead to calcium and
phosphorus deficiency. The childhood deficiency disease rickets
and the adult deficiency disease osteomalacia are diseases of
calcium deficiency that are due to either inadequate levels of
vitamin D or the inability to convert vitamin D to the active
(functional) form.
There is a long history of ultraviolet light (i.e., vitamin D)
therapy for athletes (23). In the mid-1920s sunlamps were used
by swimmers in Germany, and the effect was sufficiently positive
that it was considered a form of illegal doping by some.
Ultraviolet light therapy was also used by Russian and German
athletes in the 1930s and 1940s, where it was found that it
improved performance. In the mid-1940s in the United States, the
combined effect of a fitness program plus ultraviolet irradiation
produced significantly better fitness results than in those
undergoing athletic training without the ultraviolet irradiation. The
general consensus during these years was that ultraviolet
irradiation had a positive impact on speed, strength, endurance,
reaction time, and reduced pain.
Vitamin D may play an indirect role in resistance to injury.
Athletes in some sports may have dramatically lower sunlight
exposure because all training takes place inside. This lower
sunlight (i.e., ultraviolet) exposure may reduce vitamin D
availability to a point where both growth and bone density are
affected. Lower bone densities are known to place athletes at
higher risk for developing stress fractures, an injury that can end
an athletic career (5, 25, 49). In a survey of US national team
gymnasts, it was found that the factor most closely related to
bone density was sunlight exposure. Those with higher densities
had the greatest exposure (9). Also, sunlight exposure was more
important as a predictor of bone density in this group than
vitamin D or calcium intake from food. A study did find that
professional basketball players were at higher risk of vitamin D
deficiency following the winter months, likely from reduced
sunlight exposure (12). And another study also found a high
prevalence of vitamin D inadequacy in athletes and dancers who
have little sunlight exposure (30).

Vitamin E (Tocopherol)
Vitamin E is a generic term for several substances (tocopherols)
that have similar activity, and the unit of measure is based on the
level of tocopherol with an activity equivalent to that of α-
tocopherol (Box 5.13). For instance, β-tocopherol has a lower level
of activity than α-tocopherol, so more of it would be necessary to
get the same effect (57). Vitamin E is found in green leafy
vegetables, vegetable oils, seeds, nuts, liver, and corn. It is
difficult to induce a vitamin E deficiency in humans, and it also
appears to be a relatively nontoxic vitamin. Vitamin E is a potent
antioxidant that serves to protect membranes from destruction by
peroxides. Peroxides are formed when fats (especially
polyunsaturated fats) become oxidized (rancid). These peroxides
are called free radicals because they bounce around
unpredictably inside cells, altering or destroying them. Because
vitamin E is an antioxidant, it helps to capture oxygen, thereby
limiting the oxidation of fats to protect cells.

Box 5.13 Vitamin E (Tocopherol) Basic Information

DRI
Adult males: 15 mg/d
Adult females: 15 mg/d
Recommended intake for athletes: 15 mg/d
Functions
Antioxidant protection of cell membranes
Good food sources
Polyunsaturated and monounsaturated vegetable and
cereal oils and margarines (corn, soy, safflower, olive)
Lesser amounts in fortified cereals
Lesser amounts in eggs
Deficiency
Rare; if it occurs, possible increased risk of cancer and
heart disease
Toxicity
Tolerable ULs:
200–300 mg/d for young children (age 1–8 yr)
600–1,000 mg/d for children and adults (age 9–70+
yr)
 Several studies on vitamin E and physical performance have
been conducted, but none has found an improvement in either
strength or endurance with vitamin E supplementation (21, 87,
88, 94). Several studies evaluating whether vitamin E
supplementation reduced exercise-induced peroxide damage had
mixed findings. Some suggest that a clear reduction in
peroxidative damage occurs, but others suggest that vitamin E
has no benefit (17, 35, 89). It was found that vitamin E (800 IU for
1–2 months) compared with placebo ingestion before a
competitive triathlon race event actually promoted lipid
peroxidation and inflammation during exercise, which was
precisely the opposite of the expectation (79). This is yet another
example of how too great an intake of a vitamin may produce
results contrary to the potential benefits that an AI provides.

Vitamin K (Phylloquinone, Menaquinone)

Vitamin K is found in green leafy vegetables and also, in small
amounts, in cereals, fruits, and meats. Intestinal bacteria also
produce vitamin K, so the absolute dietary requirement is not
known (Box 5.14). This vitamin is needed for the formation of
prothrombin, which is required for blood to clot. It is possible for
people who regularly take antibiotics that destroy the bacteria in
the intestines to be at increased risk for vitamin K deficiency. A
deficiency would cause an increase in bleeding and hemorrhages.
Vitamin K appears to be relatively nontoxic, but high intakes of
synthetic forms may cause jaundice.

Box 5.14 Vitamin K (Phylloquinone) Basic Information

DRI
Adult males: 120 mcg/d
Adult females: 90 mcg/d
Recommended intake for athletes: 700–900 mcg/d
Functions
Formation of blood clots
Enhancement of osteocalcin function to aid in bone
strengthening
Good food sources
 Phylloquinone:
Variety of vegetable oils
Dark green leafy vegetables (cabbage, spinach)
Menaquinone:
Formed by the bacteria that line the GI tract
Deficiency
Rare; if it occurs, results in hemorrhage
Toxicity
Tolerable ULs not established

Several studies have now found that vitamin K deficiency

caused from inadequate dietary intake, albeit rare in human
populations, results in low bone mineral density and/or an
increase in skeletal fractures (20). It has been found that vitamin
K–associated lower bone density can be improved with vitamin K
supplementation (20). In addition, women obtaining a minimum of
110 mcg of vitamin K were found to be at significantly lower hip
fracture risk than women with lower intakes (38). The
Framingham Heart Study also found a relationship between
higher vitamin K intake and reduced hip fracture risk (14, 15).
There are no studies on the relationship between vitamin K
and athletic performance, but for athletes involved in contact
sports, normal vitamin K status is necessary to avoid excessive
bruising and bleeding. In addition, there is evidence of a
relationship between low vitamin K status and bone loss in female
endurance athletes. In one study amenorrheic females had lower
bone densities that were not improved with 2 years of vitamin K
supplementation (62). In another study, amenorrheic female
athletes experienced an increase in bone formation when taking
vitamin K supplements (31). The contrast in these studies
highlights the difficulty for any single study to control for all the
important nutritional factors that could influence the results,
including energy intake adequacy, vitamin D status, estrogen
status (in females), and calcium intake.
A word of caution for athletes involved in any form of blood
doping, which refers to strategies that increase RBC numbers in
the circulating blood. The purpose of blood doping is to increase
oxidative capacity to enable an enhanced metabolism of fat for
energy. Most blood doping strategies, which include taking
erythropoietin or reinserting previously drawn blood, are
considered illegal by virtually all athletic organizations. Some
forms of blood doping, however, are commonly practiced and are
not considered illegal (i.e., living at high altitude to enable a
greater red cell formation or using a hypoxic tent to sleep in).
Because of the elevated blood clotting potential that vitamin K
produces, having a higher RBC density may predispose these
athletes to unwanted clots. This would be particularly true for
athletes who do blood doping and who become dehydrated, which
would cause RBC density to increase still further. Whether legal or
illegal, blood doping coupled with excess vitamin K may pose
clotting risks, especially when coupled with dehydration.

Summary

Vitamins enable normal cellular metabolic reactions inside the

cell. As an example, vitamin D stimulates intestinal cells to absorb
calcium and phosphorus, and the B-vitamins enable chemical
reactions that help cells burn the fuel derived from carbohydrate,
protein, and fat. A summary of the exercise-associated
involvement of vitamins is given in Table 5.2.
 Vitamins are either fat soluble (vitamins A, D, E, and K) or
water soluble (all others).
The fat-soluble vitamins are delivered in the fats of consumed
foods and can be stored in special storage depots. These
stored vitamins can be called upon for long periods of time to
satisfy cellular needs for these vitamins.
The water-soluble vitamins are stored throughout the body in
many tissues, but because their storage is limited they must
be consumed with more frequency.
Both fat- and water-soluble vitamins are potentially toxic if
consumed in excess.
Because the amounts needed are relatively small, few people
require vitamin supplements to satisfy dietary weaknesses,
particularly if they consume a reasonably good and balanced
diet that includes fresh and whole foods. Some issues to
consider:
The chronic consumption of too much of any vitamin may
result in just as poor an outcome as the consumption of
too little.
Athletes who satisfy total energy requirements are also
likely to satisfy vitamin requirements.
Athletes should not shy away from eating fat, as about
20%–25% of total calories from fat is needed to satisfy the
need for the fat-soluble vitamins and the essential fatty
acids.
The B-vitamins are associated with energy metabolism.
The more energy you burn, the more B-vitamins you
need. However, the B-vitamins are fortified in grains, so
even high-energy burners are unlikely to achieve a
deficiency.
Athletes who feel they eat a poor diet and may need
vitamins should consult a registered dietitian to help
determine what they need and in what amounts.

To maximize vitamin intake from your diet, try the following:

Eat a wide variety of colorful fruits and vegetables.

When possible eat fresh fruits and vegetables, especially
those in season.
 Do not overcook vegetables, as long cooking times reduce
nutrient content.
Steam or microwave your vegetables rather than boiling them
— nutrients seep out in boiling water only to be poured down
the drain.

Practical Application Activity

The DRI values represent the recommended intake of each

vitamin. You can assess the vitamin content of consumed foods
using the same strategy followed in earlier chapters, accessing
the online USDA Food Composition Database
(https://ndb.nal.usda.gov/ndb/search/list), but this time create a
spreadsheet with at least two water-soluble vitamins (e.g.,
vitamins C and B6) and at least two fat-soluble vitamins (e.g.,
vitamins A and E).

1. Enter the foods/beverages with amounts consumed for an

entire day, and create totals for each vitamin.
2. When completed, assess how your total intake compares
with the recommended intake (recommended dietary
allowance) for each selected vitamin.
3. Review which foods contribute most to your intake for each
vitamin.
4. If any of the values are below the recommended levels,
modify your food intake to see what changes you would
make in your diet to reach the recommended intake level.

Chapter Questions

1. Of the following, which is a function of ascorbic acid?

a. Antifungal agent
b. Collagen producer
c. Antioxidant
d. Antibacterial
e. b and c
 f. All of the above
2. Which of the following vitamins is associated with deamination
and transamination reactions in protein metabolism?
a. Thiamin
b. Riboflavin
c. Niacin
d. Pyridoxine
e. Cobalamin
3. This vitamin is involved in oxidation–reduction reactions for ATP
production and is associated with photophobia.
a. Vitamin B1
b. Vitamin B2
c. Vitamin B6
d. Vitamin B12
4. This vitamin has hormone-like actions.
a. Vitamin A
b. Vitamin C
c. Vitamin D
d. Vitamin E
5. This vitamin is part of the intermediary product of energy
metabolism, CoA:
a. Thiamin
b. Folate
c. Niacin
d. Pantothenate
6. A deficiency of this vitamin results in megaloblastic anemia.
a. Vitamin B1
b. Vitamin B6
c. Vitamin B12
d. Niacin
7. Vitamin E is an effective
a. Antioxidant
b. Agent for increasing bone mineral density
c. Substance for maintaining eye health
d. Agent for reducing muscle soreness
8. Chronic, high doses of this vitamin may result in peripheral
neuropathy.
a. Vitamin C
 b. Vitamin B6
c. Vitamin Q10
d. Vitamin B12
9. Consumption of sufficient B-vitamins generally occurs when
athletes eat enough
a. Vegetables
b. Fruits
c. Organ meats
d. Energy
10. These two vitamins work together as antioxidants:
a. Folic acid and thiamin
b. Thiamin and riboflavin
c. Vitamin C and vitamin E
d. Niacin and thiamin

Answers to Chapter Questions

1. e
2. d
3. b
4. c
5. d
6. c
7. a
8. b
9. d
10. c

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CHAPTER OBJECTIVES

Understand the primary functions of each mineral,

including the macrominerals and microminerals.
Know the minerals that have the highest prevalence of
deficiency.
Identify good food sources for each macro- and
micromineral.
Comprehend the digestion and absorption factors
associated with each mineral where there is a high
prevalence of deficiency.
Describe the issue of competitive absorption, and how the
consumption of a high level of one mineral may have a
negative impact on the absorption of another mineral.
Apply your understanding of minerals to increase the
likelihood of good athletic performance and decrease the
likelihood of poor health.
Explain the interactive effects of energy, calcium, vitamin
D, and estrogen (in females) in the development of bone
mineral density (BMD).
Analyze the factors and justifications for why certain
macro- and microminerals may be appropriately taken as
supplements.
Identify the micro- and macrominerals that are most
associated with athletic performance, and how to lower the
 risk that an athlete may develop a deficiency of each of
these minerals.

Case Study

Iron deficiency, anemia, and iron deficiency anemia

represent the most common nutrient deficiencies found in
both male and female athletes. Because of this, it is
important to look for signs of iron deficiency in all athletes,
and particularly female athletes because of their
particularly high risk of deficiency. Iron deficiency anemia is
a problem for athletic performance (it is not possible for an
athlete to perform up to his or her conditioned capacity
with an iron deficiency), and it also represents a significant
health problem with higher disease risks. Iron
deficiency/anemia also affects a general sense of well-
being because of easy fatigue and poor concentration
ability.
Alice, a 26-year-old elite female ultraendurance Ironman
competitor, was undergoing a nutrition and health
assessment when she said “I am just not doing as well as I
believe I should be doing, and I am so stressed about my
poor performance in my most recent competitions that my
stomach is bothering me.” Psychological stress and
gastrointestinal (GI) issues are clearly related, but there are
also other possibilities. To investigate one of the
possibilities, Alice was asked to provide a listing of all the
vitamin/mineral supplements and “ergogenic aids” she was
currently taking. Luckily, Alice had arrived for her
assessment carrying a bag full of the supplements and
ergogenic aids she was regularly consuming, making an
assessment of potential problems far easier and accurate.
Alice was taking everything from amino acids to creatine
monohydrate to vitamins and minerals. The vitamin and
mineral supplements were all being taken in large
megadoses, all well above 300% of the recommended
dietary allowances (RDAs). When asked why she was taking
these, Alice indicated she felt this was the best way to
prepare for her competitions. She also mentioned that a
number of other highly competitive athletes she knew were
also taking these same products and she felt if she did not
take them she would be at a disadvantage compared with
those who were. Alice was then asked to describe a typical
day of eating and workouts, with special emphasis and
clarity on her food/beverage/supplement consumption. It
caught the attention of the assessment staff that she was
taking 120 mg of iron (the RDA is 18 mg, best consumed
spread out over the day from consumed meals). Then she
clarified that she had been so miserable lately that she
thought she should take more iron, so increased the intake
to 120 mg in the morning, 60 mg at noon, 60 mg in the
evening, and 60 mg before bedtime (a whopping 300
mg/day!). This was particularly interesting because a
history of blood tests on Alice since she was 14 years old (a
12-year span) confirmed that she never had iron deficiency
or iron deficiency anemia. When asked about her GI
problems, she just could not understand it — she never had
a gut problem, with good appetite and normal bowel
function her entire life. Nevertheless, because of her GI
problem, she thought she should take more supplements
because she was afraid the GI problem would cause her to
limit her food intake.
Alice then got a quick lesson on heavy metal toxicity
and the potential medical problems she could be creating
with the high-dose supplemented iron she was consuming.
It was explained that most iron is not absorbed because the
body is trying to protect itself. Excess absorbed iron could
have a serious effect on the liver, and since 1979
supplement containers having more than 250 mg
elemental iron have warnings that severe toxicity can result
from excess consumption. Symptoms of iron overdosing
(toxicity) include vomiting, diarrhea, abdominal pain,
irritability, and sleepiness. The GI symptoms result from the
irritating effect of all the unabsorbed iron in the intestines,
which has also been found to increase the risk of colon
cancer. It was suggested to Alice that she eat “clean” for 2
weeks (no supplements, plenty of fluids, and reintroduction
of regular small frequent meals that were not excessively
spicy to let her gut heal), and then come back for a chat on
an eating and activity strategy that would dynamically
match her workout schedule.
Two weeks later, Alice returned feeling far better, with
many of the GI symptoms gone. The lesson was learned,
that “more than enough is not better than enough.” Alice
was provided an eating plan to satisfy her nutritional
needs, and returned at regular intervals to ensure that
there were no sequelae from her prior excess
supplementation.

CASE STUDY DISCUSSION QUESTIONS

1. It is commonly believed that there is no limit to how

much of a nutrient can be consumed because “if a little
bit is good then more must be better.” What strategy
would you use if working with a team of athletes to
help them understand that consumption of more than
the body can effectively utilize causes problems that
can turn into serious disease states?
2. If supplements rather than foods are being used to
satisfy the need for nutrients, what other
health/nutrition/performance risks might the athlete
encounter?
3. Many minerals are competitively absorbed. That is, if
too much of one mineral is accessing the site of
absorption, less of other minerals that are absorbed in
the same site will get absorbed. Iron is competitively
absorbed with calcium, magnesium, and zinc. With so
much iron intake, what other problems (deficiencies)
might this athlete experience?
 Iron Deficiency

Characterized by low serum ferritin but normal hemoglobin

and hematocrit. This is an initial sign that iron status is poor
and, if it continues, will result in iron deficiency anemia. The
body places a high priority on maintaining red blood cells
(RBCs), so it is possible that other iron-containing molecules
(i.e., myoglobin in muscle tissue) are depleted of iron as a
strategy to sustain RBCs. An athlete with iron deficiency is
likely to feel weak and easily fatigued, but will have normal
hemoglobin and hematocrit.

Anemia

A below-normal hemoglobin and/or hematocrit in the blood. It

may be caused by blood loss, inadequate production of RBCs,
or a fast rate of red cell breakdown. Common causes of
anemia are iron deficiency, folate deficiency, and vitamin B12
deficiency. Athletes are at higher risk of anemia because of
faster red cell breakdown and loss of iron through sweat.

Iron Deficiency Anemia

A microcytic (small red cells), hypochromic (pale red rather

than deep red) anemia (insufficient red cells) that is
characteristic of chronic iron deficiency. The most common
sign is easy fatigue, but may also be associated with cold
hands and feet, chest pain, weakness, headache, and
shortness of breath. The immune system is also affected,
with increased illness frequency and infections.

Introduction

Consumed minerals play a variety of critically important roles,

ranging from helping to strengthen bones (calcium), assuring
optimal oxygen delivery to working tissues (iron), sustaining
good blood volume (sodium), and even helping the immune
system function properly (zinc). Minerals are unique in that,
unlike other nutrients, they are inorganic compounds (i.e., they
contain no carbon or living matter). However, minerals are
functionally similar to the organic nutrients in that they work
together to produce the desired outcome. As an example,
vitamin D works to enhance the absorption of consumed
calcium. Another example is that iron is part of the protein
hemoglobin, found inside red cells and involved in cellular
respiration.

Hemoglobin

Abbreviated as Hb or Hgb, this is the iron-containing protein

in RBCs that picks up (inhaled) oxygen from the lungs and
delivers oxygen to tissues, and takes carbon dioxide from
tissues to be exhaled through the lungs. In adult males,
normal hemoglobin is 14–18 g/dL; in adult females, normal
hemoglobin is 12–16 g/dL.

Minerals have numerous major functions, including:

Adding to the strength and structure of the skeleton and

keeping it strong and resistant to fracture.
Helping to maintain the relative acidity or alkalinity of the
blood and tissue. For athletes, hard physical activity has
the tendency to lower the pH level because of lactic acid
production (i.e., the effect is to increase the relative
acidity), so having a healthy system to control acid–base
balance is critical for athletic performance.
Serving as a pathway for electrical impulses that stimulate
muscle contraction. All athletic endeavors rely on efficient
and effective muscular movement and coordination,
making this function critically important.
Providing energy metabolism. Physical activity increases
the rate at which fuel is burned. Therefore, the effective
 control of this fuel burn at the cellular level is necessary to
athletic endeavors.

All of these functions are important for athletes. Athletes

with weak, lower density bones are at increased risk of stress
fractures; poor fluid buffering (acid–base imbalance) leads to
poor endurance; poor nerve and muscle function leads to poor
coordination; and altered cell metabolism limits a cell’s ability
to obtain and store energy (113).
The established roles of minerals in the development of
optimal physical performance include involvement in glycolysis
(obtaining energy from stored glucose), lipolysis (obtaining
energy from fats), proteolysis (obtaining energy from proteins),
and help in obtaining energy from phosphocreatine (113).
Inorganic mineral nutrients are required in the structural
composition of hard (bones and teeth) and soft (muscles and
organs) body tissues. They also participate in such processes
as the action of enzyme systems, the contraction of muscles,
nerve reactions, and the clotting of blood. These mineral
nutrients, all of which must be supplied in the diet, have two
classes: the macrominerals have a higher requirement and a
greater presence in the body and the microminerals have a
lower dietary requirement and a lower presence in the body
(81, 82). Do not mistake the difference in amount as a
difference in importance, because all minerals discussed in this
chapter are highly important for sustaining health.

Macrominerals

Important Factors to Consider

Minerals have many functions related to keeping the

skeleton, muscles, heart, and brain working as they
should. Although there can be daily fluctuations in
mineral intakes, the human system does poorly with a
chronic deficiency of any of the minerals. To obtain all of
 the minerals needed for good health, a wide variety of
foods must be consumed to ensure tissues are exposed
to all of the minerals. Monotonous eating patterns (i.e.,
patterns where people continuously eat the same few
foods) increase the risk of developing a mineral
deficiency, because no single food has all of the minerals
needed to sustain health and performance.
Supplements of minerals are commonly taken. However,
even the seemingly most benign minerals, such as
calcium, may create problems if taken in excess. For
instance, calcium is a powerful buffer that may lower
gastric pH and make it more difficult to digest certain
foods, and calcium competes with other bivalent minerals
(i.e., magnesium, iron, and zinc) for absorption. Having
too much calcium interferes with the absorption of these
other minerals and increases deficiency risk. The same is
true if any of the other bivalent minerals is taken in
excess, with reduced absorption of the others. The key to
mineral nutrition is balance.

Macrominerals are those minerals that are present in the

body in relatively large quantities (compared with
microminerals) and perform important physiologic functions.
By accepted definition, macrominerals are required at a level of
100 mg/day or more, or the body content of the mineral is
greater than 5 g (5,000 mg). The macrominerals include
calcium, phosphorus, magnesium, potassium, sodium, chloride,
and sulfur. Calcium comprises ∼1.75% of total body weight,
phosphorus makes up ∼1.10% of total body weight, and
magnesium makes up ∼0.04% of total body weight, with even
smaller weight contributions for potassium, sodium, chloride,
and sulfur.

Macrominerals
Minerals required in amounts greater than 100 mg/day. These
include potassium, calcium, magnesium, sodium, chloride,
sulfur, and phosphorus. (Note: Although the macrominerals
are required in greater daily amounts than microminerals, it
makes them no more important in human health.)

Microminerals

Minerals required by the body in amounts less than 100

mg/day. These include iron, zinc, iodine, selenium, copper,
manganese, fluoride, chromium, and molybdenum. (Note:
Although the microminerals are required in smaller daily
amounts than macrominerals, it makes them no less
important in human health.)

Calcium
Calcium is an important mineral for bone and tooth structure,
blood clotting, nerve transmission, vasoconstriction and
vasodilation of blood vessels, and insulin secretion (Box 6.1)
(144). The adult dietary reference intake (DRI) for calcium
ranges from 1,000 to 1,200 mg/day, depending on age and
gender. Calcium absorption and the uptake of calcium by bones
and other tissues are regulated by vitamin D and parathyroid
hormone. Even a small drop in circulating serum calcium
increases the secretion of parathyroid hormone, which reduces
the urinary excretion of calcium and releases calcium from
bone to stabilize serum calcium. Parathyroid hormone also
converts the inactive form of vitamin D to the active form,
which enhances the absorption of both calcium and phosphorus
from the diet. A return of serum calcium to the normal level
causes a cessation of parathyroid hormone secretion. The high
consumption of several substances may increase urinary
calcium losses stimulating parathyroid hormone release. These
include (36, 47, 65, 107):
 Box 6.1 Calcium Basic Information (Chemical
Symbol Ca)

RDA
Adult males (ages 19–70 yr): 1,000 mg/d (1,200 mg/d
for older males, ages 70+ yr)
Adult females (ages 19–50 yr): 1,000 mg/d (1,200
mg/d for older females, ages 51–70+ yr)
Recommended intake for athletes: 1,300–1,500 mg/d
Functions
Bone structure and strength
Acid–base balance
Nerve function
Muscle contraction
Enzyme activation
Good food sources
Dairy products
Dark green leafy vegetables
Calcium-fortified orange juice and other calcium-
fortified foods
Soy milk
Legumes
Deficiency
Osteoporosis
Rickets/osteomalacia
Muscle dysfunction
Symptoms of deficiency
Fractures and stress fractures
Muscle weakness
Toxicity
Tolerable UL: 2,000–3,000 mg/d depending on
age/gender of group
Symptoms of toxicity
Constipation
Malabsorption of other bivalent minerals (iron,
magnesium, and zinc)
Kidney stones
 Cardiac dysrhythmia

High sodium intake

High protein intake (above 2.0 g/kg/day)
High phosphorus intake (associated with high protein intake
and processed foods)
High caffeine intake

Dietary Reference Intakes

Nutrient reference values established as scientific guides for

planning and assessing nutrient intakes of healthy people.
The DRI values, established by the Food and Nutrition Board
of the Institute of Medicine, National Academy of Sciences,
are composed of the following:

RDA: The average daily level of intake sufficient to meet

the nutrient requirements of nearly all (97%–98%)
healthy people.
Adequate Intake (AI): Established when evidence is
insufficient to develop an RDA and is set at a level
assumed to ensure nutritional adequacy.
Tolerable Upper Intake Level (UL): The maximum daily
intake unlikely to cause adverse health effects, above
which toxicity reactions are possible/likely.

Food Sources of Calcium

Many foods provide ample amounts of calcium (Table 6.1),
including legumes, dairy products, and green leafy vegetables.
This list should make it clear that dairy products are not the
only way to supply calcium in the diet. In fact, many cultures
have adequate calcium intakes with no or limited consumption
of dairy products. Here are some common examples:
Table 6.1 Calcium Content of Commonly
Consumed Foods
Food Serving Size Calcium (mg)
Broccoli (cooked) ½ cup 31
Bok choy ½ cup 79
Cheddar cheese 1.5 oz 303
Figs (dried) ¼ cup 61
Kale (boiled) ½ cup 90
Milk 1 cup 300
Orange 1 medium 60
Pinto beans ½ cup 39
Red beans ½ cup 25
Sardines (canned) 8 oz 325
Spinach (boiled) ½ cup 122
Tofu (made with ½ cup 434
calcium sulfate)

In Asia, sweet and sour sauces are made by putting a stock

bone in water that has vinegar added. The vinegar leaches
out the calcium from the bone and is consumed as part of
the sauce.
In Mexico, Central America, and South America, masa is
used to make corn tortillas. Masa is lime-soaked corn flour,
and lime is calcium salt. Consumption of the tortilla
provides calcium through the lime in the corn flour.

Green leafy vegetables (particularly spinach and rhubarb)

are high in oxalic acid, which has a high binding affinity for
calcium and other bivalent minerals (i.e., zinc, magnesium,
iron). The bioavailability of calcium and these minerals may be
poor unless the oxalic acid is removed. However, it is possible
to improve the bioavailability of these oxalate-bound minerals
through an easy food preparation technique called blanching.
Oxalate is highly water-soluble, so by dipping the vegetables
for a few seconds into boiling water a good deal of the oxalate
is removed but the minerals remain (1). You can then prepare
the vegetables as you like. This technique dramatically
improves the delivery of calcium from vegetables and has been
used by cultures (especially in Asia) that traditionally have not
consumed dairy products for thousands of years (2). As a side
benefit, vegetables that are blanched may also be more
acceptable for children to eat. Children are more sensitive to
bitter tastes than adults (we lose some of our taste sensitivities
as we age), and oxalic acid has a bitter taste. Therefore, by
removing the oxalate you also remove some of the bitter taste
that children find unacceptable.
Phytic acid, which is present in wheat bran and dried beans,
also inhibits the bioavailability of calcium and other bivalent
minerals (73). The phytic acid of wheat bran can be reduced
when yeast is used in food preparation (as in bread, rolls, etc.).
Yeast contains phytase, which enzymatically breaks down the
phytic acid in grains, making minerals more bioavailable.
Regular consumption of whole-grain flat breads, crackers, and
so forth may provide enough phytic acid to lower the
bioavailability of all of the bivalent minerals, including calcium.

Bone Density

Important Factors to Consider

Ensuring an optimal bone density takes many factors to

occur simultaneously and is more than simply consuming
enough calcium (Figure 6.1). Sustaining good bone density
requires avoiding consumption of too much protein at one
time (the excreted nitrogen causes calcium to be lost,
lowering bone density); sustaining a good calcium intake;
sustaining good energy balance and blood sugar to limit
cortisol production (cortisol breaks down bone); providing
stress (exercise) on the skeleton to provide a reason to
sustain good density; having enough vitamin D to ensure that
the consumed calcium will be absorbed; and if a female,
 sustaining normal menstrual status as estrogen helps to limit
the activity of cells (osteoclasts) that break down bone.

FIGURE 6.1: Normal and low bone mineral density. (From

Anatomical Chart Company. Understanding Osteoporosis
Anatomical Chart. Philadelphia (PA): LWW (PE); 2003.)

It is important to consider that any factors, either individual

or combined, that result in below-optimal peak BMD in growing
children may contribute to increased risk of osteoporosis
(extremely low BMD) later in life. Osteopenia is low BMD
above the threshold for normal BMD but below the threshold
for osteoporosis. A major risk factor for low BMD in athletic
children and adolescents is insufficient energy (calorie)
consumption. The inadequate consumption of energy
stimulates excess production of cortisol, which lowers both
metabolic mass (i.e., muscle and organ mass) and BMD.
Because food is more than the carrier of just “energy” (i.e.,
calories), inadequate energy consumption is also associated
with lower nutrient intake, including lower calcium intake.
Female athletes are at an even higher risk of low bone density
if they fail to consume sufficient energy, as this results in
higher risk for amenorrhea, which is associated with lower
estrogen levels. Estrogen inhibits the activity of osteoclasts, the
cells that break down bone. Therefore, low estrogen is related
to amenorrhea, which is related to poor bone development
(96).

Bone Mineral Density

A common unit of measurement (g/cm2) of the cross-

sectional density of bone. Typically assessed with a dual-
energy x-ray absorptiometer (DEXA), this is the best way
to determine if an individual has osteoporosis or osteopenia.

Dual-Energy X-ray Absorptiometry

The standard current methodology for determining BMD.

DEXA uses two or more x-ray beams of different intensities
that pass through the skeletal tissue and determines BMD by
assessing the relative absorbance of the x-ray beams. Higher
density bones have greater x-ray absorbance (i.e., less x-ray
passes through the bone).

Osteoporosis

Extremely low BMD, 2.5 standard deviations below the young

adult standard (the point of peak BMD). Osteoporosis, by
definition, is the point at which bones cannot adequately
support body weight and may spontaneously fracture.
Osteoporotic fractures typically occur in late adulthood, but
are often the result of a failure to reach an optimal peak BMD
following the adolescent growth spurt/young adulthood.

Osteopenia
Low BMD between −1.0 and −2.5 standard deviations below
the young adult standard (the point of peak BMD). This level
of low bone density may place an athlete at risk for
developing stress fractures and is a sign that energy,
calcium, and/or vitamin D may not be adequate. In females,
low estrogen associated with dysmenorrhea (abnormal
menstrual status) is also a factor in osteopenia.

Because of greater torsional forces placed on bones owing

to higher relative muscle mass and sports activities, athletes
require higher bone densities and, therefore, higher calcium
intakes than nonathletes. Physical activity in children and
adolescents has been found to aid the attainment of higher
BMD, making the bone more resistant to later fracture (112).
The skeletal bone density may be reduced to sustain normal
blood calcium, which is an important blood buffer that must be
maintained within a narrow range: 1.16–1.32 mmol/L (40). High
protein consumption, typical of the diets of many athletes,
results in higher nitrogen excretion that is associated with
higher serum calcium excretion. Calcium is taken from the
skeleton to sustain normal serum ionized calcium. These
higher urinary calcium losses that athletes may experience,
higher sweat losses than nonathletes, and higher BMD
requirements all contribute to a higher calcium recommended
intake for athletes (74). The current recommendation is for
athletes to consume 1,500 mg/day, or ∼33% more calcium
than the nonathlete requirement (96, 131). The threshold for
absorption is ∼1,500 mg/day, making it unnecessary to
consume amounts greater than this amount (22).

Serum Ionized Calcium

The calcium in the blood serum (also called free calcium),

which acts as an important blood buffer (controls pH) and
remains relatively constant (1.16–1.32 mmol/L).
 Since 1993, there has been an increased availability of an
accurate bone density measuring device, DEXA, which has
dramatically improved the ability to measure bone density and
determine risk of fracture. Studies that have used DEXA appear
to indicate that children and adolescents who have a calcium
intake at or slightly above the DRI (up to 1,500 mg) may
improve bone density. However, the relationship between
calcium supplementation and bone density in adults is less
clear (i.e., taking calcium supplements by themselves does not
necessarily lead to a greater bone density). Despite this, it
seems prudent to make certain that calcium intake is
maintained at the RDA level, that adequate physical activity is
maintained (not a problem for most athletes), and that there is
an AI of vitamin D. A recent survey of the U.S. Gymnastics
team indicated that sunlight exposure was more highly
correlated (and significantly so) to BMD than calcium intake.
Even in gymnasts with an inadequate calcium intake (i.e.,
below the DRI), having more sunlight exposure was associated
with higher bone densities (10).
Another concern with many female athletes is amenorrhea
(cessation of menses), because this is strongly associated with
either poor bone development (in young athletes) or bone
demineralization (in older athletes). The causes of amenorrhea
are complex and include inadequate energy intake, eating
disorders, low body fat levels, poor iron status, psychological
stress, high cortisol levels, and overtraining. In other words,
hard-working elite female athletes are at risk. Anything that
might lower risk, such as maintaining a good iron status and
consuming enough energy, is useful for lowering the risk of
developing amenorrhea. Even if an amenorrheic athlete has
sufficient calcium intake, that alone would not suffice to
maintain or develop healthy bones because the lower level of
circulating estrogen associated with amenorrhea would inhibit
normal bone development or maintenance.

Other Calcium-Related Issues

Obesity
Calcium consumption, primarily through the consumption of
dairy products, has also been inversely associated with
overweight and obesity in a number of studies (31, 155).
Although dairy products are an excellent source of calcium,
they contain much more than just calcium. Therefore, there
remains a question about whether calcium alone or a
combination of calcium, protein, and, perhaps, other dairy
product content, such as protein or vitamin D, works together
to help lower body fat levels. A recent study found, for
instance, that better vitamin D status (vitamin D is commonly a
fortified vitamin in dairy products) is inversely associated with
obesity (85). There is also some evidence that the increase in
parathyroid hormone, which is associated with inadequate
calcium intake, could increase fat storage (154).

Blood Pressure
There is evidence that adequate calcium intake, through the
Dietary Approaches to Stop Hypertension (DASH) diet, may
help to control blood pressure (BP) (5). The DASH diet is high in
fruits, vegetables, and low-fat dairy products. According to the
National Heart, Lung, and Blood Institute of the National
Institutes of Health, the DASH diet has the following
components:

Eating vegetables, fruits, and whole grains

Including fat-free or low-fat dairy products, fish, poultry,
beans, nuts, and vegetable oils
Limiting foods that are high in saturated fat, such as fatty
meats, full-fat dairy products, and tropical oils such as
coconut, palm kernel, and palm oils
Limiting sugar-sweetened beverages and sweets

Nerve Transmission
Calcium plays a major role in nerve impulse transmission and
muscle contraction. Nerve and muscle cells contain calcium
channels that enable calcium ions to pass through membranes
rapidly, thereby transferring the nerve impulse and stimulating
muscle fiber contraction. The same type of calcium-mediated
system is involved in breaking down glycogen to glucose and
for stimulating the secretion of insulin (24, 144).

Calcium Deficiency
Calcium deficiencies are associated with skeletal malformations
in children (as in the disease rickets, which is how it appears
in children or osteomalacia, which is how it appears in adults),
increased skeletal fragility (as in osteoporotic fracture and
stress fractures), and BP abnormalities. There are few reports of
toxicity from taking high doses of calcium, but it is conceivable
that a high and frequent intake of calcium supplements may
alter the acidity of the stomach (making it more alkaline),
thereby interfering with protein digestion. Because of a
competitive absorption between many minerals (particularly
the bivalent minerals calcium, zinc, iron, and magnesium) in
the small intestine, it is also possible that having a high amount
of calcium may interfere with the absorption of these other
minerals if they are present in the gut at the same time. Taking
high-dose calcium supplements at the same time an iron-
containing food is consumed, for example, may result in the
malabsorption of iron and eventually could contribute to the
development of iron deficiency anemia.

Rickets

A disease of children representing inadequate calcium

deposition in bones that is most likely the result of vitamin D
deficiency, but may also be related to insufficient calcium
intake. In many cases, rickets is the result of a young child’s
inability to convert vitamin D to the active form in the
kidneys. It is associated with low BMD and misshaped bones
(bowed legs, etc.).

Osteomalacia

A disease of adults that is similar to rickets (see above) that

is most likely the result of vitamin D deficiency but that may
 also be related to insufficient calcium consumption. (Note:
Rickets and osteomalacia are really the same condition.
“Rickets” is the name used when it occurs in children, and
“osteomalacia” is the term used when it occurs in adults.)

Calcium Toxicity
There have been numerous studies looking at the relationships
among calcium intake, physical activity, and bone density.
However, the relationship between calcium supplementation
and physical performance has not been well studied. In fact,
when athletes take calcium supplements it is typically for the
purpose of reducing the risk of fracture (i.e., improving bone
density) and not for the purpose of improving physical
performance. The higher gravitational forces of physical
activity are known to enhance bone density, just as physical
inactivity is known to lower bone density. However, the
development and mineralization of bone are complex and
involve several factors including:

growth phase (childhood and adolescence are associated

with faster bone development)
hormonal status (especially estrogen for women)
energy adequacy
vitamin D availability
calcium intake

Hypercalcemia (too much calcium in the blood) has been

reported in people regularly consuming calcium supplements
and/or calcium-containing antacids (95). Because calcium and
other minerals are all absorbed in the same place in the GI
tract (upper duodenum), having too much calcium may take up
all the absorption space, making it difficult to absorb the other
minerals. Symptoms of calcium toxicity include appetite loss,
constipation, fatigue, and confusion (144).

Phosphorus
Phosphorus is present in most foods and is especially high in
protein-rich foods (meat, poultry, fish, and dairy products) and
cereal grains (Box 6.2). It combines with calcium (about two
parts calcium for every part phosphorus) to produce healthy
bones and teeth. It also plays an important role in energy
metabolism, affecting carbohydrates, lipids, and proteins. The
energy derived for muscular work comes largely from
phosphorus-containing compounds called adenosine
triphosphate (ATP) and creatine phosphate. Phosphorus is also
important for maintaining acid–base balance and is a
component of phosphorylation relations that transfer a
phosphate group (PO4) from ATP to another molecule. As with
calcium, the absorption of phosphorus is largely dependent on
vitamin D, and the adult DRI is 700 mg/day. The goal of dietary
intake is to sustain serum calcium in the range of 2.5–4.5
mg/dL. Pregnancy and breast-feeding nearly double the
phosphorus requirement (1,250 mg/day) in pre-18-year-old girls
(55).

Box 6.2 Basic Phosphorus Information (Chemical

Symbol P)

RDA
Adult males (ages 19–70+ yr): 700 mg/d
Adult females (ages 19–70+ yr): 700 mg/d
Recommended intake for athletes: 1,250–1,500 mg/d
Functions
Bone structure and strength
Component of nucleic acids
Phosphorylation reactions
Acid–base balance
B-vitamin function
Component of ATP (energy)
Good food sources: All high-protein foods, whole-grain
products, carbonated beverages
Deficiency
 Deficiency unlikely, but if it occurs, results in:
Low BMD
Muscle weakness
Toxicity
Tolerable UL
3,000 mg for young children (1–8 yr), and adults
over 70 yr
4,000 mg for children and adults (9–70 yr)
Toxicity is unlikely, but if it occurs, results in:
Low BMD
GI distress

Metabolism of Phosphorus
Blood phosphorus concentration is maintained via parathyroid
hormone and vitamin D and is tied to calcium metabolism. Low
serum calcium results in parathyroid secretion, which
decreases urinary calcium excretion but increases phosphorus
excretion to achieve a calcium–phosphorus balance.
Parathyroid hormone also causes the kidneys to activate
vitamin D, which increases the absorption of both calcium and
phosphorus.

Food Sources of Phosphorus

Phosphorus is widespread in the food supply and is mostly well
absorbed. If excess phosphorus is consumed, it is also easily
excreted. The phosphorus in beans, cereals, and nuts is part of
phytic acid, which is only about 50% available to humans. Yeast
contains an enzyme, phytase, that can break down phytic acid
and make the phosphorus more bioavailable for absorption.
Therefore, consuming yeast breads/rolls delivers more
bioavailable phosphorus than the equivalent volume of flat
breads, crackers, or cereals that are not leavened (55). Phytic
acid has a high binding affinity for iron, zinc, calcium, and
magnesium, so lowering the phytic acid content of foods also
improves the absorption of these minerals.
Athletes and Phosphorus
There is a long history of supplementing with phosphorus-
containing substances to improve physical performance. In
World War I, Germany provided its soldiers with foods and
supplements high in phosphorus with the aim of improving
strength and endurance (16). This experience with phosphorus
suggests that relatively large amounts are well tolerated over
time, but there is no evidence that strength and endurance are
actually improved. The results of more recent studies on the
effect of phosphorus supplementation are mixed. A study on
runners, rowers, and swimmers who took 2 g of sodium
dihydrogen phosphate 1 hour prior to exercise all showed
performance improvements, whereas only half of the
unsupplemented athletes also showed improvements (64). In
another study, VO2max was improved on a treadmill test
following short-term phosphorus supplementation (17).
However, in yet another study evaluating the effect of
phosphate supplementation on muscular power, there was no
apparent benefit from taking the phosphate (33). Taken
together, the mixed results of these studies make it difficult to
say whether a small preexercise supplement of phosphorus will
improve performance. Clearly, more studies are needed before
an answer to this question can be attempted.

Phosphorus Deficiency
Because phosphorus is nearly everywhere in the food supply, a
deficiency is rare and typically occurs only in starvation.
However, it has been seen in people taking antacids that
contain aluminum hydroxide for long periods of time (79). This
type of antacid binds with phosphorus, making it unavailable
for absorption (21, 55). Symptoms of deficiency include poor
appetite, weakness, fragile bones, and numb fingers and toes.
If it occurs in children, a phosphorus deficiency may result in
rickets (3).

Phosphorus Toxicity
Kidney disease may be associated with excess blood serum
phosphorus (hyperphosphatemia), which is made more likely
with supplemental consumption of phosphate salt. Low-
functioning kidneys may lose their capacity to excrete excess
phosphorus. Regardless of the cause, hyperphosphatemia may
result in higher cardiovascular disease risk and higher risk of
bone disease (20). There is evidence that phosphoric acid in
some sodas and phosphate-containing additives in some
processed foods, if chronically consumed, may result in high
serum phosphorus, which could have a negative impact on
bone health (19).

Magnesium
The average human body has 25 g of magnesium, with the
majority in bones and the remaining amount in soft tissue
(115). Magnesium is the second most prevalent intercellular
mineral, after potassium, and has numerous functions (Box
6.3). Carbohydrate and fat metabolism for the production of
ATP energy involves chemical reactions that require
magnesium, and ATP itself exists mainly as a magnesium-
containing compound. Magnesium is required for the synthesis
of the genetic material deoxyribonucleic acid (DNA), and also
for the synthesis of the cellular antioxidant glutathione (116).
Magnesium is also a part of many enzymes, is a structural
component of bones and cell membranes, and is also needed
for protein synthesis, muscle function, normal heart rhythm,
and nerve impulse conduction (cell signaling) (55). Taken
together, magnesium is an important substance in over 300
metabolic systems (115).

Box 6.3 Magnesium Basic Information (Chemical

Symbol Mg)

RDA
Adult males (ages 19–30 yr): 400 mg/d
Adult males (ages 31–70+ yr): 420 mg/d
 Adult females (ages 19–30 yr): 310 mg/d
Adult females (ages 31–70+ y): 320 mg/d
Recommended intake for athletes:
400–450 mg/d if from food sources
350 mg/d if from supplements
Functions
Protein synthesis
Glucose metabolism
Bone structure
Muscle contraction
Good food sources
Milk and milk products
Meats
Nuts
Whole grains
Dark green leafy vegetables
Fruits
Deficiency
Unlikely, but if it occurs, results in:
Muscle weakness
Muscle cramps
Cardiac dysrhythmia
Toxicity
Tolerable UL: 350 mg if taken as supplements
Symptoms of toxicity
Nausea
Vomiting
Diarrhea

Food Sources of Magnesium

Dark green leafy vegetables are high in magnesium because
chlorophyll contains magnesium. Whole grains and nuts also
are good sources of magnesium, whereas meats and dairy
products contain lower amounts. Processed and refined foods
have the lowest concentration of magnesium, as the processing
may remove the germ and bran of the grain, where the
magnesium resides. People who live in areas with hard water
obtain an important amount of magnesium from the water they
drink, and some bottled waters also contain magnesium.
However, there is a large range in the magnesium content of
bottled water, ranging from 1 to 120 mg/L (38). Table 6.2
contains magnesium content of commonly consumed foods.

Table 6.2 Magnesium Content of Commonly

Consumed Foods
Foods Serving Size Magnesium (mg)
Almonds 1 oz 77
Apple, raw 1 medium 9
Banana 1 medium 32
Beef, ground 3 oz 20
(90% lean)
Bread, whole 2 slices 46
wheat
Cereal, all bran ½ cup 112
Cereal, shredded 1 serving 61
wheat
Hazelnuts 1 oz 46
Lima beans ½ cup 37
Okra, cooked ½ cup 37
Peanuts 1 oz 48
Rice, brown, 1 cup 86
cooked
Spinach, cooked ½ cup 78

Several factors may affect magnesium absorption, including:

High zinc consumption, primarily from supplements,

interferes with the absorption of magnesium (125). High
intakes of dietary fiber, likely from associated phytic acid,
interfere with the absorption of magnesium (55, 116).
Low protein intakes (<30 g/day) may lower magnesium
absorption in young boys, whereas higher protein intakes
 (∼93 g/day) may increase magnesium absorption in young
boys (118). Ability to dissolve well in water affects
absorption. Supplements come in several forms
(magnesium oxide, sulfate, citrate, aspartate, lactate, and
chloride), with better absorption from the forms that
dissolve well in liquid (the citrate, aspartate, lactate, and
chloride forms) (39, 97, 110).

Magnesium Requirements
Magnesium is present in most foods, is essential for human
metabolism, and is important for maintaining the electrical
potential in nerve and muscle cells. A deficiency in magnesium
among malnourished people, especially alcoholics, leads to
tremors and convulsions. It is involved in more than 300
reactions in which food is synthesized to new products, and it is
a critical component in the processes that create muscular
energy from carbohydrate, protein, and fat (123). The adult DRI
for magnesium is 280–350 mg/day. Dietary surveys indicate
that large proportions of the U.S. population have magnesium
intake below the recommended level (114). Chronically low
magnesium intakes may increase the risk of several chronic
disorders, including hypertension and cardiovascular disease,
type 2 diabetes, and osteoporosis (30, 75, 108, 134). There is
also evidence that sustaining acceptable magnesium status
may help to avoid migraine headaches (52).

Athletes and Magnesium

It is possible that athletes training in hot and humid
environments could lose a large amount of magnesium in
sweat. Were this to occur, a magnesium deficiency could, given
the importance of magnesium in muscle function processes,
cause athletes to underachieve athletically. In one study where
magnesium supplements were given to athletes, there was an
improvement in physical performance (128). There is some
limited evidence that consuming low-dose magnesium
supplements at the level of the DRI (about 350 mg/day) may
have a beneficial effect on endurance and strength
performance in athletes who have blood magnesium levels at
the low end of the normal range (13, 44). However, with the
exception of these studies, there is little other research
evidence that magnesium deficiency is common among
athletes or that supplementation improves performance. In
fact, with the exception of athletes who are known to reduce
total energy intake in an attempt to maintain or lower weight
(wrestlers, gymnasts, skaters, etc.), it appears as if most male
and female athletes have adequate magnesium intakes (51,
81, 82).

Magnesium Deficiency
In otherwise healthy people, the risk of magnesium deficiency
is relatively low because the urinary excretion of magnesium is
reduced when dietary intake is low. However, heavy and
chronic alcohol consumption cause a high urinary loss of
magnesium, overriding the normal system for sustaining body
magnesium levels, resulting in high risk of magnesium
deficiency in alcoholics (115). Other groups that are also at risk
of deficiency include type II diabetics and people with GI
disorders (celiac disease, Crohn’s disease, irritable bowel
syndrome). Symptoms of mild magnesium deficiency include
the following:

Loss of appetite
Nausea
Vomiting
Fatigue
Weakness

Symptoms of severe magnesium deficiency include the

following:

Numbness and tingling in the fingers and toes

Muscle cramps and seizures
Abnormal heart rhythm
Personality changes
Osteoporosis
Migraine headaches
Magnesium Toxicity
The body’s capacity to systematically excrete excess
magnesium via the urine helps to avoid toxicity reactions that
theoretically could result from supplements and/or drugs that
are high in magnesium (98). (This assumes, of course, that the
kidneys are healthy and functioning normally and that a state
of dehydration does not compromise urine production.) There
are reports that high supplemental intakes of magnesium may
result in diarrhea and GI distress (39). It is due to this very
laxative effect of magnesium salts that it is included in
laxatives meant to resolve constipation. Although rare, there
are reports in both the young and old that excess and chronic
consumption of laxatives that contain magnesium may result in
fatal magnesium toxicity (91, 103).

Sodium
Sodium is an essential mineral commonly referred to as salt,
which is actually sodium chloride (Box 6.4). Although these two
minerals are discussed separately, humans consume the vast
majority of sodium with chloride in the form of table salt. There
is no question that salt is required in multiple processes that
support life, but it is also clear that excess salt consumption
creates health risks in large numbers of people (49). Once
again, more than enough is not better than enough.

Box 6.4 Sodium Basic Information (Chemical

Symbol Na)

AI
Adult males (ages 19–50 yr): 1.5 g/d
Adult males (ages 51–70 yr): 1.3 g/d
Adult males (ages 70+ yr): 1.2 g/d
Adult females (ages 19–50 yr): 1.5 g/d
Adult females (ages 51–70 yr): 1.3 g/d
Adult females (ages 70+ yr): 1.2 g/d
Recommended intake for athletes:
 >1.5 g/d; high sweat losses of sodium may
increase requirement to >10 g/d. (Whatever it
takes to replace losses. Athletes may have a
requirement that far exceeds the general AI.)
Functions
Water balance
Nerve function
Acid–base balance
Muscle contraction
Foods high in sodium
Processed and canned foods
Pickles
Potato chips
Pretzels
Soy sauce
Cheese
Deficiency
Hyponatremia (low blood sodium)
Muscle cramping
Nausea
Vomiting
Anorexia
Seizures
Coma (extremely dangerous)
Toxicity
Tolerable UL:
2.3 g/d (about 5.8 g of table salt)
Major symptom: hypertension

Salt is involved in body water balance and acid–base

balance, and the sodium (Na+, which is a cation) and chloride
(Cl−, which is an anion) that constitute salt are the main
extracellular (outside the cell, including blood and fluid)
mineral electrolytes. The other major functions of sodium and
chloride include:
 Cation

A positively charged ion that has more protons than

electrons. Typically, cations are illustrated with a “+” sign.
Examples: sodium (Na+), calcium (Ca+), magnesium (Mg+),
and potassium (K+).

Anion

A negatively charged ion that has more electrons than

protons. Typically, anions are illustrated with a “−” sign.
Examples: chloride (Cl−), sulfur (S2−), and hydroxide (OH−).

Electrolytes

Electrolytes are minerals that are dissociated into ions

(charged particles) in solutions, making them capable of
conducting electricity. They also help to regulate fluid
balance, transport nutrients into cells, help normal muscle
and mental function, help convert food calories into cellular
energy, and regulate pH. The main extracellular (outside the
cell; mainly blood) electrolyte is positively charged (cation)
sodium, and the main intracellular (inside the cell) electrolyte
is positively charged (cation) potassium.

Maintaining cell membrane function: The balance between

sodium and chloride outside the cell and potassium inside
the cell creates an electrical charge that helps cells bring in
the nutrients they require and excrete metabolic by-
products (122).
Absorption of protein (amino acids), glucose, and water:
Sodium chloride is needed to maintain sufficient fluid in the
GI tract and the blood, so that consumed nutrients can be
absorbed into the blood (59).
Maintaining blood volume: Maintenance of adequate blood
volume is important for delivery of nutrients to cells and for
 removal of metabolic by-products away from cells. For
athletes, the blood volume does double duty because the
blood volume must also “feed” the sweat glands so that
body temperature can be maintained. Insufficient sodium
chloride consumption is associated with low blood volume,
poor sweat rates, and higher risk of muscle cramping (59).

The following terms are used when discussing sodium and

conditions relevant to low or high levels of sodium:

Hypo = Low
Hyper = High
Emia = Blood
Na = Symbol for sodium
Hyponatremia = Low (hypo) sodium (Na) in the blood
(emia)
Hypernatremia = High (hyper) sodium (Na) in the blood
(emia)

Food Sources of Sodium

Sodium is present in small quantities in most natural foods and
is found in high amounts in processed, canned, cooked, and
fast foods. Although most people are capable of excreting
excess sodium, some are sensitive to sodium, because they do
not have this capability. In these individuals, the retention of
sodium causes an overaccumulation of extracellular fluid and
contributes to high BP. The intake of sodium can be limited by
consuming natural, whole foods and avoiding commercially
prepared foods that are likely to be high in sodium. Food labels
provide information about sodium content (Table 6.3). The Food
and Drug Administration’s (FDA) daily reference values for the
sodium content of 2,500 calorie diets are less than 2,400 mg.
The estimated daily sodium requirement is 500 mg.

Table Sodium on Food Labels: Understanding What

6.3 the Labels Mean
Term Definition
Table Sodium on Food Labels: Understanding What
6.3 the Labels Mean
Term Definition
Sodium Less than 5 mg sodium per serving (serving size
free listed on label)
Low 140 mg sodium or less per serving size listed on
sodium label. If the serving weighs 30 g or less, 140 mg
sodium or less per 50 g of food. If the serving is two
tablespoons or less, 140 mg sodium or less per 50 g
of the food
Very low 35 mg sodium or less per serving size listed on the
sodium label. If the serving weighs less than 30 g, 35 mg
sodium or less per 50 g of food. If the serving is two
tablespoons or less, 35 mg sodium or less per 50 g
of the food
Reduced A minimum of 25% lower sodium content than the
or less food with which it is compared
sodium

1 teaspoon of salt = 6 g = 2,325 mg sodium.

A sample of the salt content of commonly consumed foods

can be found in Table 6.4. In general, the lowest salt
consumption is found in fresh, whole, unprocessed foods
including fruits, vegetables, and legumes. Processed foods are
considerably higher in salt content.

Table 6.4 Salt and Sodium Content of Commonly

Consumed Foods (Listed from Low to
High Sodium)
Food Amount Salt (mg) Sodium (mg)
Olive oil 1 tbsp 0 0
Orange juice 1 cup 0 0
Pear (fresh) 1 med 5 2
Tomato 1 med 15 6
(fresh)
 Table 6.4 Salt and Sodium Content of Commonly
Consumed Foods (Listed from Low to
High Sodium)
Food Amount Salt (mg) Sodium (mg)
Carrot (fresh) 1 med 105 42
Bread, whole 2 slices 660 264
wheat
Corn flakes 1 cup 665 266
cereal
Bread, white 2 slices 850 340
Hot dog 1 hot dog 1,300 510
(beef)
Ham 3 oz 2,500 1,000
Pretzels 2 oz (10 pretzels) 3,000 1,200
(salted)
Potato chips 8 oz (1 bag) 3,300 1,300
(salted)
Macaroni and 1 cup 3,400 1,400
cheese
(canned)

5 g salt = 2 g sodium.

Sodium Requirements
The DRIs established by the Food and Nutrition Board of the
Institute of Medicine established an AI level for sodium that is
an estimate of the amount required by moderately active
people to replace sodium loss in sweat and to ensure that the
diet is adequate for other nutrients. This recommended intake
level, which ranges from 1 g/day in young children to 1.5 g/day
in adults, is far below the level commonly consumed by most
people living in Western societies. In 2015, the Dietary
Guidelines Advisory Committee found that only two nutrients,
sodium and saturated fat, are commonly overconsumed by
large segments of the United States and pose a health risk
(138). The recommendations established by this advisory group
are for the general population to consume less than 2,300 mg
dietary sodium per day, which although more than the AI, is
still significantly less than the current U.S. sodium
consumption.

Athletes and Sodium

One of the key ingredients of sports beverages is sodium,
because it helps to drive the desire to drink and to maintain
blood volume. Maintenance of blood volume is an important
factor in athletic performance because it is related to the ability
to deliver nutrients to cells, remove metabolic by-products from
cells, and maintain the sweat rate to avoid overheating.
Because sweat contains sodium and athletes can lose a large
volume of sweat, the general sodium recommendation for
athletes is to consume whatever amount of sodium is needed
to stay in sodium balance. The recommended level of sodium
intake by athletes, therefore, is likely to be significantly higher
than that of nonathletes.
During prolonged exercise in hot and humid environments,
hyponatremia (low sodium in the blood) may occur. The
common causes of hyponatremia are high fluid consumption
that contains insufficient sodium to satisfy sweat loss, or
possibly the consumption of nonsteroidal anti-inflammatory
drugs, such as aspirin and Motrin, which may be a sweat loss
that is highly concentrated in sodium (7). Additional
information on sodium, chloride, and hydration strategies is
included in Chapter 7.

Sodium Deficiency
With the exception of hyponatremia (see below), which may
occur in athletes who consume sodium-free beverages, sodium
chloride deficiency is not commonly observed, even in
individuals who are purposefully on low-salt dietary intakes
(59).

Hyponatremia
Low (hypo) sodium (Na) in the blood (emia) is most likely to
occur in people who spend long periods of time in a hot
environment with heavy sweating, but consume beverages that
fail to adequately supply sufficient sodium to recover the
amount lost in sweat. It is also seen when fluid consumption
exceeds fluid losses (146). The normal serum sodium
concentration is 135–145 mmol/L, whereas hyponatremia is
typically diagnosed with serum sodium concentrations of lower
than 135 mmol/L. A serum sodium concentration lower than
120 mmol/L is considered dangerous. It is a relatively common
water–electrolyte imbalance that occurs in ∼10% of people who
participate in endurance events. A recent study found an
extremely high incidence of hyponatremia during 28 days of
high-volume rowing training (87). Of the 30 junior elite rowers
studied, 70% achieved hyponatremia at least one time during
the 28 days of training. Because the symptoms of
hyponatremia may be similar to those of dehydration (i.e.,
hyponatremia may occur when hydration state is poor), care
should be taken that they are not confused (37).

Important Factors to Consider

It is possible for physicians caring for those they believe to be

dehydrated, but are actually suffering from hyponatremia, to
be incorrectly treated with rapid infusion of large volumes of
hypotonic solutions. This treatment in someone with
hyponatremia may result in coma and death (101).

Sodium Toxicity
A number of population-based studies suggest that a
chronically high intake of salty foods may increase the risk of
developing stomach cancer (133). Because high salt intakes
stimulate an increase in urinary excretion of calcium, high salt
consumption has been found to be associated with greater risk
of developing osteoporosis (low BMD resulting in higher
fracture risk) (26). The increased loss of calcium may also play
a role in the development of kidney stones. Although all of
these potential problems are important, the greatest toxicity
associated with excess sodium intake is hypertension (high BP).
Although humans not suffering from primary hypertension have
an effective mechanism for excreting excess sodium, high
sodium intakes do increase BP and lowering sodium intake
decreases BP, even in those without primary hypertension (60).
Taken together, the problems associated with excess salt intake
can have a profoundly negative impact on health and should
encourage people to carefully manage salt consumption.

Kidney Stones

Kidney stones are composed of calcium oxalate or calcium

phosphate and occur in up to 15% of adults who have high
urine calcium. Extremely high levels of animal protein (>2.0
g/kg/day), common among certain groups of athletes, may
increase urinary calcium excretion and, therefore, the risk of
kidney stones. Other risk factors for kidney stones include
dehydration (forcing the kidneys to produce a concentrated
urine with lower urinary volume) and chronically high intakes
of calcium, oxalate (often from excess consumption of some
raw dark greens that are high in oxalate), sodium, and
vitamin C. Chronically low intakes of citrate (high in citrus
fruits but also in other fruits and vegetables) and low calcium
intake may also elevate kidney stone risk. Certain medical
conditions also result in high risk for kidney stones, including
gout (high uric acid), Crohn’s disease and colitis (both of
which often result in dehydration), and some inherited
disorders that affect kidney function.

Chloride
Chloride, another extracellular mineral, is essential for the
maintenance of fluid balance and is also an important
component of gastric juices (Box 6.5). Combining with
hydrogen, chloride is an important component of hydrochloric
acid in the stomach. Hydrochloric acid lowers gastric pH (i.e.,
makes the stomach more acidic) to aid in the digestion of
protein, the activation of intrinsic factor (needed for absorbing
vitamin B12), and the absorption of iron, zinc, magnesium, and
calcium. Chloride also works with sodium and potassium in
transporting nervous system electrical charges throughout
body tissues.

Box 6.5 Chloride Basic Information (Chemical

Symbol Cl)

AI
Adult males (ages 19–50 yr): 2.3 g/d
Adult males (ages 51–70 yr): 2.0 g/d
Adult males (ages 70+ yr): 1.8 g/d
Adult females (ages 19–50 yr): 2.3 g/d
Adult females (ages 51–70 yr): 2.0 g/d
Adult females (ages 70+ yr): 1.8 g/d
Recommended intake for athletes:
2.3 g/d or more to match the increase in sodium
intake with high sweat losses
Functions
Water balance
Nerve function
Parietal cell (stomach) HCl production
Good food sources
Table salt (∼60% chloride and 40% sodium)
Any food high in “salt/table salt”
Deficiency (rare)
Associated with frequent vomiting
May lead to convulsions
Toxicity
Tolerable UL
3,500 mg/d, or the equivalent of 5,800 mg of
table salt
Cl intake is associated with Na intake, so an
excess intake is typically associated with
hypertension (from the excess sodium)
 Virtually all the chloride we consume is associated with table
salt (sodium chloride), so there is a parallel between sodium
and chloride intakes. In addition, chloride losses are closely
linked to sodium losses, so a deficiency of one is likely to be
related to a deficiency of the other. Because most people
consume excessive amounts of sodium as a result of a heavy
table salt intake, chloride intake is also high (estimated at
6,000 mg/day) and well above normal requirements, which is
750 mg/day (58).

Chloride Deficiency
Although rare, chloride deficiencies typically occur with heavy
sweating, frequent diarrhea, or frequent vomiting (58). Sweat
losses are likely to deplete both chloride and sodium to a
greater degree than other minerals that are lost in sweat (25,
109, 136). Therefore, heavy fluid loss through sweating that is
not adequately replaced with a salt-containing beverage may
result in chloride deficiency. The symptoms of deficiency are
similar to those of sodium deficiency (as they would occur
simultaneously) and include muscle weakness, irritability,
lethargy, and appetite loss (93). Please see the section on
sodium for additional information on chloride, sodium chloride,
and table salt.

Potassium
Potassium is the main mineral found inside cells (an
intracellular electrolyte) at a concentration that is 30 times
greater than the concentration of potassium found outside cells
(Box 6.6). It is involved in water balance, nerve impulse
transmission, and muscular contractions. It is also a cofactor in
a number of enzymes necessary for carbohydrate metabolism
(15).

Box 6.6 Potassium Basic Information (Chemical

Symbol K)
 RDA
Adult males (ages 19–70+ yr): 4.7 g/d
Adult females (ages 19–70+ yr): 4.7 g/d
Recommended intake for athletes:
4.7 g/d or more with high levels of sweat loss
Functions
Water balance
Glucose delivery to cells
Good food sources
Citrus fruits
Potatoes
Vegetables
Milk
Meat
Fish
Bananas
Deficiency
Hypokalemia, which is associated with anorexia,
dysrhythmias, and muscle cramping
Toxicity
Hyperkalemia, a condition that may lead to
arrhythmias and altered heart function (may lead to
death). Potassium supplements are generally NOT
recommended for this reason

The differences in concentrations between sodium (outside

the cell) and potassium (inside the cell) create an electrical
energy gradient that pumps sodium outside the cell in
exchange for potassium. The energy requirement for these
electrical energy pumps is estimated to account for between
20% and 40% of the total energy required while in a state of
rest (15, 122).

Food Sources of Potassium

The best food sources for potassium include fruits and
vegetables (Table 6.5). Supplements in the United States do not
contain more than 99 mg of potassium because a high single
dose of excess potassium may result in hyperkalemia, which is
associated with cardiac arrhythmia and heart failure (86).

Table 6.5 Some Commonly Consumed Foods

High in Potassium
Food Serving Potassium (mg)
Baked potato 1 medium potato 926
(with skin)
Raisins ½ cup 598
Prune juice 6 oz 528
Banana 1 medium 422
Spinach (cooked) ½ cup 420
Tomato juice 6 oz 417
Orange 1 medium 237
Almonds 1 oz 200

Source: United States Department of Agriculture, Agricultural Research Service, Food

Composition Database [Internet]. Available from: https://ndb.nal.usda.gov/ndb.
Accessed April 24, 2018.

The typical intake of potassium ranges from 1,000 to 11,000

mg/day (1–11 g/day), with people consuming large amounts of
fresh fruits and vegetables having the highest intakes. It has
been found that regular consumption of more potassium (i.e.,
through greater consumption of fruits and vegetables) is
associated with lower stroke risk, lower risk of osteoporosis,
and lower risk of kidney stones (45, 132, 135).

Potassium Requirements
There is good evidence that relatively high levels of potassium
(∼3,500 mg/day) are beneficial in controlling high BP (58).
However, excess intake may lead to toxicity, which occurs with
intakes of ∼18,000 mg (18 g) potassium, hyperkalemia, and
sudden cardiac arrest (58). The DRI estimated that daily
potassium requirement is 4,700 mg.

Athletes and Potassium

Although it is well established that potassium is critical to heart
and skeletal muscle function, the amount of potassium lost in
sweat during exercise is relatively small and does not seriously
affect the body’s potassium stores. Therefore, sweat-related
losses of potassium should not seriously affect athletic
performance in the well-nourished athlete (25). Some terms
used in the discussion of potassium are as follows:

Hypo = Low
Hyper = High
Emia = Blood
K = Symbol for potassium
Hypokalemia = Low (hypo) potassium (K) in the blood
(emia)
Hyperkalemia = High (hyper) potassium (K) in the blood
(emia)

Potassium Deficiency
Low plasma potassium is referred to as hypokalemia. Dietary
deficiency is rare and typically only occurs with chronic
diarrhea and vomiting or laxative abuse. Individuals taking
medications for high BP force the loss of sodium, and in this
process potassium is also lost. These individuals are
encouraged to replace this lost potassium through the intake of
potassium supplements or foods high in potassium (fruits,
vegetables, and meats). Symptoms of deficiency include early
fatigue, muscle weakness, muscle cramps, bloating,
constipation, and pain. If severe, hypokalemia may result in
abnormal heart function (cardiac arrhythmia) (122). Higher risk
of potassium deficiency occurs with chronic alcohol
consumption, severe diarrhea, excess use of laxatives, eating
disorders (anorexia nervosa and bulimia), and congestive heart
failure (43).
Potassium Toxicity
Although rare, high serum potassium (hyperkalemia) occurs in
people taking diuretics or in those with chronic renal failure.
Symptoms include tingling fingers and toes, muscle weakness,
and heart arrhythmia that may result in death. There is no
established tolerable UL for potassium by the Institute of
Medicine (59). However, supplemental intake of potassium has
been reported to cause GI problems, including diarrhea,
nausea, and vomiting (43).

Microminerals

The microminerals (trace elements) are present in extremely

small amounts but have important roles to play in human
nutrition. These microminerals are needed in amounts less than
100 mg/day and have body contents of less than 5 g. They
include iron, iodine, zinc, copper, fluorine, manganese,
molybdenum, selenium, and chromium.

Iron
A primary requirement for iron is to form the oxygen-
transporting compounds hemoglobin (in blood) and myoglobin
(in muscle) and is also found in a number of other compounds
involved in normal tissue function (Box 6.7). These functions
include (148):

Box 6.7 Iron Basic Information (Chemical Symbol

Fe)

RDA
Adult males (ages 19–70+ yr): 8 mg/d
Adult females (ages 19–50 yr): 18 mg/d
Adult females (ages 51–70+ yr): 8 mg/d
Recommended intake for athletes:
15–18 mg/d
 Functions
Oxygen delivery (as hemoglobin and myoglobin)
Part of numerous oxidative enzymes
Essential for aerobic metabolism
Good food sources
Meat, fish, poultry, and shellfish
Lesser amounts in:
Legumes
Dark green leafy vegetables
Dried fruit
Note: Cast-iron cookware increases iron content
of cooked foods
Deficiency
Fatigue
Lower infection resistance
Poor ability to concentrate
Low energy metabolism (with possible hypothermia).
Toxicity
Toxic levels of tissue iron (hemochromatosis)
Liver damage

Energy metabolism. Iron-containing compounds are

involved in electron transport that is critical to the
production of ATP energy.
Detoxification reactions. Enzymes that are iron-containing
are involved in removal of toxic pollutants.
Antioxidant protection. Peroxidases are iron-containing
substances that protect cells from being damaged by
reactive oxygen species (free radicals), such as hydrogen
peroxide.
DNA synthesis. Iron-dependent enzymes are needed for the
synthesis of DNA, a critical genetic substance for all cell
functions.
Enzymes. Iron is literally in hundreds of protein substances,
including enzymes.
 Iron is reused and conserved when iron-containing
substances, such as heme, break down. However, iron is lost
through bleeding, sweating, and urination. The total body
content of iron is ∼2–5 g, and only a small amount of iron must
be absorbed (∼1–2 mg/day) to compensate for small losses
(42). The daily iron exposure from food and fluids is regulated
through controlled absorption, which typically can vary from
3% to 23% of dietary intake, depending on physiologic need
(higher when body stores are low or erythropoiesis is high),
bioavailability of the iron in the consumed foods, and relative
absorption competition from other minerals (25, 46). To satisfy
requirements that may arise from fluctuations in dietary intake,
humans store iron in the form of ferritin, which is found in the
liver, bone marrow, and spleen. Serum ferritin is a marker of
stored iron because a proportion of stored iron “leaks” into the
serum and can be measured (142). The amount in serum is
proportionate to the amount in storage, so serum ferritin
provides a satisfactory marker of stored iron. When iron is
required by tissues, an iron-transporting protein, transferrin,
takes iron from storage (ferritin) and transports it to the tissue
requiring it. In the case of hemoglobin, transferrin picks up iron
from ferritin, and transports it to a copper-containing protein,
ceruloplasmin, that picks up iron from transferrin and hands off
the iron to heme to produce hemoglobin.

Ferritin

An iron storage protein that releases it for tissue use in an as-

needed basis. Serum ferritin is an indirect marker of the total
stored iron in the body. In adult males, normal ferritin
concentration is 12–300 ng/mL; in adult females normal
ferritin concentration is 12–150 ng/mL (14).

Food Sources of Iron

Iron is available in a wide variety of foods, including meats,
eggs, vegetables, and iron-fortified cereals. A typical balanced
diet for an omnivore supplies ∼6 mg/1,000 kcal of iron. Milk
and other dairy products are poor sources of iron. The most
easily absorbed form of iron is heme iron, which comes from
meats and other foods of animal origin. Interestingly, heme iron
also enhances the absorption of nonheme iron from nonmeat
sources (57). Nonheme iron, which is not as easily absorbed as
heme iron, is found in fruits, vegetables, and cereals. However,
nonheme iron absorption may be enhanced by consuming
foods high in vitamin C, which can reduce ferric iron to a more
elemental form, ferrous iron, that has better bioavailability. The
absorption of nonheme iron found in nonmeat foods may be
inhibited by phytic acid (a substance associated with bran in
cereal grains), antacids, and calcium phosphate. In general, red
meats are considered to provide the most abundant and easily
absorbable source of iron. It is for this reason that vegetarians
are considered to be at increased risk for iron deficiency
anemia. Nevertheless, with proper planning, the consumption
of vegetables and fruits high in iron, and sound cooking
techniques that enhance iron absorption, vegetarians can
obtain sufficient iron.

Maximizing Iron Intake in a Vegetarian Diet

For vegetarians who want to improve iron absorption from
foods, consider the following:

Dark green vegetables have iron, but they also have oxalic
acid, which reduces iron availability. To remove the oxalic
acid from the vegetables, blanch them by putting them in a
pot of boiling water for 5–10 seconds. Much of the oxalate
is removed but the iron remains.
High-fiber cereals (those with a high bran content) have
large amounts of phytic acid, which binds with iron and
reduces iron availability. Switch to whole-grain cereals
rather than consuming bran-added cereals.

Iron in vegetables is in a form that has a lower rate of

absorption than iron in meats. To improve the rate of
absorption, add vitamin C to the vegetables by squeezing
lemon or orange juice on them before eating.

Iron Requirements
The recommended intake for iron ranges from 8 mg/day for
adult men to 18 mg/day for adult women. The requirement for
pregnancy, because of the significant expansion of the blood
volume, is 27 mg/day. Given the usual concentration of iron in
an omnivorous diet (∼6 mg/1,000 kcal), an adult woman would
require ∼3,000 kcal/day to be exposed to the recommended 18
mg. Surveys indicate that the average female daily intake of
iron is 12 mg/day, or 33% below the recommended level (57).
These same surveys indicate that the average daily intake for
men is 16–18 mg/day, or well above the recommended level.

Athletes and Iron

Regular and intense athletic training may increase blood loss
from the GI tract and may also increase red cell breakdown
(hemolysis) of RBCs to a significant degree. The Food and
Nutrition Board has estimated that these factors may raise the
iron requirement for athletes by 30% above regular
requirements (57). Athletes have good reason to be concerned
about iron status, because oxygen-carrying capacity (via
hemoglobin in blood and myoglobin in muscles) is a critical
factor in physical endurance. Iron deficiency is one of the most
common nutrient deficiencies, and it appears as if athletes
have about the same rate of iron deficiency anemia as the
general public (6, 25). Two types of anemia are macrocytic
hypochromic anemia and microcytic hypochromic
anemia.

Macrocytic Hypochromic Anemia

Literally, insufficient RBCs that are large (macro) and low in

color (hypochromic) because of low hemoglobin content. This
form of anemia, commonly referred to as pernicious anemia,
is specific to insufficient vitamin B12, insufficient folic acid, or
inadequate amounts of both.

Microcytic Hypochromic Anemia

Literally, insufficient RBCs that are small (micro) and low in

color (hypochromic) because of low hemoglobin content. This
form of anemia is associated with insufficient iron.

There may be several reasons why some athletes suffer

from low iron levels. These include:

Low dietary intake of iron. It is possible that some athletes

may consume foods with an inadequate total intake of iron.
This may be especially true with athletes who are limiting
total energy intake as a means (albeit ineffective) of
maintaining or reducing weight.
Consumption of foods with low iron absorption rates. Many
athletes consume large amounts of carbohydrates and are
limiting the intake of red meat. Although iron exists in
nonmeat sources, the absorption rate of iron in these foods
is typically less, as well as the total iron content.
Increased iron losses (hematuria). Some forms of exercise,
particularly long-distance running and concussive sports,
cause small amounts of hemoglobin and/or myoglobin to be
lost in the urine because of a rupturing of RBCs (9).
Loss of iron in sweat. Although iron losses in sweat are low
(about 0.3–0.4 mg/L of sweat), a typical absorption rate of
iron from food of about 10% would require that 3–4 mg of
additional dietary iron be consumed for each liter of sweat
produced. Runners commonly lose, particularly in hot and
humid environments, up to 2 L of sweat per hour (6, 141).
Increased RBC breakdown. A number of studies have
documented higher rates of intravascular hemolysis in
athletes than in nonathletes (120). Hemolysis occurs when
exertional forces cause a ballistic and premature
breakdown of RBCs. Athletes have RBCs with a life
expectancy of ∼80 days, whereas in nonathletes RBCs last
∼120 days (Table 6.6).

Table 6.6 How Iron Deficiency or

Iron Deficiency Anemia
Affect Sports
Performance
Anemia Iron Deficiency
Lower oxygen delivery to Higher rate of glucose
cells oxidation
Decreased oxygen uptake Higher lactic acid production
(lower VO2max)
Lower endurance Higher respiratory quotient
performance (higher proportion of
carbohydrate consumed to
meet energy needs)
Lower oxidative metabolism
Higher glucose oxidation
Higher lactic acid production
Higher respiratory quotient
(higher proportion of
carbohydrate consumed to
meet energy needs)

One of the major impacts of both iron deficiency and iron deficiency anemia is
compromised fat metabolism (an oxygen-dependent metabolic pathway),
which increases the reliance on carbohydrate as an energy substrate. Because
carbohydrate storage in humans is limited, the result is lower endurance at all
exercise intensities.

Sports anemia. It is common for many athletes to appear

as if they are anemic at the beginning of training season
because there is a large increase in blood volume at the
initiation of training. This increase in blood volume has the
effect of diluting the constituents of the blood, including
RBCs, making it appear as though there is an anemia.
However, after a short time, the body increases the
 production of RBCs to remove the appearance of anemia
(8).

There are differences in how an athlete might respond in the

presence of frank anemia (reduction in the number and size of
RBCs) versus iron deficiency (low serum iron and low stored
iron, but normal RBCs) anemia (Figure 6.2) (147).
FIGURE 6.2: Difference between normal (A) and abnormal (B)
red blood cells seen in iron deficiency anemia. (From BWeksler
B, Schecter GP, Ely S. Wintrobe’s Atlas of Clinical Hematology.
2nd ed. Philadelphia (PA): LWW (PE); 2018.)
 Although iron-deficient athletes are known to experience a
performance deficit, there appears to be no benefit in providing
iron supplements to athletes who have a normal iron status
(16). Further, iron supplementation is often associated with
nausea, constipation, and stomach irritation. However, in
athletes who have had blood tests that demonstrate either an
anemia or a marginal level of stored iron, iron supplementation
is warranted. The best means of providing iron supplements to
reduce the chance of potential negative side effects is to
provide 25–50 mg every third or fourth day rather than daily
doses (129).

Iron Deficiency
There are multiple health risks from poor iron status. In children
with iron deficiency, poor mental development,
underachievement in school, and behavior problems have been
documented (89). Because lead binds to the same molecules
as iron, an iron deficiency increases the risk that more lead can
be taken up by tissues, resulting in lead toxicity (149). During
pregnancy, there is a large enlargement of the blood volume,
with a requirement that the components of the blood, including
iron-containing RBCs, also increase. A failure to consume
sufficient iron during pregnancy has been found to increase the
risk of premature birth, low birth weight infants, and maternal
death (151). It should be noted that having excessively high
hemoglobin is also associated with pregnancy outcomes,
including hypertension and preeclampsia (151). Poor iron
status is also associated with ineffective immune function,
leading to higher risk of infectious disease (104). Worldwide,
the most common nutrient deficiency is iron deficiency. There
are three levels of iron deficiency (Table 6.7):

Table 6.7 Stages of Iron Deficiency (Too Little Iron)

and Measured Values
The three stages leading from iron deficiency to iron deficiency
anemia are as follows:
 1. An insufficiency supply of dietary iron causes iron stores in
bone marrow to be depleted. (This stage is typically
without symptoms except muscle weakness and is
associated with depleted myoglobin and low serum
ferritin.)
2. Iron deficiencies develop, with reduced hemoglobin
production. (This stage shows very low serum ferritin, low
hematocrit, and normal hemoglobin.)
3. Iron deficiency anemia from inadequate hemoglobin
production and a failure to produce sufficient RBCs with
adequate hemoglobin content. (This stage shows absent
myoglobin, very low serum ferritin, very low hematocrit,
and low hemoglobin.)

Measured Normal Stage 1 Stage 2 Iron- Stage 3

Value Depleted Deficient Iron
Stores Erythropoiesis Deficiency
Anemia
Tissue iron Normal Depleted Absent Absent
(myoglobin)
10–95
ng/mL
for
men
10–65
ng/mL
for
women

Stored iron Normal Low Very low Very low

(serum
ferritin) 20–500
ng/mL
for
men
20–200
ng/mL
 for
women

Serum iron Normal Normal Low Very low

(hematocrit)
39%–
54%
for
men
34%–
47%
for
women

Red cell iron Normal Normal Normal Low

(hemoglobin)
14–18
g/dL
for
men
11–16
g/dL
for
women

Camaschella C. New insights into iron deficiency and iron deficiency anemia. Blood
Reviews 2017; 31: 225-233.
Clénin GE, Cordes M, Huber A, Schumacher YO, Noack P, Scales J, and Kriemler S.
Iron deficiency in sports – definition, influence on performance and therapy.
Schweizerische Zeitschrift für Sportmedizin & Sporttraumatologie 2016; 64(1): 6-13.
Cowell BS, Rosenbloom CA, Skinner R, and Summers SH. Policies on screening
female athletes for iron deficiency in NCAA Division I-A institutions. International
Journal of Sport Nutrition and Exercise Metabolism 2003; 13: 277-285.

Depleted ferritin (stored iron), but functional iron (i.e.,

hemoglobin, myoglobin muscle iron, iron-containing
enzymes) remains normal.
Depleted ferritin, myoglobin, and iron-containing enzymes,
but normal hemoglobin.
 Depleted ferritin, myoglobin, iron-containing enzymes, and
low hemoglobin resulting in microcytic, hypochromic
anemia (low number of RBCs, and remaining cells are small
and low in red color).

As can be seen, it is possible to be in an iron-compromised

state that could have an impact on both a sense of well-being
and athletic performance without actually being diagnosed with
anemia. The diagnosis of anemia is typically made through an
evaluation of hemoglobin and hematocrit (Figure 6.3).
However, iron is stripped from myoglobin and iron-containing
enzymes to keep hemoglobin normal if storage iron (ferritin) is
low (142). Because of this, it may appear that iron status is
normal when it is actually low. For this reason, the assessment
of iron status in athletes should include the evaluation of
ferritin in addition to hemoglobin and hematocrit.
FIGURE 6.3: Commonly observed signs of iron deficiency. In
addition to illustrated glossitis (red tongue; A) and koilonychias
(transverse ridging and spoon nails; B), the most common sign
is early fatigue and poor concentration as well as whitish lower
eyelids. (From Weksler B, Schecter GP, Ely S. Wintrobe’s Atlas
of Clinical Hematology. 2nd ed. Philadelphia (PA): LWW (PE);
2018.)

Hematocrit
 Abbreviated as Hct, it is also referred to as packed cell
volume and is the volume percentage of RBCs in the blood. In
adult males, normal hematocrit is 45%; in adult females
normal hematocrit is 40%.

The lower the storage level, the higher the absorption;

however, the absorption rate rarely goes above 10%–15% of
the iron content of consumed food. This variable absorption
mechanism is aimed at maintaining a relatively constant level
of iron and avoiding an excess uptake, which is a health risk.
Despite this variable absorption rate, people with marginal
intakes of iron are at risk for developing iron deficiency and
eventual anemia.
Iron deficiency anemia is characterized by poor oxygen-
carrying capacity, a condition that is known to cause
performance deficits in athletes. Iron deficiency is also
associated with poor immune function, short attention span,
irritability, and poor learning ability. Children experiencing fast
growth, women of menstrual age, vegetarians, and pregnant
women are at increased risk for developing iron deficiency
anemia. Periods of growth and pregnancy are associated with a
higher requirement of iron because of a fast expansion of the
blood volume, and iron is an essential component of RBCs.
Women of menstrual age have higher requirements because of
the regular blood (and iron) losses associated with the
menstrual period. For this reason, women of childbearing age
have a higher requirement for iron (18 mg) than men of the
same age (10 mg). Symptoms of iron deficiency anemia are
listed in Box 6.8.

Box 6.8 Symptoms of Iron Deficiency Anemia

Eyes: Yellowing
Skin: Paleness, coldness, yellowing
Respiratory: Shortness of breath
Muscular: Weakness
 Intestinal: Changed color of stool
Central nervous system: Fatigue, dizziness, fainting
(severe anemia)
Blood vessels: Low blood pressure
Heart: Palpitations, rapid heart rate, chest pain (severe
anemia), angina (severe anemia), heart attack (severe
anemia)
Spleen: Enlargement

Iron Toxicity
Some people are at risk for developing iron toxicity because
they are missing the mechanisms for limiting absorption. Young
children, in particular, may be at risk for iron toxicity if they
ingest supplements intended for adults. According to the Food
and Nutrition Board, the accidental consumption of high doses
of iron-containing products is the largest cause of poison-
related fatalities in children under 6 years of age (57). Many
iron supplements intended for adults have levels of iron that
are more than 300% of the recommended daily level, and iron
overload may be fatal (94).

Zinc
Zinc has many functions, including forming enzymes,
involvement in the structure of tissues, and multiple regulatory
activities (Box 6.9). Enzymes help chemical reactions — such
as the healing of wounds — occur at a proper rate, and zinc is
present in over 300 enzymes (88, 102). Zinc-containing
enzymes are also involved in the metabolism of carbohydrates,
fats, and proteins. The structures of many proteins and cell
membranes are also zinc dependent, and insufficient zinc
increases the risk that cell membranes will be oxidatively
damaged, as it is part of an important antioxidant enzyme
called copper–zinc superoxide dismutase (57). It appears that
the absorption of dietary folate is reduced with poor zinc status
(66). In addition, zinc is related to vitamin A metabolism, with
insufficient dietary intake of zinc causing a variety of health
problems that may be related to vitamin A, including stunted
growth, slow wound healing, and failure of the immune system
(12). Zinc is competitively absorbed with other bivalent
minerals (iron, magnesium, calcium, copper), so high levels of
zinc consumption may result in malabsorption of these
minerals (66, 92).

Box 6.9 Zinc Basic Information (Chemical Symbol

Zn)

RDA
Adult males (ages 19–70+ yr): 11 mg/d
Adult females (ages 19–70+ yr): 8 mg/d
Recommended intake for athletes:
11–15 mg/d
Functions
Part of numerous enzymes involved in energy
metabolism
Protein synthesis
Immune function
Sensory function
Sexual maturation
Good food sources
Meat, fish, poultry, shellfish, eggs
Whole-grain foods
Vegetables
Nuts
Note: Pumpkin seeds are a good vegetarian source of
zinc
Deficiency
Impaired wound healing
Impaired immune function
Loss of appetite (anorexia)
Failure to thrive (in children)
Dry skin
Toxicity
 Tolerable UL: 40 mg/d.
Symptoms:
Impaired immune system
Slow wound healing
Hypogeusia (loss of taste sensation)
Hyposmia (loss of smell sensation)
High low-density lipoprotein:high-density
lipoprotein cholesterol ratio
Nausea

Food Sources of Zinc

The content and bioavailability of zinc in meats, eggs, and
seafood are high, but zinc is also available in pumpkin seeds,
nuts, and legumes (Table 6.8). The sulfur-containing amino
acids (cysteine and methionine) found in foods of animal origin
enhance zinc absorption, whereas phytic acid in whole
grains/bran products that are unleavened inhibits zinc
absorption (66).

Table 6.8 Zinc Content of Commonly

Consumed Foods
Food Serving Zinc (mg)
Beef, broiled 3 oz 6.64
Pumpkin seeds, dried ½ cup 5.04
Milk, 2% fat 1 cup 1.17
Chicken, baked 3 oz 1.05
Beans, cooked ½ cup 0.94
Salmon, cooked 3 oz 0.70
Spinach, cooked ½ cup 0.68
Potato, baked (skin 1 medium 0.53
and flesh)
Peanut butter 1 tbsp 0.40

Zinc Requirements
The adult RDA for zinc is 12–15 mg/day, whereas surveys
indicate that the average zinc intake for adult women is 9
mg/day and for adult men 13 mg/day (57).

Athletes and Zinc

Zinc levels at the lower end of the normal range, or lower, have
been observed in male and female endurance runners. Athletes
with lower serum zinc values had lower training mileage (i.e.,
could probably not train as hard) than those who had higher
values (32, 48, 124). Therefore, there appears to be a
performance deficit in the small number of athletes who have
poor zinc status.
The effect of zinc supplementation on performance has not
been extensively studied, and the level of supplementation in
these studies has been extremely high (around 135 mg/day).
Also, the athletes tested were never assessed for zinc status
prior to the initiation of the research protocol. Nevertheless,
this level of intake did lead to an improvement in both
muscular strength and endurance (72). Athletes should be
cautioned that this level of zinc intake has never been tested
over time for safety, so it may well have negative side effects.
Toxicity and malabsorption of other nutrients are both likely
and possible with this level of intake (41, 53, 126).
Because oxygen-carrying capacity, and therefore iron status,
is essential for helping athletes perform up to their conditioned
capacity, many athletes consume high levels of iron. However,
iron supplementation may interfere with zinc absorption. For
athletes supplementing with zinc, a malabsorption of copper
may occur that could develop into an anemia. Therefore, any
athlete considering supplementation with either iron or zinc
should be careful that the amount consumed is not excessive
(90). A safer and less expensive approach is to consume an
adequate amount of a wide variety of foods to optimize tissue
exposure to all nutrients in a balanced way.

Zinc Deficiency
Zinc deficiency, while rare, is associated with multiple diseases
and conditions, including:
 Growth impairment: Failure to thrive (i.e., poor linear
growth and weight gain) in young children is associated
with zinc deficiency, perhaps because zinc regulates a
hormone, insulin-like growth factor-1 (IGF-1), that is
involved in muscle and bone development (84).
Poor neurologic development: Zinc deficiency is associated
with poor attention and poor motor development in
newborns and young children (11).
Inadequate functioning of the immune system: Adequate
zinc status is necessary for the normal functioning of cells
that help protect tissues from invasion of foreign
substance, including bacteria and viruses (119).
Macular degeneration of the eye in older adults: A high
level of zinc is found in the macula (a portion of the retina
in the back portion of the eye), and the zinc content of the
macula declines with age. Antioxidants, zinc, and copper
are part of the standard formula provided for helping older
adults lower the risk of macular degeneration (35).

The people most at risk of zinc deficiency include the

following (66, 71):

Young children
Pregnant and lactating women (particularly adolescents)
People with malabsorption syndromes, including celiac
disease, Crohn’s disease, and ulcerative colitis
Alcoholics (increased urinary zinc excretion)
Diabetics (frequent urination increases urine zinc losses)
People with chronic renal disease
People 65 years of age and older
Strict vegans (high phytic and oxalic acid associated with
cereals and vegetables reduces zinc absorption)

Zinc Toxicity
The tolerable UL for zinc has been established and is set at 40
mg/day for adult males and females. Excessive intake can
cause anemia, vomiting, and immune system failure. Some
toxicity has occurred as a result of zinc contamination from
food containers, while there are also cases of toxicity from
nasal sprays containing high levels of zinc (57). The zinc-
containing nasal sprays may produce an irreversible loss of the
sense of smell (anosmia) and an irreversible loss of the sense
of taste (hypogeusia) and should, therefore, be avoided (29).

Iodine
Iodine is an essential component of thyroid hormones
triiodothyronine (T3) and thyroxine (T4), which control energy
metabolism, growth, and nervous system development (Box
6.10). Thyroid hormone production involves both the pituitary
gland and the hypothalamus. When thyrotropin-releasing
hormone (TRH) is created by the hypothalamus, the pituitary
gland secretes thyroid-stimulating hormone (TSH). TSH
stimulates the thyroid glad to trap iotine and release thyroid
hormones thyroxine (T4) and triiodothyronine (T3) into the
circulating blood. When there is sufficient consumption of
iodine, there is adequate T4 and T3, and this results in lower
levels of TRH and TSH. When the circulating T4 level is low, the
pituitary gland increased secretion of TSH to stimulate greater
iodine trapping and greater release of both T3 and T4. When
there is a chronic iodine deficiency, the resulting persistently
elevated TSH may result in an enlargement of the thyroid
gland, which is referred to as goiter. (See Figure 6.4). Goiter
was once common in the United States because certain
geographic areas have foods grown in soils with a low iodine
content. It remains a prevalent nutritional deficiency disease in
certain parts of Asia, Africa, and South America. Pregnant
women with low iodine intakes may give birth to cretinous or
mentally retarded infants. In the United States, an early public
health measure to ensure that everyone had an AI of iodine
was to add iodine to salt, a strategy that eliminated goiter
(156). An excessive intake of iodine has the effect of
depressing thyroid activity, so taking additional supplemental
doses of iodine is not recommended.
FIGURE 6.4: Thyroid function demonstrating the different
production of T3 and T4 associated with adequate and
inadequate iodine intakes. From Linus Pauling Institute, Oregon
State University. Thyroid hormone function. Available from:
http://lpi.oregonstate.edu/mic. Accessed April 23, 2018.

Box 6.10 Iodine Basic Information (Chemical

Symbol I)

RDA
Adult males (ages 19–70+ yr): 150 mcg/d
Adult females (ages 19–70+ yr): 150 mcg/d
Recommended intake for athletes: 150 mcg/d
Functions
Forms thyroid hormone T4, which is involved in
metabolism control
 Good food sources
Iodized salt and seafood
Depending on soil, some vegetables may also be
good sources
Deficiency
Goiter (enlarged thyroid gland with inadequate T4
production), with low metabolic rate and associated
obesity
Note: Inadequate iodine intake with associated lower
T4 production was once relatively common in the
United States, but the use of iodized salt effectively
eliminated this condition.
Toxicity
An excessive intake of iodine depresses thyroid
activity, so taking supplemental doses of iodine is not
recommended.

Food Sources of Iodine

A major source of iodine in Western countries is iodized salt. In
some countries, such as Canada, iodized salt is mandated. In
the United States, however, iodized salt is voluntary. As a
result, only about half of the salt in the United States is iodized,
and a smaller proportion of consumed salt is iodized (77). Sea
water also has high levels of iodine, making salt-water seafood
a good source as well. It is possible that other foods, including
vegetables and fruits, are also good dietary sources of iodine,
but this depends on the iodine content of the soil in which the
food was grown. Other sources of iodine include eggs and
poultry. See Table 6.9 for the iodine content of commonly
consumed foods, but consider that, except for iodized salt that
has a predictable amount of iodine, other foods vary depending
on the preparation and the soil in which they were grown.

Table 6.9 Iodine Content of Commonly

Consumed Foods (in mcg)
Food 6.9
Table ServingContent
Iodine Size Iodine (mcg)
of Commonly
Consumed Foods (in mcg)

Food Serving Size Iodine (mcg)

Iodized salt 1 g (1,000 mg) 77
Cod fish 3 oz 99
(cooked)
Milk (2%) 8 oz (1 cup) 99
Potato with skin 1 medium 60
(baked)
Shrimp (boiled) 3 oz 35
Turkey breast 3 oz 34
(baked)
Navy beans ½ cup 32
(cooked)
Egg (chicken, 1 large egg 12
boiled)

Iodine Requirements
The recommended intake of iodine for adult males and females
is 150 mcg/day (57). Surveys suggest that the dietary intake of
iodine in the United States is adequate, ranging from 138 to
268 mcg/day. In the extremely rare case of people living near a
nuclear accident or a nuclear blast, consumption of potassium
iodide (a supplemental form of iodine) in very high doses (130
mg/day) may help to saturate the thyroid with nonradioactive
iodine, thereby reducing the uptake by the thyroid of
radioactive iodine-131. Studies suggest that this strategy
successfully reduces the risk of radiation-causing thyroid
cancer (153).

Athletes and Iodine

There are no data suggesting that the iodine intake of athletes
is inadequate, and no data suggesting that elevating iodine
intake would have a positive impact on performance. On the
contrary, the normal absorption of minerals is competitive, so
elevating the intake of iodine may have the effect of reducing
the absorption of other minerals (iron, copper, etc.), which
would have a negative impact on performance. Although there
are no studies to confirm that this is so, athletes who
chronically restrict food intake can be expected to have a
chronically low intake of all nutrients, including iodine. There
are data to suggest that inadequate energy intake does
suppress T3 and IGF-1, both of which are associated with
energy metabolism and tissue development and repair (68).

Iodine Deficiency
Approximately 80 mcg/day of iodine is used to synthesize the
thyroid hormones and, while a relatively small requirement,
iodine deficiency exists. Countries with large proportions of the
population suffering from iodine deficiency have made efforts
to reduce iodine deficiency disease through improved
availability of iodized salt. On a worldwide basis, however,
iodine deficiency is still sufficiently prevalent that it is widely
believed to be the most common cause of brain damage (156).
The primary condition associated with deficiency is the disease
goiter, although hypothyroidism without goiter is still
responsible for developmental problems, particularly in children
(28). It should be noted that the United States is not a country
currently suffering from a high prevalence of iodine deficiency.
However, recent surveys suggest that the average per capita
intake of iodine has decreased in recent years, perhaps
because of an increased availability of nonionized “designer”
salts on the market, and a public health effort to lower salt
consumption because of its well-known association with
hypertension (18).

Iodine Toxicity
Although toxicity from iodine is rare, there is an established
tolerable UL, which is 1,100 mcg/day for adult males and
females. There are some conditions that are associated with
iodine sensitivity, including Graves disease and Hashimoto
thyroiditis. Individuals who have had a portion of the thyroid
surgically removed may also be sensitive to iodine (57). There
is no evidence that excess iodine is beneficial for health, so the
consumption of foods that provide sufficient iodine should help
to avoid an excess exposure and toxicity to those who are
sensitive and should satisfy the iodine requirement for those
who are not.

Selenium
Selenium is an important antioxidant mineral in human
nutrition. It is part of glutathione peroxidase and other
antioxidants that protect cells from oxidative damage (Box
6.11). It is difficult to determine dietary adequacy, however,
because the selenium content of food is determined by soil and
water where the food is grown. Nutritional supplements,
including sodium selenite and high-selenium yeast, are
effective sources of selenium, but excessive intake may be
toxic, so proper care in taking appropriate levels of selenium is
important.

Box 6.11 Selenium Basic Information (Chemical

Symbol Se)

RDA
Adult males (ages 19–70+ yr): 55 mcg/d
Adult females (ages 19–70+ yr): 55 mcg/d
Recommended intake for athletes: 50–55 mcg/d
Functions
Antioxidant (part of glutathione peroxidase)
Good food sources
Meat, fish, seafood
Whole-grain foods
Nuts
Depending on soil, some vegetables may also be
good sources
Deficiency
Unlikely; if it occurs, results in heart damage
Toxicity
 Tolerable UL: 400 mcg/d for adults (lower for children)
Toxicity is rare; if it occurs, results in nausea, GI
distress, and hair loss

Food Sources of Selenium

The foods with the highest concentrations of selenium are
organ meats (e.g., liver), seafood, and red meats (muscle).
Soils where foods are grown vary widely in selenium content,
making it difficult to specify which vegetables are good
sources. The food with the highest selenium concentration,
assuming they are grown in selenium-rich soil, is Brazil nuts.
This is followed by sea foods, beef, and seeds (Table 6.10).

Table 6.10 Sources of Selenium from

Commonly Consumed Foods
Food Serving Selenium (mcg)
Brazil nuts (from high- 6 nuts 544
selenium soil)
Tuna fish (cooked) 3 oz 92
Shrimp (cooked) 3 oz 42
Pork (roasted) 3 oz 33
Beef (grilled) 3 oz 31
Chicken (roasted) 3 oz 26
Sunflower seeds ¼ cup 19
Bread, whole wheat 2 slices 16

Selenium Requirements
The recommended intake of selenium ranges from 20 mcg/day
in children to 70 mcg/day in breast-feeding women. Surveys
suggest that selenium requirements are adequate in nearly all
the U.S. population, with intakes in U.S. adults ranging from
100 to 159 mcg/day from the consumption of foods, or two to
three times above the recommended intake of 55 mcg/day
(56).
Athletes and Selenium
Because exercise (particularly endurance exercise) is
associated with an increased production of potentially
damaging oxidative by-products (peroxides and free radicals) in
muscle fibers, it has been theorized that selenium plays a role
in reducing muscular oxidative stress (152). It has also been
theorized that selenium deficiency may result in muscle
weakness and increased recovery time from exhaustive
exercise (16). There is no evidence, however, that consumption
of additional selenium, either through foods or supplements,
has a beneficial impact on exercise performance (105, 130).

Selenium Deficiency
Although rare, poor selenium status will negatively affect
selenium-related antioxidant status, increasing susceptibility to
oxidative stress, tissue damage, and, potentially, cancer. Those
most at risk of selenium deficiency include people who,
because of GI surgery, receive their nutrition through a vein
(total parenteral nutrition), bypassing normal food consumption
and nutrient absorption through the gut. People with
compromised GI tracts (e.g., celiac disease and Crohn’s
disease) appear also to be at risk. In these individuals,
selenium deficiency is associated with heart damage and
muscular weakness (27). There are no data to suggest that
athletes are at high risk of selenium deficiency.

Selenium Toxicity
Excessive intake of selenium is toxic and may be fatal (56). The
tolerable UL for selenium in adult males and females is set at
400 mcg/day. Early signs of chronic selenium toxicity include
brittle nails and hair and hair loss.

Copper
Copper-containing enzymes are involved in iron metabolism,
production of ATP energy, bone formation, collagen production,
and neurotransmission (137) (Box 6.12). The important role
copper plays in iron metabolism has been long recognized. The
copper-containing protein, ceruloplasmin, can convert ferrous
iron to ferric iron, making it possible to transfer iron for RBC
formation (140). It is interesting that individuals with
inadequate ceruloplasmin are more at risk for developing iron
overload disease, which can be fatal, at similar levels of iron
consumption (69).

Box 6.12 Copper Basic Information (Chemical

Symbol Cu)

RDA
Adult males (ages 19–70+ yr): 900 mcg/d
Adult females (ages 19–70+ yr): 900 mcg/d
Recommended intake for athletes: 900 mcg/d
Functions
Part of iron-transport protein ceruloplasmin
Oxidation reactions
Good food sources
Meat, fish, poultry, shellfish, eggs
Nuts
Whole-grain foods
Bananas
Deficiency
Rare; if it occurs, results in anemia (inability to
transport iron to RBCs)
Toxicity
Tolerable UL: 10 mg/d. Toxicity is rare; if it occurs,
leads to nausea and vomiting

Food Sources of Copper

Copper is widely distributed in the food supply and is
particularly high in beef liver, shellfish, nuts, seeds, and whole
grains (Table 6.11.) Copper intake for the adult U.S. population
is slightly above the recommended intake (900 mcg/day), with
adult men having an average daily intake of between 1,000
and 1,100 mcg, and adult women having 1,200–1,600 mcg.

Table 6.11 Copper Content of Commonly

Consumed Foods
Foods Serving Size Copper (mcg)
Beef liver, cooked 1 oz 4,128
Oysters, cooked 6 medium 2,397
Clams 3 oz 585
Hazelnuts, dry 1 oz 496
roasted
Mushrooms, raw 1 cup 223
white, sliced
Shredded wheat 2 biscuits 167

Copper Requirements
The recommended intake of copper ranges from 340 mcg/day
in young children to 1,300 mcg/day in breast-feeding women.
The recommended intake amount is based on multiple studies
to ensure avoidance of any copper-related deficiencies (57). As
another good example of why nutritional balance is important,
excessive consumption of calcium, phosphate, iron, zinc, and
vitamin C reduces copper absorption and, therefore, alters the
requirement.

Athletes and Copper

Very few studies have been performed on the relationship
between copper and athletic performance. Studies of blood
copper concentrations in athletes and nonathletes have not
revealed any significant differences, but the athletes have a
slightly higher (3–4%) concentration of serum copper than
nonathletes (81, 82). In a study evaluating the copper status of
swimmers during a competitive season, there was no difference
in preseason and postseason copper status. In this study, the
majority of swimmers were consuming adequate levels of
copper (more than 1 mg/day) from food (83). An evaluation of
elite athletes involved in different types of activities found
normal copper status in these athletes (70).

Copper Deficiency
Copper deficiency resulting in a disease state is extremely rare,
and mainly seen in individuals who have inborn errors of
copper metabolism. The most common indication of copper
deficiency is iron deficiency anemia that does not improve
following strategies to improve iron status (57). In a relatively
low number of cases, newborn infants fed cow’s milk formula,
which is low in copper, may not have a normal growth velocity
(121).

Copper Toxicity
Toxicity of copper is rare, but when it occurs it may result in
liver and kidney failure, coma, and death. The U.S. tolerable UL
for copper in adults is ∼10 times the recommended intake level
and is set at 10,000 mcg/day. In people with genetic
intolerance to copper (Wilson’s disease), the UL is likely to be
excessive and result in copper accumulations in tissues that
would be damaging.

Manganese
Although there is still much to learn about manganese, current
information has established that it is a trace mineral involved in
energy metabolism, bone formation, immune function,
antioxidant activity, and carbohydrate metabolism (147) (Box
6.13). In the mitochondria (the oxygen-using energy factories
of cells), manganese superoxide dismutase is the primary
protective antioxidant (76). Animals that suffer from
manganese deficiency develop fragile skeletons, and
production of the same protein that helps to stabile bone joints,
collagen, is manganese (and vitamin C) dependent (63, 99).

Box 6.13 Manganese Basic Information (Chemical

Symbol Mn)
 AI
Adult males (ages 19–70+ yr): 2.3 mg/d
Adult females (ages 19–70+ yr): 1.8 mg/d
Recommended intake for athletes: 2.0–2.5 mg/d
Functions
Energy metabolism
Fat synthesis
Bone structure
Good food sources
Whole-grain foods
Legumes
Green leafy vegetables
Bananas
Deficiency
Poor growth and development in children
Toxicity
Tolerable UL: 11 mg/d
Symptoms:
Neurologic problems
Confusion
Easy fatigue

Food Sources of Manganese

Food sources of manganese include coffee, tea, chocolate,
whole wheat, nuts, seeds, soybeans, dried beans (e.g., navy
beans, lentils, split peas), liver, and fruits. As with several other
minerals, the intake of foods high in oxalic acid (present in dark
green leafy vegetables) may inhibit manganese absorption.
(See section on calcium for ways of reducing the oxalic acid
content of foods.) Much like iron, manganese absorption is
enhanced with vitamin C and meat intake.

Manganese Requirements
The AI for manganese in the United States for adult men is 2.3
mg/day, and for adult women 1.8 mg/day. The AI level of intake
level is higher for pregnancy (2.0 mg/day) and breast-feeding
(2.6 mg/day), an amount that should be easily obtained with
the increase food consumption associated with both pregnancy
and lactation.

Athletes and Manganese

There are no current studies suggesting that athletes are at
higher risk of manganese deficiency, and no studies suggesting
that athletic performance would be enhanced with higher
intakes of manganese.

Manganese Deficiency
Although manganese deficiency is rare, deficiencies are
associated with skeletal problems (undermineralized bone and
increased risk of fracture) and poor wound healing. There is
also some indication from animal studies that manganese
deficiency could be associated with impaired glucose tolerance
and poor carbohydrate and lipid metabolism (63). However,
there are currently no human studies with similar findings. It
appears that those at greatest risk for deficiency are those on
diets (inadequate intake) or where malabsorption occurs.
Manganese is in competition with calcium, iron, and zinc for
absorption, so an excess intake of these other minerals may
decrease manganese absorption and lead to deficiency
symptoms.

Manganese Toxicity
Welders are at risk of inhaling manganese dust, which has been
recognized as a health risk that can result in central nervous
system problems (62). Chronic toxicity from excess manganese
can worsen the neurologic disorders and make them
permanent, with physical symptoms that mimic Parkinson’s
disease, and psychological symptoms that include
hallucinations (106). Besides welders, people most at risk for
manganese toxicity include those with iron deficiency
(manganese replaces iron and accumulates in the brain) and
children (they have less absorption protection for heavy metals
than adults) (150). The tolerable UL for manganese is relatively
low because of the relatively high risk of developing neurologic
problems with excess manganese exposure. For this reason,
individuals should be cautious about consuming manganese
supplements. For adult males and females, the UL is 11
mg/day, or ∼5 times greater than the average daily intake of
adults living in the United States.

Chromium
The trace mineral chromium is widespread in the food supply
and environment (Box 6.14). Chromium is also known as
glucose tolerance factor because of its involvement in helping
cells use glucose through normal insulin function. It appears to
improve insulin function by enhancing insulin sensitivity in
cells, thereby aiding the transportation of glucose out of the
blood and into cells (54). A deficiency of chromium is known to
be associated with poor blood glucose maintenance (either
hypoglycemia or hyperglycemia), an excessive production of
insulin (hyperinsulinemia), excessive fatigue, and a craving for
sweet foods. It is also associated with irritability, which is
commonly associated with poor blood glucose control, weight
gain, type 2 diabetes, and higher cardiovascular disease risk
(147). There is limited evidence that frequent and intense
exercise may increase chromium deficiency risk.

Box 6.14 Chromium Basic Information (Chemical

Symbol Cr)

AI
Adult males (ages 19–50 yr): 35 mcg/d
Adult males (ages 51–70+ yr): 30 mcg/d
Adult females (ages 19–50 yr): 25 mcg/d
Adult females (ages 51–70+ yr): 20 mcg/d
Recommended intake for athletes: 30–35 mcg/d
Functions
Glucose tolerance (glucose–insulin control)
Good food sources
Brewer’s yeast
 Mushrooms
Whole-grain foods
Nuts
Legumes
Cheese
Deficiency
Glucose intolerance
Toxicity
Unlikely

Food Sources of Chromium

The best food sources of chromium include whole grains and
meats. Nutritional supplements, commonly in the form of
chromium picolinate, are taken as a means of reducing weight
or body fat, but the results of studies on this supplement have
produced mixed results. Initial studies of chromium picolinate
supplementation suggested that this supplement was effective
at increasing muscle mass and decreasing body fat in
bodybuilders and football players (34). However, subsequent
controlled studies have failed to reach the same conclusions
(23, 50). Other supplements for chromium include chromium
polynicotinate, chromium chloride, and high chromium yeast.
Dietary sources include whole-grain breads and cereals, meats,
and high chromium yeast.

Chromium Requirements
There is insufficient information on chromium status to set a
recommended intake level or an estimated average
requirement, so the current standard of intake is based on the
AI estimation, which is based on the average chromium content
of healthy diets (57). The AI for chromium ranges from 25
mcg/day in adult females to 35 mcg/day in adult males, with
higher recommendations for pregnant and breast-feeding
women.

Athletes and Chromium

Because chromium is not well absorbed, there is little evidence
to suggest that an excessive intake of chromium will result in
toxicity. However, the toxicity of chromium has not been
directly tested, so athletes should be cautious about taking
supplements. One study suggests that chromium picolinate has
the potential of altering DNA, and thus producing mutated,
cancerous cells (127). Taken together, these studies suggest
that, to maintain an optimal chromium status, athletes should
consume foods low in sugar and a diet that contains whole
grains and, if the athlete is not a vegetarian, some meat. It is
important to consider that insulin, besides being closely
associated with carbohydrate metabolism, is also involved in
protein and fat metabolism (117). Normal metabolism of these
energy substrates is critically important for all athletes. A
number of studies have investigated whether chromium
supplementation enhances fat-free mass in people who do and
do not exercise. The results of these studies suggest that
chromium supplementation does not contribute to an improved
body composition (more muscle mass, less fat mass) (67, 80).

Chromium Deficiency
Deficiency of chromium is rare, but it has been described in
people who have been fed intravenously for long periods of
time (111). High consumption of simple sugars (sweets) may
also place people at risk for deficiency. It appears, from a
number of surveys, that a large proportion of the U.S.
population consumes inadequate levels of chromium, a factor
that may be associated with the excess weight commonly
found in greater numbers of the population.

Chromium Toxicity
The usual form of chromium that is consumed (trivalent
chromium; Cr3+) is not considered to be highly toxic because of
its relatively low rate of absorption and rapid urinary excretion
(100). Although there is no current tolerable UL for chromium
currently set by the Food and Nutrition Board, the Board has
stated that high supplemental intakes of chromium may be
toxic (57). A usual form of chromium that is taken as a
supplement is chromium picolinate. Although there has been
some concern from laboratory studies that chromium picolinate
may cause cancer, there are no studies on humans indicating
that cancer is a risk factor when taking 400 mcg/day (a level
well above the AI) (57, 61). At higher levels (600 mcg/day),
however, chromium picolinate taken over a 5-month period was
associated with the development of chronic renal failure (143).

Summary

Minerals are inorganic substances that have multiple

functions. They are attached to proteins to provide strength
and structure to the skeleton (such as calcium and
phosphorus); they help to sustain the pH of the blood and
tissues; they are involved in creating nerve impulses that
stimulate muscle movement, and they are integral parts of
hormones that control the rate of energy metabolism.
A large number of athletes, particularly female athletes, are
at risk for calcium and iron deficiency, both of which are
essential for health and athletic performance. Low bone
density that results from poor calcium intake may increase
stress fracture risk, and poor iron status lowers the
capacity to deliver oxygen to working cells and remove
carbon dioxide from these cells, resulting in reduced
aerobic endurance and early fatigue. Other minerals are
equally important for athletic performance, mental acuity,
muscle function, and nerve function.
Minerals must be consumed regularly to ensure good
health. Mineral deficiencies take a long time to correct (for
instance, iron deficiency may take more than 6 months to
resolve), so athletes could suffer poor performance for long
periods of time if mineral deficiencies are allowed to occur.
Of all the minerals, iron and calcium have been found by
multiple studies to be the most likely to be deficient in
athletes.
 Because of limited absorption capacity, it is typically better
to spread out the intake of minerals during the day, rather
than by consuming minerals in single, large doses. Eating
good foods throughout the day is a preferred strategy.
One cup of milk provides about 240 mg of calcium. With a
calcium requirement of 1,200–1,500 mg/day, an athlete
would have to consume ∼5 cups of milk or an equivalent
amount from other foods to satisfy this daily requirement.
Meat is the easiest way to obtain iron and zinc, so
vegetarians may be at increased risk without careful
planning to consume well-prepared dark green vegetables
and enriched grains to obtain these minerals. However,
good dietary planning can dramatically reduce the risk that
vegetarians have from iron and/or zinc deficiency.
Sodium is critically important for maintaining blood volume
and the sweat rate. The current general population sodium
recommendation does not apply to athletes. The more an
athlete sweats the more sodium they require in a sports
beverage, with the normal range of between 50 and 200
mg/cup. The athlete goal is to replace all the sodium lost
through sweat.

Practical Application Activity

Iron deficiency is one of the most common nutrient

deficiencies, with high prevalence among the general
population and athletes. Using the procedure described in
earlier chapters, create a spreadsheet with iron, calcium,
zinc, and potassium, and the RDA for each of these minerals.
Look up the mineral content of the foods consumed by
accessing the online USDA Food Composition Database (139)
(https://ndb.nal.usda.gov/ndb/search/list). Analyze your food
intake for the mineral content of the foods you consume and
determine their adequacy using the procedure described
below.
 Create three new analysis days and plug in your foods
and activities for each hour of the day for each day.
When completed, “analyze” the average daily iron
consumed over the 3 days, and see how it compares with
the DRI/RDA for your age and gender.
If not adequate, try modifying your diet by eating more of
the foods that are good sources of iron.
Once done, now assess the adequacy of other minerals,
including calcium, zinc, and potassium, to see if the
intake of these minerals meets the DRI/RDA standard.

Chapter Questions

1. The primary cation in extracellular fluid is:

a. Sodium
b. Potassium
c. Calcium
d. Chloride
2. The primary cation in intracellular fluid is:
a. Sodium
b. Potassium
c. Calcium
d. Chloride
3. Of the following foods, which are good sources of potassium?
a. Orange
b. Banana
c. Blueberries
d. Bread
e. A, B, and C
f. All of the above
4. Which of the following nutrients are associated with BMD?
a. Calcium and vitamin C
b. Sodium and vitamin D
c. Vitamin D and calcium
d. Potassium and sodium
5. Which mineral listed below is most associated with immune
function?
a. Selenium
b. Magnesium
c. Zinc
d. Calcium
6. Without _________, consumed calcium is likely to be excreted
in the _______.
a. Vitamin E, urine
b. Vitamin D, fecal matter
c. Thiamin, urine
d. Niacin, fecal matter
7. In industrialized nations, the most common nutrient
deficiencies are:
a. Potassium and iron
b. Selenium and iodine
c. Calcium and iron
d. Zinc and manganese
8. Severe and chronic iron deficiency will result in:
a. Macrocytic, hyperchromic anemia
b. Microcytic, hypochromic anemia
c. Pernicious anemia
d. Macrocytic, normochromic anemia
9. Production of cortisol is likely to aid vitamin D activity and
increase BMD.
a. True
b. False
10. Iron absorption is limited for the following reason:
a. Excess iron absorption is toxic and associated with liver
disease.
b. People commonly consume excess iron, so the controlled
absorption helps to limit tissue exposure.
c. Most people have subtle zinc deficiency, which negatively
impacts iron absorption.
d. A and C

Answers to Chapter Questions

1. a
2. b
3. f
4. c
5. c
6. b
7. c
8. b
9. b
10. a

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CHAPTER OBJECTIVES
Explain the different compartments that hold body water and the factors
that cause water shifts between these compartments.
Know the mechanisms (organs, hormones, etc.) available to the human
system for sustaining a state of water balance.
Explain the major factors associated with causing a state of dehydration
and hypohydration.
Demonstrate how acclimated athletes are at lower risk of developing
dehydration and hypohydration.
Recognize how and why some people develop hypertension, and identify
dietary strategies that can be followed to lower blood pressure (BP) in
some individuals.
Describe the reasons why some people are at higher risk of developing
hypohydration.
Describe the reasons why some people are at higher risk of developing
hyponatremia.
Explain how to induce shifts in extracellular osmolarity, and how these
shifts can have an impact on blood volume and sweat rates.
Analyze the current strategies available to endurance athletes for
achieving a state of hyperhydration.
Distinguish between heat index (HI), relative humidity, and temperature
and how these may affect dehydration risk.

Case Study

Sally was an amazing, hard-working runner. She successfully ran 5Ks for
her university, but was trying to run longer distances to try to compete for
a spot on her country’s 10K or marathon Olympic roster. She started
training longer distances and found that her 10K time was getter gradually
better. Sally entered her first 10K race and, to everyone’s amazement,
came in the top three. With that success, she decided to work toward going
the 26.2 miles for the marathon.
Her country was not known for producing top-notch marathoners, and
Sally saw this as an excellent opportunity to make a name for herself. To
prepare, Sally followed her proven formula for the 5K (3.1 miles) and 10K
(6.2 miles) by gradually increasing her practice mileage in her morning run
and her late afternoon run. To her surprise, she started “hitting the wall”
after 10K, but figured if she persisted she could eventually pass that
barrier and go the distance. To her dismay, it did not happen. She just
could not get her body to go past 10K without stopping, and she knew that
stopping was a terrible way to win a race. She decided to call a retired
marathoner to see if she could get some ideas for how to do better, and
the marathoner asked her to write down her training protocol: “Sleep,
Wake up, Glass of Orange Juice, Morning Practice Run, Shower, Dress,
Breakfast . . ..” The marathoner realized right away what was happening,
and asked the key question: “What do you drink during your morning run?”
The answer was “Nothing . . . I never drink anything during my practice
runs.” The response was immediate: “You are trying to emulate your 5K
training, but you are increasing the distance dramatically. You are running
out of fuel and fluid, making it difficult to sustain normal blood sugar,
normal blood volume, and the normal sweat rate, making it difficult to
adequately cool yourself. Try drinking a suitable fluid in the same pattern
that you are able to drink during the Olympic marathon . . . every 5
kilometers.”
So, Sally figured out how to put some beverages on the trunk of her car,
run 2.5 km out and 2.5 km back, grab a drink, and repeat this pattern.
Almost immediately the carbohydrate, electrolytes, and water in the
beverage started helping and Sally was soon able to go the distance. She
learned something critically important. It takes more than a desire to
compete — You also have to do the right things.

CASE STUDY DISCUSSION QUESTIONS

Make a list of what nutrients Sally loses during a training marathon run
(26.2 miles) and then approximate the volume of each nutrient that she
loses. (Sally is 105 lb, age 25 years, the typical training temperature is
70°F, and her practice time for the 10K is 45 minutes. She loses 4 lb from
beginning to end of her training.)

1. How much liquid should she consume to prevent dehydration? Use the
sweat rate calculator that follows to predict how much she should
drink, and the optimal volume to consume at timed intervals.
2. What are Sally’s liquid needs during the practice run? Create a
consumption/drinking pattern with a sports beverage of your making
(you create the contents) that will satisfy Sally’s needs during her 10K
practice run, with a drinking frequency and volume that would be
necessary. Consider the following:
Volume of fluid
Electrolytes and their concentration
Carbohydrates and their concentration
Drinking frequency and volume
Problems the runner may encounter
 Gastric emptying
Excess consumption
Diarrhea

Sweat Rate Calculator

A. Body weight preexercise [lb]
B. Body weight postexercise [lb]
C. Change in body weight (an estimate of sweat loss) [“A” − “B”,
lb]
D. Conversion of sweat loss in lb to oz [1 lb = 16
oz] “C” ×
16
E. Volume of fluid consumed during exercise [oz]
F. Unreplaced sweat loss in oz “D” − “E”
G. Exercise time [min]
H. Sweat rate per minute [oz/min]
“D”/“G”
I. Amount of additional fluid to be consumed per minute to “F”/“H”
match sweat rate (oz)
J. Calculate the volume of additional fluid to be consumed “I” × 15
every 15 minutes to match sweat rate
K. Calculate the total volume of fluid that should be “H” × 15
consumed every 15 minutes to match sweat rate

Introduction

It is difficult to imagine any nutrient more important for sustaining health and
athletic performance than body water. A good hydration state ensures not only
adequate total body water but also a good balance of extracellular fluid
(ECF) and interstitial fluid (ISF). Although all nutrients are required for
sustaining health, the performance deficit that occurs in a poorly hydrated
person, resulting in either hypohydration or hyponatremia, may occur more
quickly and is more noticeable than with any other nutritional substance. Water
is the single biggest component of human weight, ranging from ∼50% to 70%
of body weight, depending on body composition. Athletes typically have more
body water than nonathletes because of a greater proportion of lean tissue,
which is composed of more water than fat tissue (fat tissue is essentially
anhydrous) (76, Table 7.1). People who live in moderate climates typically lose
∼2.5 L (2.6 quarts) of water per day performing normal activities (49). Men
working in hot climates can lose as much as 12 L (12.7 quarts) of water per
day (6). Ultraendurance cyclists performing in a hot environment were found to
lose up to 12.7 L (13.4 quarts) of water per day (8).
Table 7.1 Body Fat Percent and Body Water as Percent of Total
Weight
Body Fat Body Water Percent
Percent
Females
4–20 58–70
21–29 52–58
30–32 49–52
33+ 37–49
Males
4–14 63–70
15–21 57–63
22–24 55–57
25+ 37–55

Source: Wang Z, Deurenberg P, Wang W, Pietrobelli A, Baumgartner RN, and Heymsfield. Hydration of fat-
free body mass: review and critique of a classic body-composition constant. American Journal Clinical
Nutrition. 1999; 69(5): 833-841.

Extracellular Fluid

This represents the fluid outside the cell and includes blood (intravascular
fluid [IVF]) and interstitial water. The primary electrolyte controlling the
volume of extracellular water is sodium. Blood-associated extracellular water
is necessary as a transport agent for nutrients and oxygen to muscle, organ,
fat, and skeletal cells and is necessary for transporting fluid to sweat glands.
Low extracellular water is associated with low sweat rates and poor cooling
capacity. Intracellular fluid (ICF) is the fluid inside the cell.

Interstitial Fluid

The fluid that surrounds cells and is part of the ECF and that is not a
component of blood (another component of the ECF). Excess interstitial
water results in edema.

Intracellular Fluid

ICF represents the fluid inside cells, which contains water, sugars,
neurotransmitters, amino acids, and other small proteins involved in cellular
function. The primary electrolyte controlling the volume of intercellular water
is potassium.

Hypohydration
 This represents the result of losing more body water than is replaced (i.e.,
dehydration), resulting in a state of hypohydration. Severe hypohydration is
associated with body water deficits of 6%–10% of body weight and is
associated with reduced exercise performance, decreased cardiac output,
lower sweat production, and reduced muscle blood flow. The urine osmolality
when in a state of hypohydration is >900 mOsm/kg, whereas euhydration
(definition follows) is <700 mOsm/kg. Although muscle cramps have multiple
causes, including muscular fatigue, they may be associated with
hypohydration and electrolyte imbalances.

Hyponatremia

The condition refers to low (hypo) sodium (na) in the blood (emia), which
results in lower blood volume, poor blood flow to working muscles, lower
sweat rates, headaches, nausea, and loss of balance. Blood sodium in a state
of hyponatremia is <135 mmol/L. Blood volume is normalized on the main
extracellular electrolyte, sodium, and when sodium is low, water leaves the
blood to normalize the sodium concentration. The water goes to the
surrounding tissue and creates edema, and if the edema occurs in the brain,
it can cause serious confusion and a coma. In athletes, the likely cause of
hyponatremia is overconsumption of fluids in excess of sweat and urinary
losses, or high consumption of sodium-free or hypotonic sports beverage
(typically water), and as sodium is lost in the sweat but not replaced,
hyponatremia occurs. Women typically are smaller than men and have lower
sweat rates than men and may be at greater risk of overdrinking that could
result in hyponatremia.

Euhydration

Also referred to as normohydration, this refers to being in a state of

adequate or normal hydration that is associated with normal sweating
capacity, good control of body temperature, adequate delivery potential of
nutrients to body tissues, and adequate removal potential of metabolic by-
products from body tissues. A euhydrated state is associated with a urinary
osmolality of <700 mOsm/kg.

The elevated water loss in physical activity is the result of a basic reality:
More energy is used by working tissues per unit of time during physical activity
than when not active, and humans are relatively inefficient (typically ranging
from 20% to 40%) at converting “burned” fuel to muscle movement. Therefore,
about 60%–80% of this burned energy creates heat (51). Because humans
must maintain a relatively stable body temperature of ∼98.6°F (37°C), sweat is
produced to dissipate this excess heat. The greater the intensity of activity, the
greater the heat production and the greater the sweat loss to maintain body
temperature. The requirement for water and associated elements found in
sweat is, therefore, determined by the amount of sweat that has been lost.
(Table 7.2 shows the element concentrations typically found in sweat.)
 Table 7.2 Concentrations of Electrolytes in Sweat, Plasma, and
Intracellular Water
Sweat Plasma Intracellular Water
(mmol/L) (mmol/L) (mmol/L)
Sodium 20–80 130–155 10
Potassium 4–8 3.2–5.5 150
Calcium 0–1 2.1–2.9 0
Magnesium <0.2 0.7–1.5 15
Chloride 20–60 96–110 8
Bicarbonate 0–35 23–28 10
Phosphate 0.1–0.2 0.7–1.6 65
Sulfate 0.1–2.0 0.3–0.9 10

Source: Maughan RJ. Fluid and electrolyte loss and replacement in exercise. In: Harries M, Williams G,
Stanish WD, Micheli LL, editors. Oxford Textbook of Sports Medicine. New York (NY): Oxford University
Press; 1994, p. 82–93.

Besides sweat, water is also lost through urine, fecal matter, breathing
(expired air), and tears. However, unless someone is losing a great deal of
water from diarrhea or following the consumption of a diuretic that induces
increased urinary volume, nothing compares with the amount of water that can
be lost through sweat (Table 7.3).

Table 7.3 Typical Daily Water Loss in an Inactive Man

Weighing 70 kg (154 lb)
Source of Water Loss Amount (L) Amount (oz)
Kidneys (urine) 1.40 47.3
Breathing (expired air) 0.32 10.8
Gastrointestinal tract 0.10 3.4
(fecal matter)
Skin 0.65 22.0
(perspiration/sweat)
Skin (insensible loss) 0.53 17.9
Total 3.0 101.4

The loss of body water increases dramatically through physical activity, with even greater water losses if
the activity is of high intensity and performed in high heat and humidity. Water losses may also be
increased through diarrhea and conditions that increase urinary volume output.
Source: Maughan RJ, Burke LM. Handbook of Sports Medicine and Science, Sports Nutrition. Oxford: Wiley
Blackwell; 2002, p. 52.

The electrolytes (the major intracellular electrolyte is potassium and the

major extracellular electrolyte is sodium) influence the hydration state by
determining the distribution of body water. By definition, electrolytes are
substances that conduct electrical currents, such as a nerve impulse, and have
either a negative charge (anion) or a positive charge (cation). The major
electrolytes are sodium, chloride, potassium, magnesium, calcium,
bicarbonate, and sulfate. Because sodium, chloride, and potassium are of
particularly high importance to water balance and in helping to determine
where body water goes, these electrolytes are the focus of this chapter.

Water Has Many Functions

It is hard to imagine any normal body function that can take place without
sufficient water in the system. Body tissues require water for many essential
functions, including:

Regulation of body temperature: Humans are not efficient at converting

metabolized energy into muscular movement, with ∼60%–80% of
metabolized energy creating heat. We cannot acquire the additional heat
associated with higher energy metabolism (i.e., we must sustain a nearly
stable body temperature), so the excess heat is dissipated through the
evaporation of sweat.
Nutrient transport: Nutrients are transported to tissues via blood, which is
primarily water. A drop in blood volume through inadequate replacement of
water inhibits the normal transportation of nutrients to tissues and
compromises tissue function.
Joint lubrication: Water is the major lubricant in joints, including the spine,
helping to reduce stiffness and soreness. As an added benefit, sustaining a
good hydration state helps to diminish the concentration in joints of
potential inflammatory agents, such as uric acid.
Metabolic waste removal: Tissues are constantly producing metabolic
waste products that must be removed, as they are potentially toxic.
Nitrogenous waste, for instance, is highly toxic and requires chronic
removal through urine. This removal takes place primarily through the
kidneys, but waste products are also removed through the skin. Both urine
(kidneys) and sweat (skin) production are water dependent.
Digestion: The digestion of foods into component nutrients and nonnutrient
waste is highly water dependent from the very beginning (saliva) to the
end (producing a lubricated stool that avoids constipation). Poor hydration
inhibits digestion and normal bowel habits.
Absorption: Absorption of nutrients through the intestinal wall and into the
blood is water dependent. A poor hydration state inhibits nutrient
absorption, limiting the potential multiple benefits that are received from
consumed foods.
Immunity: Through blood and lymph, water distributes white blood cells,
minerals, vitamins, and glucose to cell for normal cell function. The white
blood cells and other immune system cells that are distributed to tissues
improve disease resistance.

Other Functions of Water

Central Nervous System Function
The central nervous system (CNS) does not have a nutrient storage capacity,
so must be fed continuously by nutrients and oxygen transported by blood,
which is water based. Minor interruptions in blood flow to the CNS (brain
ischemia) have the potential of causing neurologic damage and if the blood
flow interruption continues, potentially, death. Brain ischemia is also referred
to as cerebral ischemia or cerebrovascular ischemia and describes a condition
in which insufficient blood flows to the brain to satisfy the brain’s metabolic
demands. The insufficient blood flow results in inadequate oxygen delivery
(hypoxia) that may result in death of brain tissue and, potentially, cerebral
infarction (ischemic stroke).

Cardiovascular Health
Sustaining a good hydration state enables the heart to more effectively pump
blood to working muscles and other tissues. Maintenance of a good hydration
state is an important principle for sustaining athletic performance and,
importantly, reducing heart stress.

Sustaining Water Balance

Humans have multiple systems for sustaining water balance, but these
systems can easily be strained with a gross failure to consume sufficient water
and associated electrolytes. It has been estimated that, for sedentary people
living in a temperate client, daily water turnover is ∼2–2.5 L, but men working
in hot environments may experience sweat losses of 10–12 L (95).
Avoiding a state of dehydration requires that the water lost through sweat
and urine must be adequately replaced. Water comes from multiple sources,
including the fluids that are directly consumed, the water in fresh fruits and
vegetables, and the water produced from energy metabolism (e.g.,
Carbohydrate + Oxygen = Energy + Carbon Dioxide + Water), which provides
∼1 mL water for each kilocalorie of energy expended (Table 7.4).

Table 7.4 The Water Content (Percent of Total Weight) of

Foods Commonly Consumed
Very high water Plain oatmeal, soy milk, tofu, cooked brussels sprouts,
content (over 80%) cucumber, carrots, watermelon
High water content Cooked barley, hard-boiled egg, low-calorie salad
(65%–80%) dressings, bananas, most fish
Medium water Cooked pinto beans, broiled ground beef, roasted
content (50%–65%) chicken
Low water content Plain bagel, cheddar cheese, regular salad dressings
(30%–50%)
Very low water Toasted whole wheat bread
content (15%–30%)
Extremely low water Most ready-to-eat cereal, baked taco shell, regular
content (below 15%) peanut butter, fruit leather, sun dried tomatoes, raisins
 No water content White granulated sugar, oils

Source: USDA. https://www.ars.usda.gov/is/np/NutritiveValueofFoods/NutritiveValueofFoods.pdf Accessed

7/24/2018

Dehydration

This represents a state of low body water, typically the result of losing more
water via sweat, vomiting, or diarrhea than was replaced. Dehydration refers
to the process of losing body water and, if it continues, results in a state of
hypohydration. Dehydration is likely to be associated with a drop in blood
volume, which results in lower cooling capacity as a result of lower sweat
rate. As physical activity is heat producing, requiring greater amounts of heat
to be dissipated via sweat, athletes who become dehydrated must diminish
the energy expended (i.e., they must slow down) to produce less heat. Put
simply, dehydrated athletes with fluid deficits >2% body weight can
experience compromised cognitive function and reduced aerobic exercise
performance, particularly if the exercise occurs in hot weather. Anaerobic
performance deficits are more commonly seen with dehydration associated
with 3%–5% loss of body weight. There is concern that purposefully
dehydrating to “make weight” prior to a competition may negatively affect
performance.

Approximately 33% of total body water is in blood plasma and the spaces
between cells (ECF), whereas ∼66% of total body water is inside cells (ICF).
The amount of water held in the body is affected by several factors, including
body composition. The fat-free mass in a well-hydrated state is composed of
about 72%–75% water, whereas the fat mass contains much less water of
about 10%–20%, which is mainly from the plasma running through fat tissue
(95). Fat itself is essentially anhydrous (i.e., without water). Because females
typically have higher body fat levels than men, female bodies hold
proportionately less water. A 70 kg (154 lb) male with average body
composition has ∼42 L (44.4 quarts) of water. (Note: 1 L of water = 1 kg, so 42
L = 42 kg or 92.4 lb water.) In this example, 60% of weight in the 70 kg male is
water (Figure 7.1).
FIGURE 7.1: Water distribution in a human body. The average adult male body
is approximately 60% water. Average adult females have slightly less body
water, and average children have slightly more body water. Higher body fat
levels are associated with lower total body water as a percent of weight. (From
Szlyk PC, Sils IV, Francesconi RP, Hubbard RW, and Armstrong LE. Effects of
water temperature and flavoring on voluntary dehydration in men. Physiology
& Behavior. 1989; 45(3): 639–47.)

66% of a person’s total body weight is from water

65% of total body water is intracellular
35% of total body water is extracellular
Well-hydrated muscles are about 75% water
Bones are about 22% water
Fat is essentially anhydrous, having only about 10% water content
Blood is about 83% water
Average males are about 60% water weight
Average females are about 50% water weight
Obese individuals are about 40% water weight
Athletes are about 70% water weight

The loss of body water is also affected by a number of factors, including:

Ambient temperature: Higher temperature results in greater water loss

through higher sweat rates. The body has to remove heat associated with
higher energy metabolism and also must remove heat associated with
higher temperature.
Ambient humidity: Higher humidity results in greater loss through higher
sweat rates. It is difficult to evaporate water (sweat) into a high-water
(high-humidity) environment. As a result, cooling capacity is less efficient
so more sweat is produced in an attempt to improve cooling (Figure 7.2).

FIGURE 7.2: Sweat rates during different climatic conditions.

Combinations of any of these three result in even higher sweat rates.

Age: Several studies have suggested that the temperature regulation of

preadolescent children is as effective as an adult (60, 73). However, most
studies have found that temperature thermoregulation in young
(preadolescent) children and older adults is less effective as that in young
adults (39, 41, 45, 65, 159). A recent study found that young boys and
adult men had similar thermoregulatory responses to 80 minutes of
exercise in the heat performed at a fixed metabolic heat production.
However, sweat volume was found to be lower in boys, despite similarities
in the absolute metabolic heat production and the evaporative heat
balance requirement (85).
Urinary loss: Urine is always being produced to excrete metabolic by-
products and as a means of adjusting the concentration of intercellular
(inside the cell) and extracellular (outside the cell, including blood plasma)
electrolytes and total body water volume. Certain substances may induce a
diuretic effect, including high-potassium foods (e.g., fresh fruits and
vegetables) and drugs consumed for the purpose of lowering blood volume
(e.g., lasix, aldactone, dyazide).
Gastrointestinal (fecal) loss: The typical loss of water from the
gastrointestinal (GI) tract is relatively low (∼0.10 L/day). However, a state
of diarrhea can dramatically increase GI tract water loss to 100× more. Any
number of conditions may result in diarrhea, including bacterial infection
 (e.g., rotavirus, Escherichia coli), consumption of foods/food substances
that the individual has an intolerance to (e.g., lactose intolerance), or
heavy consumption of high osmolar substances that have a slow
absorption rate (e.g., the food additive sorbitol or the sweetener high-
fructose corn syrup [HFCS]).
Protein consumption: High-protein diets are associated with dehydration,
even in athletes who consume the same amount of water as athletes
consuming less protein but who are not dehydrated. The dehydration is
caused by the removal of nitrogen from the excess protein. The resulting
elevated blood urea nitrogen (BUN) must be removed via urine, resulting in
an increased urine formation (161).
Salt consumption: Blood volume is, to a great degree, determined by the
availability of sodium. Low salt (sodium chloride) consumption has the
effect of lowering blood volume and increasing water loss. High salt
consumption requires the formation of more urine to excrete the excess, as
the body attempts to maintain urine osmolarity (67).
Clothing: The type of clothing worn may influence the ability to dissipate
heat via sweat. Clothing made of material (e.g., cotton) that traps water
results in ineffective cooling because of lower evaporation, resulting in
more sweat formation and greater water loss. Some athletic clothing is
made of materials specifically designed to release water and enhance
evaporative cooling. These moisture-wicking materials help to transport
liquid to the surface, thereby enhancing evaporation and cooling.
Conditioned state: People who are physically fit and well acclimated to the
environmental conditions are capable of producing more sweat to enhance
cooling, and the sodium content of the sweat produced is lower than that
in less well-conditioned people, enabling better maintenance of plasma
volume.

Systems for Regulating Water Balance

Important Factors to Consider

Total body water volume = ∼60% of total body weight

Extracellular fluid volume = ∼20% of body weight
IVF: On average, ∼3.5 L (∼20% of ECF) of fluid that is inside the
blood vessels (i.e., the blood plasma) and the fluid that makes up
lymph.
ISF: On average, ∼10.5 L (∼80% of ECF) of fluid in the space that
surrounds cells, but does not include blood plasma or lymph.
ICF volume = ∼40% of body weight
ICF: On average, ∼28 L of fluid contained inside cells.
The approximate volume of the different fluid compartments is
provided only for relative comparison purposes. Fluid shifts occur
between compartments because of hydrostatic and osmotic pressure
and because of changes in body temperature. As an example, water
 shifts to the skin to enhance the sweat rate when body temperature
rises.

Fluid Balance
Sustaining water balance involves assuring the volume of water lost equals the
amount of water that is replaced. Water is always being lost through breathing,
insensible (not noticed) skin loss, sweat (noticeable water on the skin), urine,
and the GI tract (fecal loss). We replace water through the drinks we consume,
from the water in foods we consume, and through the water created from
energy metabolism (Table 7.5).

Table 7.5 Water Balance

Water out = Water in
Air (breathing) Drinks
Skin loss (insensible) Foods
Skin loss (sweat) Water of metabolism
Urine
Feces

Source: United States Department of Agriculture, Agricultural Research Service, 2012. Available from:
http://www.ars.usda.gov/ba/bhnrc/ndl. Accessed November 4, 2016.

Electrolytes

Sodium and Chloride (Salt)

Sodium and chloride are consumed as salt, and both of these electrolytes are
involved in multiple body functions (see Table 7.5). Importantly, sodium (Na+)
and chloride (Cl−) are the main electrolytes of the ECF, which includes blood
plasma (64). The main cation (positively charged ion) inside the cells is
potassium, whereas sodium is the primary cation outside the cell in the ECF.
Although both potassium and sodium exist inside and outside cells, the
concentration of sodium is ten times higher outside the cell than inside, and
the concentration of potassium is thirty times higher inside the cell than
outside. Pumps in the cell membrane use energy to remove sodium from inside
the cell in exchange for potassium. The energy usage in this process is
significant, accounting for ∼20%–40% of the resting energy used by average
adults (21). These concentration differences between the primary intercellular
and extracellular electrolytes impact cell membranes and account for multiple
functions that include fluid shifts, muscle contraction (including cardiac
function), and nerve impulse transmission (138, Table 7.6).

Table 7.6 Electrolyte Functions and Homeostasis

 General Distribution of body fluids through osmosis and the
functions sodium–potassium pump
Acid–base balance (pH and buffers)
Regulation of nerve impulse transmission
Muscle contractility

Sodium
(Na+) The main extracellular fluid (ECF) electrolyte
40% found in bones, 10% in intracellular fluid (ICF), and
50% in ECF
Kidneys regulate excretion (the aldosterone system)
Lost through both sweat and urine

Potassium
(K+) The main ICF electrolyte
Maintains fluid balance in the ICF environment
In enzymatic reactions involving protein and glycogen
synthesis
Nerve and muscle activity
Kidneys excrete K even when dietary intake is low
Excessive loss of K may lead to cardiac dysrhythmias that
can be fatal
High potassium may be protective against hypertension
Very high potassium intake may result in cardiac
dysrhythmias that can be fatal

Chloride
(Cl−) The main anion (−) in ECF
Required for acid–base balance
Required for nerve impulse transmission
Part of HCl produced in the stomach and required for
normal digestion

Sodium absorption influences the absorption of other nutrients, including

amino acids, monosaccharides (primarily glucose), chloride, and water.
Chloride is a major component of the hydrochloric acid in the stomach and
lowers the gastric pH to enable the digestion of proteins and other nutrients
(75).
Because sodium is the primary cation in the ECF (including blood volume),
blood volume is, to a large extent, controlled through processes that regulate
sodium. Greater sodium consumption results in either higher blood volume or
higher urinary sodium losses. Receptors that monitor BP and blood osmolarity
communicate changes to the hypothalamus, which forms vasopressin (arginine
vasopressin and antidiuretic hormone [ADH]). The two main actions of
vasopressin are (138):
 Regulation of ECF volume by influencing renal processing of water.
Vasopressin results in decreased urine formation (hence the name “ADH”)
that ultimately results in greater blood volume and BP (Figure 7.3).

FIGURE 7.3: Production of antidiuretic hormone (ADH). (From Lippincott

Professional Development. Philadelphia [PA]: LWW, August 2014.)

Vasoconstriction that serves to compensate for low blood volume by

increasing vascular resistance.

The release of vasopressin results primarily from the following conditions:

Hypovolemia (low blood volume). The decrease in blood volume is

detected by receptors in the arterial wall, which signals the hypothalamus
to release vasopressin by the pituitary gland.
Hypotension (low BP). The lower BP stimulates vasopressin release through
sympathetic nerve activity.
Rise in osmolarity (high blood sodium). The increase in osmolarity, typical
of what occurs in dehydration, stimulates vasopressin release.

When osmolarity is low (low blood sodium), aldosterone is produced through

a cascade of reactions that are stimulated through the release of renin. Renin
converts angiotensinogen to angiotensin I, which is then converted to
angiotensin II. Angiotensin II not only constricts blood vessels to increase BP
but also stimulates the production of aldosterone (Figure 7.4). Aldosterone
causes the kidneys to retain sodium, which eventually results in higher blood
osmolarity and an increase in plasma volume and BP (138).
FIGURE 7.4: Production of aldosterone. (From Cohen BJ, Hull K. Memmler’s
The Human Body in Health and Disease. 13th ed. Philadelphia [PA]: LWW [PE];
2015.)

It is not common for people to experience a salt (sodium chloride)

deficiency as a result of inadequate dietary intake. However, it has been found
that hyponatremia (hypo = low; NA = sodium; emia = blood plasma; low
plasma sodium) may occur in athletes who exercise for long periods in a hot
environment and fail to consume sufficient sodium during the exercise (2).
Severe vomiting and/or diarrhea and the use of some diuretics (chlorthalidone)
that induce sodium loss may also result in hyponatremia (156). More
information on hyponatremia is included later in this chapter.
The recommended intake for sodium is based on the adequate intake (AI)
level to replace the loss of sodium through sweat in moderate activity (Table
7.7). Please note that the average consumption of sodium is well above the
level recommended by the Food and Nutrition Board (75).

Table 7.7 Adequate Intake for Sodium and the Equivalent Salt
(Sodium Chloride) Required to Achieve This Level of
Intake
Group Age Male and Female Sodium Male and Female Salt
(Years) Intake (g/d) Intake (g/d)
Adolescents 14–18 1.5 3.8
Adults 19–50 1.5 3.8
Adults 51–70 1.3 3.3
Adults 71+ 1.2 3.0
Pregnancy 14–50 1.5 3.8
Table 7.7 Adequate Intake for Sodium and the Equivalent Salt
(Sodium Chloride) Required to Achieve This Level of
Intake
Group Age Male and Female Sodium Male and Female Salt
(Years) Intake (g/d) Intake (g/d)
Breastfeeding 14–50 1.5 3.8

The full table that included the recommended intake levels for infants and children is included in the
Appendix.
Source: Institute of Medicine, Food and Nutrition Board. Sodium and Chloride. Dietary Reference Intakes
for Water, Potassium, Sodium, Chloride, and Sulfate. Washington (DC): National Academies Press; 2005.
p. 269–423.

Disease Risks With Excess Intake of Salt

Important Factors to Consider

Most people have effective mechanisms for excreting excess sodium in

the urine. However, about 10% of the population is missing these
mechanisms, making them at high risk of retaining too much sodium
with a resultant high BP (hypertension). Sustained high BP is a risk factor
for cardiovascular and kidney disease, making it important for everyone
to have BP checked periodically to determine if he or she is hypertensive.
People with hypertension must be cautious about how much salt they
consume and are also encouraged to eat foods high in potassium to help
pull fluid out of the blood and into cells to help control blood volume/BP.

There are several disease risks associated with chronic consumption of

excess sodium, which is far more prevalent than underconsumption of sodium.
The 2015–2020 Dietary Guidelines for Americans recommend that Americans
consume less than 2,300 mg of sodium per day as part of a healthy eating
pattern. According to the Centers for Disease Control and Prevention (27), 90%
of children and 89% of adults aged 19 and older consume more than 3,400
mg/day, or over 1,000 mg more per day than the recommended maximum.
Recent findings indicate that the global sodium intake is 3,960 mg/day (128).
Reading the label to help understand the level of sodium in packaged foods is
useful (Table 7.8). Please note that the label refers to the per serving amount,
which may be a lower amount than people are accustomed to eating.

Table 7.8 Interpreting the Sodium Content on Nutrition

Facts Label in Packaged Foods
Label Meaning
Sodium free Less than 5 mg sodium per serving
Salt free Less than 5 mg sodium per serving
Very low sodium 35 mg sodium or less per serving
Table 7.8 Interpreting the Sodium Content on Nutrition
Facts Label in Packaged Foods
Label Meaning
Low sodium 140 mg sodium or less per serving
Reduced sodium or At least 25% lower sodium than the regular product
less sodium
No salt added The amount of sodium per serving must be listed on the
label

Hypertension
There is clear evidence that chronic consumption of a high level of salt
increases the risk of high BP, whereas lowering salt consumption lowers BP
(43, 46). Chronic high BP is associated with heart disease and early death (47,
53). Some individuals are more sensitive to sodium intake than others,
including those with diagnosed hypertension. Higher sodium sensitivity risk is
also seen in people who are overweight, African-Americans, and older adults
(157). It is likely that many of these high-risk individuals have a genetic
predisposition to sustaining an elevated aldosterone production, which inhibits
sodium excretion (55). The type of foods consumed may have a desirable
change in BP. Consumption of the Dietary Approaches to Stop Hypertension
(DASH) diet, which is high in fruits, vegetables, whole grains, poultry, fish, low-
fat dairy, and nuts, has been effective in lowering BP in people who have
hypertension (3).

Kidney Stones
Elevated dietary intake of salt is associated with greater excretion of urine
calcium, and kidney stones are strongly associated with high calcium in the
urine. It has been found that high sodium intakes (∼5,000 mg/day) result in a
30% increase in developing kidney stones when compared with people
consuming less sodium (∼1,500 mg/day) (36). Other studies have found that
lowering sodium intake lowers the risk of developing kidney stones (18).

Gastric Cancer
The chronic consumption of high-salt foods (Table 7.9) has been found to
increase gastric cancer risk. High-salt foods may inflame the stomach lining,
which increases the possibility of bacterial infection (Helicobacter pylori) that is
associated with gastric ulcers and cancer (150). The original associations with
salt intake and gastric cancer were found in Asian populations, where the
consumption of high-salt foods is common (69, 88).

Table 7.9 A Sampling of Sodium and Salt Content in Foods

Commonly Consumed
Foods Amount Sodium Sodium Chloride (Salt)
(mg) (mg)
Orange juice 1 cup 0 0
Table 7.9 A Sampling of Sodium and Salt Content in Foods
Commonly Consumed
Foods Amount Sodium Sodium Chloride (Salt)
(mg) (mg)
Almonds 1 cup 1 3
(unsalted)
Tomato 1 medium (fresh) 6 15
Carrot 1 medium (fresh) 42 105
Bread, whole 2 slices 264 660
wheat
Cereal, 1 cup 266 665
cornflakes
Dill pickle 1 spear 300 800
Hot dog (beef) 1 hot dog 510 1,300
Ham 3 oz 1,000 2,500
Pretzels 2 oz or 10 pretzels 1,000 2,500
(salted)
Macaroni and 1 cup (from 1,300 3,300
cheese canned)

Source: United States Department of Agriculture. National Nutrient Database for Standard Reference,
Release 28.

Osteoporosis
The development of strong bones involves many factors, including adequate
availability of calcium and vitamin D, adequate bone stress, estrogen
availability (in women), and adequate energy intake. Any single factor may
compromise bone mineral density, and there is concern that high sodium
consumption may be a negative factor in bone health. Because high levels of
sodium intake are known to elevate calcium excretion, there is concern that
this calcium loss may increase the risk of developing low bone density.
Although more studies are needed to confirm this risk, a study has found that
postmenopausal women with high salt consumption had lower bone mineral
density of the hip (44).

Potassium
Although sodium is the primary cation (positively charged electrolyte) outside
cells, potassium (K+) is the primary cation inside cells. The different
concentrations of potassium and sodium inside and outside cells create an
electrochemical “charge” in the cell membrane. The cell’s membrane uses this
electrical charge to pump sodium out of the cell and potassium into the cell
and, in doing so, is involved in muscle contraction and nerve impulse
transmission.
Besides this critically important cell membrane function, potassium is also
involved in carbohydrate metabolism through the enzyme pyruvate kinase
(137). The AI level, established by the Food and Nutrition Board of the Institute
of Medicine, is 4,700 mg/day for all adolescents and adults, both male and
female, and is found to satisfy potassium needs while having the effect of
lowering BP and lowering the risk for kidney stones. The recommended
potassium intake for breastfeeding women is slightly higher (5,100 mg/day).
(See the Appendix for the full recommended intakes, including infants and
children.) Dietary surveys of the U.S. population indicate that potassium intake
is approximately half of the recommended level (61, Table 7.10). As a general
rule, fruits and vegetables are an excellent source of dietary potassium.

Table 7.10 A Sampling of Potassium Sources in Foods

Commonly Consumed
Foods Serving Size Potassium (mg)
Almonds 1 oz 200
Orange 1 medium (fresh) 237
Sunflower seeds 1 oz 241
Tomato 1 medium (fresh) 292
Raisin bran 1 cup 362
cereal
Banana 1 medium (fresh) 422
Acorn squash ½ cup (cooked) 448
Lima beans ½ cup (cooked) 485
Raisins ½ cup 598
Plums, dried ½ cup 637
(prunes)
Potato (with skin) 1 medium (baked) 926

Source: United States Department of Agriculture. National Nutrient Database for Standard Reference,
Release 28.

Potassium Deficiency
Potassium deficiency is referred to as hypokalemia (hypo = low; k =
potassium; emia = blood) and typically results from excess potassium loss
rather than inadequate intake (54). Conditions associated with high potassium
losses include diarrhea and vomiting, excess use of laxatives, high alcohol
consumption, some prescribed diuretics (thiazide and/or furosemide), and
depletion of magnesium. Congestive heart failure is associated with
hypokalemia, as is high consumption of black licorice or drinks and products
containing licorice. Licorice contains an acid (glycyrrhizic acid) that increases
urinary excretion of potassium while retaining sodium (108).
Several studies suggest that the combination of excess salt consumption,
coupled with inadequate potassium intake, increases the risk for several
diseases, including hypertension, kidney stones, osteoporosis, and stroke. The
current recommendations for greater consumption of fresh fruits and
vegetables are, to a large degree, to lower sodium intake and elevate
potassium intake to reduce these disease risks.

Hypertension
Studies examining the dietary intakes of Americans have found that those with
higher intakes of potassium have lower BP than those with lower intakes of
potassium (61). The DASH diet has provided additional evidence that higher
potassium intakes help to lower BP (5).

Kidney Stones
High levels of calcium loss via urine increase kidney stone risk, and it has been
found that low potassium intakes increase urinary calcium (50, 86). This is a
powerful relationship, as several studies found that diets high in potassium or
with a high potassium intake relative to animal protein consumption
significantly reduced the incidence of kidney stone development (35, 50).

Osteoporosis
There is strong evidence that higher potassium intakes are protective of bones,
likely because potassium helps to develop bicarbonate, which buffers acidity. A
failure to provide sufficient potassium lowers bicarbonate formation, forcing
the removal of calcium from bone to use calcium as a buffer. Greater
consumption of fruits and vegetables has the effects of buffering system
acidity, helping to keep calcium in bones (151, 168).

Potassium Toxicity
Although it is more common for people to consume insufficient potassium,
potassium toxicity may occur when the intake of potassium is greater than the
capacity of the kidneys to clear the excess (76). This condition, referred to as
hyperkalemia, is most likely to occur with intakes of prescribed supplements
that exceed 18,000 mg in a single dose. Hyperkalemia may also occur with
severe trauma, such as a burn that covers a large proportion of the body,
damages cells, and causes a sudden elevated plasma potassium. Some
nonprescription medications, including nonsteroidal anti-inflammatory drugs
(NSAIDs), are associated with hyperkalemia, as are some prescription
antihypertensive agents (β-blockers, etc.) (92).

Exercise and the Balance of Fluids and Electrolytes

Systems for Adding and Removing Heat

There are multiple ways that an athlete can acquire heat and multiple ways
that an athlete can dissipate the acquired heat (Figure 7.5).
FIGURE 7.5: Systems for adding and removing heat in an exercising athlete.
(From Sawka MN, Latzka WA, Montain SJ. Effects of dehydration and
rehydration on performance. In: Maughan RJ, editor. Nutrition in Sport. London:
Blackwell Science; 2000. p. 205–17.)

Important Factors to Consider

Exercise increases the rate at which energy is burned. Greater energy

expenditure results in more heat production, and because humans are
only ∼30% efficient at converting metabolized fuel to energy, ∼70% of
all metabolized energy burned creates heat that must be dissipated to
avoid a potentially dangerous rise in body temperature.
The primary system humans have for removal of heat is the evaporation
of sweat. Because exercise increases the necessity to remove heat, the
rate at which fluids are lost is increased to maintain body temperature.
The greater the energy expenditure per unit of time (i.e., the greater the
exercise intensity), the greater the heat production, and the greater the
sweat rate to dissipate the produced heat.

Factors That Affect Body Temperature

The following factors affect body temperature in humans:

Solar radiation
Air temperature
Air humidity
Ground thermal radiation
Ground reflected solar radiation
Energy metabolism (contracting muscle, etc.)
Sweat
Respiration
Convection
Clothing or protective equipment
Wind
Conditioned state

Regardless of the source of heat or cooling, the body must maintain a

relatively constant temperature to avoid thermal stress (too cold or too hot)
(Figure 7.6).

FIGURE 7.6: Heat balance equation. (From Kronenberger J, Ledbetter J.

Lippincott Williams & Wilkins’ Comprehensive Medical Assisting. 5th ed.
Philadelphia (PA): WK Health and Pharmacy; 2016.)

Physical activity creates heat, which must be dissipated for the athlete to
continue the activity. Failure to dissipate sufficient heat may elevate core body
temperature to a point that results in heat illness and, if severe, death. The
primary system for dissipating heat is the production of sweat, the evaporation
of which has a cooling effect. It should be obvious that inadequate sweat
production results in poor heat removal and heat stress. Temperature
regulation represents the balance between heat produced or gained (heat in)
and heat removed (heat out), and when working correctly, these are in balance
and body temperature is maintained. Both internal and external factors can
contribute to body heat. Radiant heat from the sun contributes to body
temperature, and the heat created from burning fuel also contributes to body
temperature. Somehow, the body must dissipate the same amount of heat that
has been acquired to sustain constant body temperature.
Exercise increases heat production significantly, requiring the loss of this
excess heat. The body moves heat from the muscles to the skin where the heat
can be removed to the surrounding environment. This makes blood flow to the
skin important during physical activity (80). Once at the skin, heat can be
removed via evaporation, conduction, radiation, and convection (see Figure
7.6):

Conduction: Heat transfer driven by temperature difference. Because air

has a high thermal resistance, heat transfer from the body to the air is a
minor mechanism for heat loss in humans. This is also a minor contributor
to body temperature maintenance, except where athletes are exposed to
cold surfaces, such as figure skaters and hockey players.
Convection: Heat transfer via movement of fluids. When a fluid passes by
tissue, it absorbs the higher heat of the tissue and transfers the heat via
convection to cooler tissue. This is a minor contributor to body
temperature maintenance, except in athletes who are exposed to cold air,
such as mountain climbers, or cold water, such as swimmers. When the
ambient temperature is very high (above body temperature), convection
can add heat to the body.
Moving more blood to the skin to allow heat dissipation through radiation.
Heat is removed from all hot objects (hotter than the environment) via
radiation, much like a heat radiator in the home. Sun radiation can add
heat to the body, whereas radiative cooling occurs when the athlete is in
an environment cooler than the body temperature. This is typically a minor
contributor to body temperature maintenance, except when the athlete is
in direct sunlight or in a cold environment.
Increasing the rate of sweat production and evaporation. This involves
changing the state of the heat transfer vehicle (fluid) to a vapor
(evaporation) and is the major contributor to body temperature
maintenance during exercise. Approximately 80% of the heat removal
during vigorous exercise is the result of sweat evaporating off the skin (80).

These systems account for the majority of thermoregulation, but during

exercise the majority of all heat loss occurs via the evaporation of sweat.
Sustaining the sweat rate relies on maintenance of the plasma (blood) volume.
Lowering the blood volume results in lower blood flow to the skin with a
reduction in sweat production. Exercise increases the requirement for blood
that goes beyond the production of sweat. Exercise also increases the blood
flow requirement to working muscles to satisfy the demand for energy and
nutrients and to remove the metabolic by-products of burned fuel. Lower blood
volume compromises that capacity to satisfy all of these requirements,
resulting in decreased athletic performance. The maintenance of blood volume
is sufficiently important for athletic performance that many consider it to be
the primary factor determining if physical work can continue at a high intensity.
 The metabolism of energy is only about 20%–40% efficient, with the
remaining 60%–80% of energy burned by tissues creating heat. When the rate
of energy metabolism increases, the heat creation is also increased. This heat
must be dissipated, so the heat-out systems must be turned up. High-intensity
activity may increase heat production to a level 20 times greater than the heat
produced while at rest (127). Failure to dissipate this higher level of exercise-
associated heat production may put the athlete at risk for heat illness, with an
even higher risk of heat illness if environmental heat and humidity are
additional contributors to heat stress. There is a large variability in sweat rates
during physical activity, depending on exercise duration and intensity, fitness
of the athlete, and how well the athlete has acclimatized to the environment
(e.g., heat, altitude, humidity). Consider that a well-trained athlete who is
training in a hot and humid environment commonly loses 1–1.5 L of fluid per
hour and can lose 2.4 L of fluid per hour or more (31, 136, 164).

Heat Index
The HI (also called the apparent temperature) combines the temperature and
relative humidity in the immediate surroundings to provide a value of how
humans perceive the temperature. A high HI results in greater sweat rates
because high humidity results in less effective cooling from sweat evaporation
(it is difficult to evaporate the water of sweat into high water content of the
environment). As a result, the sweat volume is increased in an attempt to
achieve better cooling. High HI values may make it extremely difficult or
impossible to achieve adequate sweat-related cooling, making activities
dangerous because of the higher risk of heat illness (Figure 7.7; also see Figure
7.2). As demonstrated in Figure 7.2, exercising in higher heat and humidity
results in higher sweat rates than when the exercise occurs in a cooler and
dryer environment, regardless of the exercise intensity.
FIGURE 7.7: The heat index with heat stress risks at different heat index
values. Individual reactions to heat will vary. Heat illnesses can occur at lower
temperatures than indicated on this chart. Exposure to full sunshine can
increase values up to 15°F. (From Anderson MK, Parr GP. Fundamentals of
Sports Injury Management. 3rd ed. Philadelphia [PA]: WK Health and Pharma;
2011.)

Heat Index

A measure of the combined temperature and humidity and is calculated for

shady areas.

Wet Bulb Globe Temperature

The wet bulb globe temperature (WBGT) represents the relative heat stress
experienced from a combination of direct sunlight, temperature, humidity,
wind speed, sun angle, and cloud cover, which affects solar radiation. Although
the multiple factors used to predict the WBGT may be difficult to
simultaneously measure, the factors used to predict WBGT make it an
important index for predicting the heat stress that may be faced by an athlete
(16). It is for this reason that the WBGT method of predicting heat stress is
recommended by the American College of Sports Medicine (7, 146).
 Wet Bulb Globe Temperature

A measure of the heat stress in direct sunlight, which simultaneously

considers temperature, humidity, wind speed, sun angle, and cloud cover
(affecting solar radiation).

Factors Affecting Loss of Fluids and Electrolytes

The following factors that affect fluid and electrolyte loss are considered when
discussing athletes and exercise:

Ambient temperature: Higher temperature results in greater sweat rates.

Ambient humidity: Higher humidity results in greater sweat rates.
Clothing/equipment: Clothing that traps moisture against the skin results in
ineffective evaporation and greater sweat rates and may also lower
convective heat loss through the increase in skin blood flow.
Body surface area: Enhanced sweat production capacity is seen in adults
with larger body surface areas.
Conditioning: Well-conditioned athletes have enhanced sweating capability
(i.e., can sweat a greater volume per unit of time to enhance evaporative
cooling).
Fluid balance: Better fluid balance states are associated with higher sweat
rates. Dehydration reduces the sweat rate by ∼15% and can be elevated
to a normal sweat rate via restoration of water balance (43, 123).
Activity intensity: Higher-intensity activities are associated with more
energy utilization per unit of time with more metabolic heat production,
which requires greater sweat rates to dissipate this heat.
Gender: Women not only have lower sweat rates than men but also have
lower rates of energy expenditure than men because of (typically) lower
muscle mass, and possibly other gender-specific variability in sweat glands
and the adaptation to exercise (74, 105).
Age: Children have fewer sweat glands and produce less sweat per gland
than adults. Therefore, children are at high risk of heat stress.

Ideally, athletes will learn to consume fluids during exercise to mediate the
inevitable loss of fluids and electrolytes through sweat and to replace the
inevitable use of carbohydrates (both blood sugar and muscle glycogen) during
exercise. The benefits associated with consuming fluids, electrolytes, and
energy during exercise are clear and include:

Attenuation of increased heart rate through improved stroke volume:

Maintaining blood volume during physical activity helps the heart function
more efficiently. Sweat results in a lowering of the blood volume, making
consumption of fluids and electrolytes during exercise an effective means
of maintaining efficient heart stroke volume, especially during prolonged
exercise bouts of >30 minutes.
 Attenuation of increased core temperature: Maintaining an adequate
hydration state improves skin blood flow, which helps to sustain sweat
rates. This makes it easier to dissipate the heat produced from energy
metabolism.
Attenuation of higher plasma sodium, osmolality, and adrenaline: Sweat is
composed of more water and a lower concentration of electrolytes than the
concentration of electrolytes in plasma. The resultant increased plasma
osmolality causes a sodium and fluid shift that may lower sweat rates and
increase stress and the production of adrenaline. Adrenaline (epinephrine)
causes a fast breakdown of liver glycogen, which temporarily increases
blood sugar. However, the depleted liver glycogen makes it difficult to
sustain blood sugar, causing premature fatigue. Maintaining the hydration
states helps to avoid this outcome.
Reduction in net muscle glycogen usage: The failure to provide sufficient
fluid, electrolytes, and carbohydrates during physical activity increases
muscle glycogen usage, which results in early fatigue. As a simple rule: if
three elements are being reduced during exercise (water, electrolytes,
blood sugar), then all three should be replaced during exercise in an
attempt to maintain normal tissue function. Replacing just one of these
three (for instance, just water or just salt) fails to sustain the hydration
state.

Systems for Regulating Body Temperature

The control of body temperature is a function of the body’s thermostat: the
preoptic anterior hypothalamus. Receptors that monitor changes in
temperature, called thermoreceptors, are located in the brain, muscles, spine,
and skin and provide body temperature information to the preoptic anterior
hypothalamus and also to the cerebral cortex, which lets us be aware of
whether body temperature is too high (hot) or too low (cold). A primary
response to high body temperature is the production of sweat for evaporation
off the skin’s surface as a means of dissipating body heat. Being well hydrated
is an important component of sweat production. Should body temperature
become too low, a primary response is involuntary muscle shivering, which has
the effect of increasing heat production (80).

Hydration
There are multiple important functions related to health and athletic
performance associated with maintaining an adequate hydration state. Despite
the importance of hydration, however, studies have found that athletes tend to
replace less fluid than the amount lost in sweat, leading to a gradual reduction
in performance and reducing the potential benefits that should be derived from
exercise (136). Some of this difference is due to the fact that the rate of water
lost through sweat can exceed the maximal rate of water absorption from
consumed fluids. It has been noted that 50 mL of fluid/minute may be lost
through sweat, but only 20–30 mL of fluid may be absorbed by intestines (23).
But some of this inadequate fluid replacement is due to poor hydration
strategies followed by people who exercise.
Well-hydrated athletes are referred to as euhydrated or normohydrated;
those with below-normal body water levels are referred to as dehydrated or, if
severe, hypohydrated; and those with above-normal body water levels are
referred to as hyperhydrated. We have systems for controlling body water
levels that involve forcing an increased retention of body water or an increased
loss of body water, all mediated through a series of hormones that monitor
blood osmolality (the molecular concentration in the blood of electrolytes,
including sodium, chloride, and potassium, and other substances), and
baroreceptors in blood vessels that sense shifts in BP and signal the brain with
the information to sustain appropriate BP.
Excretion of fluids and metabolic by-products is a primary function of the
kidneys, which are stimulated by hormones and enzymes to adjust the volume
of water and electrolytes excreted or retained. The concentration of sodium is
a primary influence on the osmolality of ECF, which is maintained within a
narrow range. Because sweat is hypotonic (the concentration of sodium in
sweat is lower than the concentration of sodium in plasma), prolonged exercise
results in a higher plasma osmolality because more water is lost than sodium.
As a means of preserving body water volume, urine production during and
shortly after exercise is slightly decreased (127, 167). As shown in Table 7.2,
sodium chloride (salt) in sweat far surpasses all other electrolytes in sweat and
is a primary reason why sports beverages contain salt.
Poor hydration habits in athletes are due to several reasons, including:

The drinking tradition in the sport

Failure to take advantage of opportunities to consume fluids
The lack of a timely thirst mechanism (the athletes driven to drink after the
fluid is needed)
Poor fluid availability
Fluids that do not taste good to the exercising athlete

All of these factors can be overcome with training and planning and will go
a long way toward sustaining the athlete’s performance over the entire
practice or competition.

Issues Related to Hydration

There are several situations and conditions that are related to hydration and
fluid consumption, as follows:

Exercise in hot and humid environments causes more sweat production to

maintain body temperature, so requires more fluid consumption.
Some conditions, such as diabetes, cause an increase in urinary water loss,
increasing the requirement for water. Cystic fibrosis increases the loss of
salt through sweat, increasing the requirement for salt in the water that is
consumed.
 Some people take drugs for the treatment of high BP, glaucoma,
osteoporosis, kidney disease, and heart failure, for example, which
increase urinary frequency. Careful monitoring of the hydration state with
the intake of appropriate amounts of water to avoid dehydration is
important when these water-losing drugs are taken.
Athletes who exercise while wearing heavy protective clothing (e.g.,
football players) sweat more heavily because the clothing inhibits
evaporative cooling. Sweating more increases the need for more water.
High-intensity exercise increases the amount of energy used to satisfy
muscle energy requirements. Approximately 70% of the burned energy is
heat creating. This extra energy cannot be acquired, as that would
increase body temperature to an unsafe level, so the sweat rate increases
to dissipate the extra heat. The higher the exercise intensity, the greater
the need for water per unit of time.

Fluid Balance and Exercise

Exercise results in faster loss of water and electrolytes as well as a fast
utilization of blood glucose and muscle glycogen. Therefore, optimal hydration
requires replacement of all three: water, electrolytes, and carbohydrate (WEC).
When not exercising, the rate of WEC reduction is relatively slow and,
therefore, it is relatively easy to maintain a state of hydration. Because the
WEC level drops so slowly, consuming an occasional glass of water, other fluid,
and/or high-water-content foods (that also contain carbohydrate and
electrolytes) may be sufficient to adequately maintain the state of hydration.
Physical activity, however, makes the rate of WEC reduction proceed extremely
quickly. Depending on exercise intensity and environmental temperature and
humidity, it is possible to have sufficient sweat losses within a relatively short
period of time, resulting in difficulty to adequately replace WEC. This could
affect exercise performance and, if allowed to continue, could result in serious
heat illness. Particularly when sweat rates are high, waiting to drink an
appropriately composed fluid makes it virtually impossible to return to a well-
hydrated state while the exercise continues and sweat loss remains high.
Therefore, athletic endeavors resulting in high sweat rates require that the
athlete begin the activity in a well-hydrated state, and initiate a frequent fluid
(WEC) consumption pattern that minimizes the difference between fluid lost
and fluid consumed (146).
The usual nonathlete recommendation for sustaining hydration in people
experiencing relatively low sweat rates is to consume ∼3.7 L (3.9 quarts) of
water per day, including beverages and the water contained in foods (75). The
athlete requirement for fluid is higher (sufficient to replace fluids lost in sweat),
and surveys have found that both male and female athletes fail to accurately
estimate the total volume of sweat loss and fail to create a strategy that
minimizes the difference between sweat loss and fluids consumed. The result
is often the consumption of fluids far less than needed to sustain an optimal
state of hydration and performance (145).
 Even relatively small changes in hydration state can manifest significant
reductions in performance. The goal for athletes, therefore, is to initiate
exercise well hydrated and to stay within at least 2% of preexercise body
weight, while avoiding weight gain (136, 146). Regardless of the activity, it
appears that losing significantly more water than this marginal level results in
performance deficits. Therefore, a strategy for maintaining hydration during
exercise should be developed and practiced to allow the body systems to
adapt to the strategy. It is also important to consume fluids that are
appropriately composed to ensure that fluids are distributed appropriately. It
has been found (135, 136) that poor hydration

results in inadequate ICF and ECF;

affects muscle and skin (sweat glands) and lowers the sweat rate potential;
decreases cardiac stroke volume (the heart has to work harder);
lowers plasma volume, diminishes fluid delivery to working muscles,
decreases delivery of energy to working muscles, and lowers the removal
of metabolic by-products from working muscles;
negatively affects athletic performance; and
elevates core temperature to a degree that is particularly serious in hot
and humid environments.

WEC is lost at a faster rate while exercising, so an important strategy for

avoiding performance loss, clearly, is also to replace WEC at a faster rate. If
the frequency of drinking when not exercising is once every 2 hours, then the
frequency of drinking during exercise could easily be imagined to be every 10–
15 minutes. Waiting too long between drinking opportunities is a bad strategy,
because it allows WEC to decrease in such a way that it cannot be adequately
replaced. If you wait to drink, you may be able to stabilize the body’s hydration
state, but that state will be too low.

How the Body Acclimatizes to Exercise

Conditioned athletes who have acclimatized to exercise in more hot and humid
environments do better than athletes who have not acclimatized. The typical
body adaptations to exercise in the heat include the following (137):

Plasma volume expands to increase total blood volume, making it easier

for the heart to pump more blood per stroke (stroke volume improves).
More blood flows to the muscles and skin.
Less muscle glycogen is used as an energy source during exercise,
improving endurance (81, 124).
The sweat glands hypertrophy (enlarge) and produce 30% more sweat.
Salt in sweat decreases by about 60% to conserve electrolytes, which
helps to maintain blood volume.
Sweat is initiated at a lower core temperature, which helps to keep body
temperature normal.
 The psychological feeling of stress is reduced, lowering the production of
adrenalin and cortisol and resulting in improved endurance.

Monitoring Fluid Balance During Training

Without sufficient WEC intake, blood volume can quickly lower to have a
negative impact on the sweat rate, causing body temperature to rise quickly.
However, it is difficult to consume sufficient fluids during hard physical work,
mandating that athletes and/or their coaches have a well-developed hydration
plan. For instance, an athlete who loses 1 L of water per hour should have a
plan for consuming about four cups of WEC per hour. Although it is difficult to
know precisely how much fluid is being lost during exercise, this simple
strategy can help provide athletes with an estimate of how much is lost and,
therefore, how much should be consumed. One liter of water weighs ∼2 lb, and
1 pint (16 oz) of water weighs ∼1 lb. Knowing these weights can provide an
estimate of how much fluid is lost and how much the athlete should try to
consume during activity. To estimate the water requirement during activity, do
the following:

Write down the ambient temperature and humidity (HI).

Write down the time just before the exercise session.
Write down body weight (preferably nude weight) in pounds. Using kg is
much easier as no calculations are necessary (1 kg lost = 1 L).
Perform the exercise and monitor how much fluid (in ounces) is consumed
during the exercise period.
When the exercise is completed, calculate the time of exercise by
subtracting ending time from beginning time.
Take off the sweaty clothing and towel dry.
Once completely dry, write down body weight (preferably nude weight) in
pounds.
Calculate the amount of fluid lost via sweat by subtracting your body
weight at the end of exercise from your body weight at the beginning of
exercise (1 lb = 16 oz).
The amount of extra fluid that should be consumed is equivalent to 16 oz
of fluid for each pound lost, provided in volumes that range from 2 to 8 oz
and in time intervals that range from 10 to 20 minutes.

Differences in the amount to drink and the frequency of drinking are related
to the total amount of fluid that must be replaced. It is easiest to have the
lowest amount with the least frequency (i.e., 2 oz every 20 minutes), but
athletes should try to never go longer than 20 minutes without drinking
something during exercise (Example 7.1).

Example 7.1 Consuming Fluid During Exercise

Thomas weighs 160 lb at the beginning of his 2-hour football practice and
drinks 1 pint (2 cups; 16 oz) of fluid during the practice.
 At the end of practice, Thomas weighs 158 lb, so he needs to calculate
how to consume an additional 2 pints of water during the practice for a
total of 3 pints (6 cups or 48 oz) over 2 hours.
There are 12 ten-minute increments in 2 hours, so Thomas has 12
opportunities to consume a total of 48 oz of fluids if he chooses to drink
some fluids once every 10 minutes.
Forty-eight ounces divided by 12 equals 4 oz of fluid (1/2 cup) every 10
minutes.
It may be difficult to consume that much fluid if the athlete is
unaccustomed to it, so Thomas should try training himself to drink that
much by gradually increasing the fluid consumption over several weeks to
try to achieve an equal pre- and postexercise weight. The main point is
this: any fluid amount greater than the current amount consumed is
beneficial if the athlete experiences weight loss during the activity.

All of this is made more complex by environmental conditions and the level
of conditioning an athlete has. Better-conditioned athletes are better able to
cool themselves because they have developed more efficient sweat systems.
This allows better-conditioned athletes to perform longer, but it also requires
that they consume more fluids. When the environment is hot and humid, water
does not evaporate off the body easily, so it does not have the desired cooling
effect.

The higher the temperature, the more the athlete sweats.

The higher the humidity, the more the athlete sweats, but with reduced
cooling efficiency.
Clothing that traps sweat against the skin (i.e., does not breathe) has a
reduced cooling efficiency, so it forces the athlete to sweat more.
Well-conditioned athletes sweat more volume per unit of time, resulting in
improved cooling potential. However, this higher sweat rate requires a
greater during-exercise fluid consumption.
Several factors affect fluid intake and the rate consumed fluids leave the
stomach (gastric emptying) and enter the small intestine. The two main
factors for fluid intake are thirst experienced by the athlete and taste of
the beverage consumed (143). It has been found that many athletes fail to
consume sufficient fluids even if ample fluids are available (referred to as
voluntary dehydration), but most athletes fail to consume sufficient fluids
simply because they are not thirsty (59, 120). The thirst sensation,
therefore, should not be considered an appropriate indicator of the need
for fluids in athletes (129). It appears that thirst in athletes occurs only
after the loss of 1.5–2.0 L of water (93). Should an athlete begin drinking at
the point of thirst, there is little chance of achieving an adequately
hydrated state during exercise. This delay in the sensation of thirst is a
strong argument for athletes to train themselves to consume fluids on a
fixed schedule, regardless of whether they are thirsty.
 The appeal (color, odor, temperature, mouth feel, etc.) of a beverage is
another important factor in whether it will be consumed. In general, it appears
that athletes prefer cool beverages with a slightly sweet flavor (133, 163).
Heavily sweetened beverages of around a 12% carbohydrate solution,
including sodas and fruit juices, are not as widely tolerated during exercise as
beverages with a 6% or 7% carbohydrate solution (40, 71). It appears,
however, that when in a relaxed and nonexercising state, more highly
sweetened beverages are preferred. This points to an interesting phenomenon
of exercise: The organoleptic properties (i.e., the perception of taste) of foods
and beverages differ when exercising than when not exercising (109). Given
the extensive research on the benefits of consuming a sports drink with a 6%–
7% carbohydrate solution and electrolytes, regardless of whether the activity
lasts half an hour or longer than 4 hours, it appears clear that athletes should
adapt to drinking a sports beverage in a way that optimizes tolerance and
hydration. Consumption of sports beverages results in better performance than
water whether you do sprints or endurance work (15, 77).

Dehydration
When significantly more fluids are lost than are consumed, dehydration occurs.
By definition, hypohydration means that total body water is below the optimal
state, with as little as a 2% drop in body weight from sweat loss resulting in a
measurable reduction in athletic performance (25). It has also been found that
76.3% of male athletes involved in different sports, including basketball,
gymnastics, swimming, running, and canoeing, were hypohydrated, with an
average training-related body weight loss of −1.1% (9). Importantly,
interventions that encourage fluid intake clearly improve hydration status and
exercise performance (78). Common risks for dehydration include the following
(7, 25, 110):

Vomiting
Diarrhea
Inadequate fluid replacement
Poor fluid availability
Induced high sweat rates (as in saunas)
Delayed drinking (waiting until thirsty)
Laxatives
Diuretics (and substances with a diuretic effect)
Dieting
Febrile illness (illness with high body temperature)

The only logical strategy for avoiding dehydration during exercise is to

correctly assume that there is a constant output of fluids that must be
balanced through the constant consumption of an equal volume of fluids.
Athletes should recognize the signs of dehydration, including thirst, urine
volume, and urine color (Figure 7.8). Thirst may be an obvious sign, but both
low urine output and dark urine color are signs of dehydration that may
precede the sensation of thirst.

FIGURE 7.8: Dehydration urine color chart. The darker the urine color the
greater the degree of dehydration.

The tradition in some sports is for athletes to purposefully dehydrate

themselves in an attempt to improve appearance or to try to make a
competitive weight classification. Other athletes simply fail to consume fluids
even when they are readily available to them (voluntary dehydration) and
become dehydrated, whereas other athletes become dehydrated as a result of
heavy training, particularly in hot and humid environments, when adequate
fluid consumption is difficult (referred to as involuntary dehydration) (10).
Regardless of the dehydration cause, athletes can be certain that dehydration
results in inferior performance outcomes and reduced mental function (79,
113).

Exertional Heat Illnesses That May Be Related to Poor Hydration

Exertional heat illnesses that may be related to poor hydration include heat
cramps, heat exhaustion, heat syncope, and heatstroke/sunstroke (Table 7.11).

Table Differences in Exertional Heat Illnesses

7.11
Muscle (Heat) Heat Syncope Heat Heatstroke
Cramps Exhaustion
Table Differences in Exertional Heat Illnesses
7.11
Muscle (Heat) Heat Syncope Heat Heatstroke
Cramps Exhaustion
Symptoms Acute, painful, Collapsing in Inability to Severe
involuntary the heat, continue hyperthermia
muscle resulting in exercise leading to
contractions loss of because of overwhelming of
presenting consciousness cardiovascular the
during or after insufficiency thermoregulatory
exercise system with
possible central
nervous system
dysfunction and
core temperature
>104.9°F
(40.5°C)
Cause(s) Dehydration, Standing High skin High metabolic
electrolyte erect in a hot blood flow, heat production
imbalances, environment, heavy and/or reduced
and/or causing sweating, heat dissipation
neuromuscular postural and/or
fatigue pooling of dehydration,
blood in the causing
legs reduced
venous return
Treatment(s) Stop Lay patient Cease Immediate
exercising, supine and exercise, whole-body cold-
provide elevate legs remove from water immersion
sodium- to restore hot to quickly reduce
containing central blood environment, core body
beverages volume elevate legs, temperature
provide fluids
Recovery Often occurs Often occurs Often occurs Highly
within minutes within hours within 24 h; dependent on
to hours same-day initial care and
return to play treatment;
not advised further medical
testing and
physician
clearance
required before
return to activity

Source: Adapted from Casa DJ, DeMartini JK, Berjeron MF, et al. National Athletic Trainers’ Association
position statement: exertional heat illnesses. J Athl Train. 2015;50(9):986–1000.
Heat Cramps
Exercise-associated muscle cramps, often referred to as heat cramps, occur
suddenly and may occur during and/or following physical activity (26). The
most likely reasons for these cramps include dehydration coupled with
electrolyte imbalance, fatigue, altered muscle control, and any combination of
these (14, 116, 141). Heat cramps are most likely to occur in people who sweat
heavily and who lose a higher than normal amount of sodium and other
electrolytes (including potassium, calcium, and magnesium) in the sweat
(141). For these individuals, drinking adequate amounts of salt-containing
beverages during exercise is particularly useful. Heat cramps also appear to
occur late in the day after consumption of large volumes of plain water (12).
Severe muscle cramps affect athletic performance, with the recommendation
that there should be no further exercise (26).

Heat Cramps

Skeletal muscle cramps are most often associated with muscular fatigue and
may occur in athletes participating in all sports and in all environmental
conditions. There is evidence that muscle cramps may be associated with a
state of hypohydration and electrolyte imbalances. Profuse sweating,
particularly when not well acclimatized to hot/humid environments and
coupled with high sweat sodium losses, appears to place athletes at greatest
risk for cramping.

There is evidence that skeletal muscle cramps are associated with muscular
fatigue, dehydration, and serum electrolyte deficits and are commonly
experienced by athletes who are not acclimatized to the heat, athletes who
sweat heavily, and athletes with high sodium sweat loss (136, 146). It has
been recommended that athletes experiencing exertional heat cramps
consume 16–20 oz (∼0.5 L) of a sports beverage with 0.5 teaspoon (3 g) of salt
added over a 10-minute period, followed by additional fluid and electrolytes to
restore fluid balance (13). As muscle cramping may be associated with muscle
fatigue separate from hydration issues, however, these recommendations may
not universally apply to athletes experiencing muscle cramps. Care must also
be taken to ensure that excess fluid consumption does not occur, as this may
increase the risk of hyponatremia (136, 146). To help meet the needs of
athletes who experience frequent cramping, companies have developed
products that provide a measured amount of sodium, potassium, calcium, and
magnesium for adding to a given volume of sports beverage. The common
sports beverage contains between 50 and 110 mg sodium/240 mL (1 cup) of
fluid. Endurance sports beverages typically contain more sodium, at the level
of between 150 and 200 mg sodium/240 mL.

Heat Exhaustion
Heat exhaustion refers to the athlete’s inability to continue exercising in the
current heat and humidity environment. Symptoms include weakness, red skin
rash, cold/clammy skin, a feeling of faintness, muscle cramping, fatigue,
nausea, dizziness, confusion, poor coordination, and a weak pulse (72). If there
is severe body water depletion, the athlete may also stop sweating and the
skin feels dry. The likely cause of these symptoms is poor blood flow to the
brain, with the sufferer typically on the ground but semiconscious. Symptoms
usually respond well to rapid cooling, so heat exhaustion victims should be
cooled through whatever means are available. Applying wet, ice-cold cloths to
the body or placing the victim in a cold water bath is effective (70). After a
return to full consciousness, the athlete can be given sips of cool fluid, but this
should not be forced as it may cause nausea. There is no reason for a heat-
exhausted athlete to return to physical activity on the same day. Instead, the
person should spend the remainder of the day staying cool and hydrating with
sodium-containing fluids, including sports beverages (26).
CAUTION: Under no circumstances should an athlete who has
stopped sweating continue exercising because this may cause a rapid
and dangerous hyperthermia (a dangerous rise in core temperature).

Heat Syncope
Syncope refers to dizziness, which is likely to occur in individuals who are not
well adapted to the current environmental heat and humidity (26). Thus, heat
syncope is most likely to occur when people begin exercising in a hotter and
more humid environment than they are accustomed to and is associated with
inadequate sweat rates (i.e., poor cooling) from dehydration and an
inadequate fitness level. Individuals taking diuretics, because of the lower
blood volume, are also at higher risk of developing heat-related syncope (126).

Heatstroke (Sunstroke)
Exertion-related heatstroke is a dangerous condition associated with high
body temperature (usually above 105°F or 40.5°C), hot/dry skin, and a rapid
pulse (7, Table 7.12). Although most likely to occur in environmental conditions
of high heat and humidity, the athlete may also develop heatstroke with
continued hard physical activity but compromised capacity to dissipate heat
through sweat (26). It is also possible for the athlete to be in and out of
consciousness. The first responder should call for emergency medical care and
then do whatever possible to immediately cool the athlete (cold water,
loosening clothing, cold water bath, etc.). Mortality risk increases the longer
the body temperature remains elevated (1). Fluids should not be put into the
mouth until the athlete returns to consciousness (48).

Table 7.12 Exertional Heatstroke Extrinsic

and Intrinsic Risk Factors
Extrinsic Factors Intrinsic Factors
Table 7.12 Exertional Heatstroke Extrinsic
and Intrinsic Risk Factors
Extrinsic Factors Intrinsic Factors

High ambient temperature, solar High intensity of exercise and/or

radiation, and high humidity poor physical conditioning
Athletic gear or uniforms Sleep loss
Peer or organizational pressure Dehydration or inadequate fluid
Inappropriate work-to-rest ratios intake
based on intensity, wet bulb globe Use of diuretics or certain
temperature, clothing, equipment, medications (i.e., antihistamines,
fitness, and athlete’s medical diuretics, antihypertensives,
condition attention-deficit hyperactive
Predisposing medical conditions disorder drugs)
Lack of education and awareness Overzealousness or reluctance to
of heat illnesses among coaches, report problems, issues, or
athletes, and medical staff illnesses
No emergency plan to identify and Inadequate heat acclimatization
treat exertional heat illnesses High muscle mass-to-body fat
Minimal access to fluids before and ratio
during practice and rest breaks Presence of a fever
Delay in recognition of early Skin disorder
warning signs

Source: Adapted from Casa DJ, DeMartini JK, Berjeron MF, et al. National Athletic Trainers’ Association
position statement: exertional heat illnesses. J Athl Train. 2015;50(9):986–1000.

Heat Exhaustion

A heat illness characterized by a failure to sustain cardiac output and sweat

rate, resulting in high skin temperature. Symptoms include a rapid pulse,
dizziness, fainting, paleness, and anxiety. It is one of the heat-related
conditions experienced by athletes.

Heat Syncope

Decreased relative blood volume coupled with excessive vasodilation results

in lower cardiac output and decreased BP that, because of the increased
sweat rate, lowers blood flow to the brain. The result is dizziness, mental
confusion, and fainting.

Heatstroke

Also called sun stroke, heatstroke is a life-threatening exertional heat illness

associated with overheating. When core temperature rises quickly, brain and
muscle function are adversely affected. Typically, athletes respond to these
signals by slowing down or ceasing exercise to allow core temperature to
decrease. Failure to respond to these signals may result in heatstroke with an
elevated body temperature (above 104°F), which can damage neurologic
tissue, heart, kidneys, and muscle. Heatstroke requires immediate
emergency treatment and is considered the most serious of the heat injury
conditions that can result in death.

Hyponatremia
Exercising for long periods may cause low blood sodium (hyponatremia), which
is a potentially fatal condition (140). Low blood sodium can occur when
drinking excessive amounts of water (i.e., fluids with no or low sodium),
causing a dilution of the blood sodium content. To normalize the concentration
of sodium per unit volume of blood, water leaves the blood, causing edema,
which may result in rapid and dangerous swelling of the brain (68). Low blood
sodium is most likely to occur during prolonged exercise in dehydrated athletes
who have experienced large sodium losses through sweat, but may also occur
in athletes who habitually restrict sodium consumption in the foods and
beverages they consume. Unless contraindicated because of a medical
condition and the athlete is under the careful supervision of a physician,
adding salt to meals and consuming salt-containing beverages is a desirable
strategy for avoiding low blood electrolytes and reducing hyponatremia risk.
Signs and symptoms of hyponatremia include (140):

Headache
Swollen fingers and ankles
Bloated stomach
Confusion
Pulmonary edema
Nausea
Seizures
Cramping
Coma

Prior to the 2003 Boston Marathon, USA Track & Field announced fluid
replacement guidelines for long-distance runners that are designed to lower
hyponatremia risk. Earlier guidelines encouraged runners to drink as much as
possible to “stay ahead” of their thirst, but the new guidelines advise runners
to drink only as much fluid as they lose through sweat during a race. This
recommendation suggests that athletes consume 100% of fluids lost through
sweat and no more. Higher levels of consumption, particularly of plain water,
could cause a drop in blood sodium concentration, leading to hyponatremia.
Athletes who have an increased risk of developing hyponatremia (155):

take NSAIDs (i.e., aspirin, ibuprofen);

are on a low-sodium diet;
 drink water or other no-sodium beverages during exercise;
are not acclimatized to warm weather or are poorly trained;
are of small stature (more evidence documents this than documents poor
training);
run slowly, taking longer than 4 hours to complete endurance events.

Hyponatremia risk appears highest in athletes with high sweat rates and
with a relatively high concentration of sodium, but who fail to consume
sodium-containing beverages during exercise (115). Commonly available
sports beverages contain ∼20 milliequivalents (mEq) of sodium chloride (table
salt), but even higher levels of sodium are recommended by a number of
researchers who have assessed plasma changes during prolonged exercise in
the heat (56, 130). These researchers have recommended 20–50 mEq/L.
However, most athletes with normal sweat rates and normal sweat sodium
concentrations who consume commercial sports beverages and avoid
consumption of plain water during endurance events appear to be protected
against developing hyponatremia (102, 140).
Hyponatremia is a serious condition requiring the immediate attention of
appropriately qualified health professionals. However, if no one is available,
salt tablets can be used to recover from hyponatremia, but should not
otherwise be used. A single salt tablet typically delivers 1 g (1,000 mg) of
sodium. For recovery, 1–2 tablets should be consumed per cup of water taken
every 15–20 minutes, depending on the degree to which hyponatremia
symptoms appear. Salty foods (potato chips, pretzels, etc.) may also be
consumed if salt tablets are unavailable. The total fluid consumed should
return the athlete to preexercise weight, but not cause the athlete to increase
body weight above that point (13).

Factors That Influence Effectiveness of a Sports Beverage

Factors That Affect Gastric Emptying

A number of factors influence the rate at which fluids leave the stomach, but
before these are reviewed, it is important to understand what slow or fast
gastric emptying really means. When a food or drink is described as having a
slower gastric emptying, it does not mean that all of the food stays in the
stomach longer. It means that the food or drink trickles out of the stomach and
into the intestines more slowly, so some of the food or drink remains in the
stomach longer. Gastric emptying, therefore, describes the volume of food or
drink that leaves the stomach per unit of time. Because athletes are more
comfortable exercising without an extensive amount of food or fluid in the
stomach, a beverage that leaves the stomach more quickly (i.e., has a fast
gastric emptying property) is considered desirable. In addition, fast gastric
emptying offers the possibility for a faster delivery of energy and water to
working muscles by more quickly presenting substances to the intestines for
absorption. The speed of gastric emptying is important for two reasons: (i)
athletes exercising with full stomach contents report GI distress and (ii) faster
gastric emptying translates into fluids, electrolytes, and carbohydrate that are
more readily available for absorption and, therefore, can satisfy blood and
tissue requirements more efficiently.

Carbohydrate Concentration of the Solution

Although there are individual tolerance differences, carbohydrate
concentrations exceeding 7% have generally resulted in a slower gastric
emptying rate, whereas in carbohydrate concentrations of ≤7%, gastric
emptying time is not significantly affected (131). This is one of the reasons
why the recommended carbohydrate concentration in sports beverages is
below 8%. Studies assessing how carbohydrate concentration affects
performance in team players have found that a 6% carbohydrate solution was
significantly more effective than a 10% carbohydrate solution (125). Other
studies have found similar performance benefits when the carbohydrate
concentration does not rise above 7% in a sports beverage (114, 162).

Type of Carbohydrate in the Solution

Carbohydrates come in different molecular sizes and in different molecular
combinations. For instance, glucose is a monosaccharide (a single-molecule
carbohydrate), sucrose is a disaccharide (two monosaccharides held together
with a bond), and starch is a polysaccharide (many molecules of
monosaccharides held together with bonds). The smaller the length of a
carbohydrate chain, the slower the gastric emptying time. Therefore, pure
glucose (a monosaccharide) takes longer to leave the stomach than table
sugar (a disaccharide), and table sugar takes longer to leave the stomach than
a simple starch (a polysaccharide). The size of the sugar particle is so
important that even if two beverages have the same carbohydrate
concentration, the beverage with smaller carbohydrate molecules will take
longer to leave the stomach than the beverage with larger carbohydrate
molecules (132). The type of carbohydrate consumed may also affect
performance. It has been found that a beverage containing glucose and
fructose (sucrose), when compared with a beverage containing only glucose,
resulted in higher carbohydrate oxidation and improved 100 km cycling
performance (147). Another study also found that cyclists exercising at
moderate intensity completed a time trial 8% more quickly when a multiple-
carbohydrate drink was consumed than when a glucose-only drink was
consumed (37).

Amount of Solution Consumed

The amount of fluid consumed at one time has a major influence on gastric
emptying time. When a large volume of fluid is consumed, gastric emptying
time is initially faster. When the volume of fluid in the stomach is reduced,
gastric emptying time slows. This suggests that to become more quickly
hydrated prior to competition or practice, a relatively large volume of fluid
should be consumed (approximately half a liter), followed by frequent sipping
of fluid to maintain the fluid volume in the stomach and, therefore, a faster
gastric emptying time (118).
Temperature of the Solution
Most studies indicate that the solution temperature only slightly affects gastric
emptying time. When people are at rest, fluids at body temperature leave the
stomach more quickly than either very hot or very cold fluids (142). There is
evidence that, during exercise, cool fluids leave the stomach more quickly than
fluids at room or body temperature (30).

Carbonation of the Solution

Although there are many athletes who believe that consuming a carbonated
beverage will cause gastric distress and delayed gastric emptying (the first
sports beverage was probably a “defizzed” cola), there is little scientific
evidence that this occurs. However, the studies that have evaluated the
impact of fluid carbonation on gastric emptying time have typically relied on
few subjects. In general, the studies suggest that, all other things being equal
(carbohydrate concentration, volume, temperature, etc.), carbonation has little
impact on gastric emptying (84, 134). However, carbonation does lower
voluntary fluid intake following exercise, which could impact hydration
recovery and future exercise performance (122).

State of Hydration or Dehydration

With the increasing dehydration and higher body temperatures associated with
high-intensity activity, the rate of gastric emptying slows (132). This is an
excellent reason for athletes, as much as possible, to try to maintain their
hydration state during activity. Allowing dehydration to occur makes it almost
impossible for the athlete to return to an adequately hydrated state during
exercise. If such hydration is attempted through consumption of a large
volume of fluid, it will likely add to a sense of discomfort rather than faster
rehydration.

Degree of Mental Stress

The mental stress and anxiety associated with athletic competition are major
factors in gastric emptying. Higher levels of mental stress and anxiety are
associated with a reduced gastric emptying that can have a serious impact on
the athlete’s ability to adequately rehydrate during competition (129, 165).
Obviously, the mental training techniques that may be learned from a sports
psychologist to reduce stress are an important strategy for reducing the
physiologic effects of sports-related stress and anxiety.

Type of Activity
Studies have suggested that high-intensity activity is associated with a slower
gastric emptying rate than lower intensity activity, but the differences appear
to be minor. In addition, the type of activity (running, swimming, cycling, etc.)
does not appear to have a large influence on gastric emptying rate (129).

Athlete’s Conditioning and Adaptation

The human body has wonderful adaptive mechanisms, and the ability to adapt
to higher or lower glucose concentrations and faster or slower rates of fluid
ingestion is no exception. To a certain extent, athletes can find a system for
optimal rehydration that suits them best by consistently practicing that
system. Practicing a reasonable system allows the body to adapt to it and
reduce the chance of any difficulties that could arise from trying something
new just before an important competition. Therefore, it is important for
athletes to start with general recommendations for fluid intake to maintain
their hydration state, but to make modifications that are best suited to their
own individual circumstances.

Intestinal Absorption
Once the solution (fluid) leaves the stomach and goes into the small intestine,
the water and carbohydrate that make up the solution must be absorbed into
the blood. The main factor that influences the speed with which water and
carbohydrate are absorbed is the concentration of carbohydrate in the solution
that enters the intestines (57). A solution that has a slightly lower
concentration of carbohydrate and electrolytes, relative to the concentration of
plasma, causes a faster absorption of water than a solution that has either a
much higher or a much lower concentration (101). Consumption of highly
concentrated carbohydrate solutions during exercise may cause a temporary
shift of fluids away from the muscles and into the intestines to dilute the
solution prior to absorption. This would have a negative impact on both muscle
function and sweat rates because it would cause, at least temporarily, a shift of
water away from muscle to cause tissue dehydration.

Palatability of the Beverage

The taste, flavor, and mouth feel of a beverage have an impact on voluntary
hydration patterns and volume of fluid consumption. However, exercise affects
the way fluids taste as compared with how the same fluid tastes when not
exercising. In comparing commonly consumed beverages (homemade sports
beverage, commercial sports beverage, diluted orange juice, and water), it was
found that palatability varied widely, as did their voluntary consumption during
exercise. In one study it was found that a commercially available 6%
carbohydrate solution was significantly preferred over other beverages during
exercise (121).

Optimal Sports Beverage Composition and Drinking Strategy

The evidence suggests that even a minor level of hypohydration (as little as
2% of body weight) may result in a performance and endurance decrement,
with greater levels of underhydration having a more significant impact (22,
62). It is also important to consider that it takes time, often 24 hours or longer,
to return a dehydrated athlete to a euhydrated state. Therefore, every effort
should be made to help an athlete return to a normally hydrated state prior to
the next exercise session. There is evidence that 2/day practices may fail to
provide sufficient time for dehydrated athletes to return to a hydrated state
after the first practice and before the second (89).
 Some sports require athletes to achieve a particular look (i.e., figure
skating, rhythmic gymnastics, diving) or to achieve a particular weight (i.e.,
wrestling). Many wrestlers have a regimen for fluid restriction to achieve a
desired weight classification, followed by a rehydration protocol. Besides the
inherent health dangers of doing this (there are well-documented deaths
associated with this strategy), there is doubt that dehydrated wrestlers have
sufficient time to achieve a state of adequate rehydration (38).
Some athletes are on the other side of the continuum by trying to
hyperhydrate before exercise. Long-distance runners, for instance, experience
water loss during competition that is likely to be greater than their ability to
replace it. The best-hydrated runner nearing the end of the 26.2 mile marathon
has a major advantage over runners who are less well hydrated. They have
greater blood (plasma) volume that helps to sustain the sweat rate and cooling
capacity, and this results in lower core temperature and heart rate during
activity (82, 112). Although consumption of large fluid volumes is also
associated with frequent urination, this may be mediated to a degree by
consumption of sodium-containing fluids (22).
Glycerol (a simple three-carbon lipid that is metabolized like a
carbohydrate) has historically been used by some athletes to aid
hyperhydration because it helps to retain water. There is some limited
evidence that adding glycerol to preexercise fluids at the rate of 1 g/kg body
weight improves endurance performance in hot and humid environments for
two reasons: (i) the greater total body water helps to sustain sweat rates and
cooling and (ii) the glycerol provides more carbohydrate-like metabolic fuel
(22, 91). Some athletes find that hyperhydrating with glycerol makes them feel
stiff and uncomfortable, whereas others are more comfortable with this
sensation (107).
CAUTION: Since 2010, glycerol is on the banned substance list by
the World Anti-Doping Agency (WADA) and should not be
recommended to athletes. It is included here because some athletes
continue to use glycerol as a hyperhydration aid, and those working
with them should be aware of its functionality and status as a banned
substance.
WADA has established a level of 200 mcg/mL of urinary glycerol as the
threshold for identifying athletes who have misused glycerol (144).
The degree to which the cardiovascular and heat maintenance capacity is
maintained is directly related to the degree to which dehydration can be
avoided (98, 103, 160). A failure to consume sufficient fluids during exercise
represents a major risk for developing heat exhaustion (90). It is clear that the
best strategy for athletes to follow to avoid heat exhaustion and maintain
athletic performance is to consume fluids during exercise.
Most studies that have evaluated the interaction between hydration
adequacy and athletic performance have used either plain water or sports
beverages that contain, in differing degrees, carbohydrates and electrolytes.
The results of these studies are similar in confirming the importance of fluid
consumption during exercise. However, the inclusion of carbohydrates and
electrolytes in the fluids affords the athlete certain advantages over plain
water. Studies suggest that including carbohydrates in the rehydration solution
improves the athlete’s ability to maintain or increase work output during
exercise and increases the time to exhaustion (28, 33, 106, 146, 148). This
occurs because consumed carbohydrates help to avoid the depletion of muscle
glycogen and actively provide a fuel to muscles when muscle glycogen is low.
In simple terms, exercise results in a loss of body water and electrolytes and a
lowering of blood sugar. All three should be replaced.
Different types of physical activity result in different rates of carbohydrate
utilization, but consuming carbohydrate-containing fluid helps to maintain
athletic performance regardless of the activity type. For instance, in strenuous
cycling the rate of muscle glycogen use is not affected when a carbohydrate
solution is used (32). In long-distance running, there is a reduction in the rate
of muscle glycogen usage when a carbohydrate-containing fluid is consumed
(149). In stop-and-go intermittent exercise typical of team sports, there is a
reduction in muscle glycogen usage when a carbohydrate-containing fluid is
consumed (11, 63, 166). In each of these scenarios, carbohydrate depletion is
considered to be the principal cause of reduced performance. There is even
good evidence that consumption of a carbohydrate-containing beverage is also
important for improving athletic performance in high-intensity activities, where
there is no expectation for carbohydrate depletion because of the relatively
short duration of the activity (11, 114, 139).
Carbohydrate energy, regardless of whether it is in liquid or solid form, aids
athletic performance (94). However, because providing carbohydrates in liquid
form allows the athlete to take care of multiple issues at once (energy and
fluid, and preferably also electrolytes), carbohydrate-containing liquids are
preferred. The type and concentration of carbohydrate in a sports beverage
are important considerations. There appear to be no major differences among
sucrose, maltodextrins, and starch (all different types of carbohydrates) on
exercise performance (32, 111, 119). However, sports beverages relying
extensively on either glucose or fructose for carbohydrates may cause a delay
in gastric emptying, causing a delay in absorption (17, 111). Maltodextrins are
less sweet than sucrose and fructose, so they may be used to add
carbohydrate energy to solutions without making them unpalatably sweet
tasting (63).
HFCSs are used as the source of carbohydrate in some sports beverages.
HFCS is manufactured from cornstarch, which is processed into glucose, which
is then processed via enzymes to convert a proportion of glucose to fructose.
The glucose and fructose are then blended to create HFCS 42 and HFCS 55.
HFCS is commonly used by manufacturers because it has several
characteristics that are useful in manufacturing processed foods, including:

Retains moisture, helping keep the product from drying out

Helps control bacterial growth, as the osmotic pressure created by HFCS is
greater than that of sucrose
It is a liquid, so more easily blends with other ingredients in the food
It is highly sweet
 In many food manufacturing countries HFCS is lower in cost than sucrose

The composition of HFCS 55, which is commonly used in beverages, is

similar to sucrose but has more free fructose (153):

Sucrose: 50% fructose, 50% glucose

HFCS 42: 42% fructose, 52% glucose, 6% polysaccharide (used in
beverages, processed foods, cereals, and baked goods)
HFCS 55: 55% fructose, 42% glucose, 3% polysaccharide (used in soft
drinks)
HFCS 65: 65% fructose, 35% glucose (used in soft drinks)
HFCS 90: 90% fructose, 10% glucose (typically mixed with HFCS 43 to
make HFCS 55)

Once absorbed, fructose is transported to the liver with three possible

pathways: (i) conversion to glucose and stored as liver glycogen; (ii)
conversion to triglyceride with resultant elevated serum very low density
lipoprotein; and (iii) conversion to uric acid, which is associated with possible
gout-like joint pain. Pathway 1 (conversion to glucose with storage as
glycogen) is the preferred pathway, but excess liver exposure to fructose may
overwhelm this pathway, resulting in more triglyceride and uric acid formation.
Uric acid uses nitric oxide, which disturbs oxygen delivery to working tissues
and creates another concern for athletes (19).
The volume of carbohydrate provided during exercise longer than 45
minutes is an important consideration, because providing too much
carbohydrate too quickly may induce delayed gastric emptying and GI distress
and, at least temporarily, take needed fluids away from blood (thereby
lowering fluid availability to muscle and skin) to dilute this excessively
concentrated solution. On the other hand, providing a fluid that delivers an
excessively small amount of carbohydrate (<4% carbohydrate solution) may
diminish the performance benefit. Athletes should strive to consume ∼1 g
carbohydrate/minute of exercise (i.e., 4 kcal/minute). This level of intake can
occur through consumption of sports beverages that contain between 4% and
8% carbohydrate, at a volume of ∼0.6–1.2 L/hour (28, 34). Some sports
beverages have carbohydrates precisely within this range, whereas others
have higher concentrations. Higher concentrations may cause a delay in
gastric emptying, compromising speedy delivery of needed carbohydrate to
working tissues during exercise (158). Another advantage of consuming a 4%–
8% carbohydrate solution is that, if the carbohydrate source is mixed, it has a
faster rate of intestinal absorption than water alone (147). This faster
absorption can more efficiently deliver carbohydrate to the blood and,
ultimately, working tissues.
Athletes exercising intensely for 45 minutes or longer, particularly in high
heat and humidity, will experience some degree of dehydration. For athletes
exercising most days, as is common for elite athletes, postexercise fluid
consumption becomes a critically important part of the exercise regimen
because it allows the athlete to begin each subsequent day of activity in a
well-hydrated state. The less time there is to rehydrate, the lower the
likelihood that the athlete will be capable of becoming optimally hydrated by
the beginning of the next exercise session. Because maximal absorption rates
are lower than maximal sweat rates, athletes consuming fluids during intense
exercise are, at best, only likely to provide 70% of fluid lost via sweat. Studies
have shown that most athletes replace sweat losses at a rate significantly
lower than this (20, 117). Therefore, athletes require a planned rehydration
strategy before the next exercise session begins. Despite this need, athletes
are known to remain in an underhydrated state even when fluids are made
available to them (104). This resulting voluntary dehydration suggests that
athletes should be placed on a fixed fluid replacement schedule that will
decrease the degree to which this dehydration is maintained. A way of
encouraging this is to make certain that good-tasting fluids are easily available
to the athlete as soon as the exercise session is over (24).
There is evidence that commercial sports drinks containing both
carbohydrate and sodium are more effective at restoring body water balance
than plain water (58). It appears, however, that to maximize rehydration, a
level of sodium greater than that provided in most sports drinks is desirable
(99). This added sodium can be obtained through the normal consumption of
foods, many of which have added salt (sodium) (100). Endurance sports
beverages typically have higher levels of sodium.

Fluid Intake Recommendations

Fluid intake recommendations for athletes can be summarized as follows:

Ideally, athletes should try to consume sufficient fluid to match fluid sweat
losses.
Humans have little comprehension of the rate of fluid loss during exercise,
so fluids should be consumed on a fixed schedule, regardless of thirst. (The
sensation of thirst occurs only following a large fluid deficit of 1%–2% of
body mass and should be considered an “emergency” sensation rather
than treated as the perfect time to drink.)
With intense exercise and/or exercise during a hot and humid day, it is
difficult to consume and absorb fluids at the same rate that fluids are lost
via sweat. Therefore, athletes should begin exercise in a well-hydrated
state, and drink fluids at opportunities that present themselves during
exercise and/or competition.
In some athletes, ingestion of relatively large fluid volumes may increase
GI distress, which can result in reduced performance. However, practicing
drinking ever larger volumes of fluids improves fluid consumption
tolerance. There is a maximum of gastric emptying rate (noted above).
Although a robust fluid replacement strategy is desirable, consumption of
fluids in excess of sweat and urinary losses is a primary cause of
hyponatremia (also referred to as water intoxication). Hyponatremia risk
can be made worse when sweat sodium loss is heavy, with consumption of
low-sodium beverages and with excess fluid consumption prior to the
exercise bout. The risk of hyponatremia appears to be particularly high in
women, likely because of smaller body size and lower sweat rates than
males (136, 146).

Hydration Recommendations (104, 146)

Fluid deficits of >2% body weight can compromise cognitive function and
aerobic exercise performances, particularly in hot weather.
Fluid deficits of 3%–5% body weight can compromise performance in
anaerobic, high-intensity, or skill-intensive activities, and aerobic activities
performed in a cool environment.
Fluid deficits of 6%–10% body weight have pronounced negative impacts
on exercise tolerance, decreases in cardiac output, sweat production, and
skin and muscle blood flow. Common signs of hypohydration include thirst,
flushed skin, apathy, dizziness, nausea, GI cramping, and loss of body
weight.
Assuming the athlete is in a satisfactory state of energy balance, daily
hydration state may be estimated by measuring body weight upon waking
and after voiding. Significant daily changes that exceed 2% of body weight
are likely representative of changes in total body water.
Prior to beginning exercise athletes should attempt to achieve euhydration
through consumption of 5–10 mL/kg (2–4 mL/lb) fluids 2–4 hours prior to
exercise. The goal is to achieve a urine color suggesting adequate
hydration (see Figure 7.8).
Sweat rates vary during exercise from 0.3 to 2.4 L/hour (has been recorded
up to 3.9 L/hour), depending on exercise intensity, duration, fitness,
acclimatization to the heat, and environmental heat and humidity. Fluid
consumption patterns should attempt to minimize net fluid loss to less
than 2% body weight. Routine measurements of body weight pre- and
postexercise at different environmental conditions should help guide
athletes on how well their hydration practices are achieving this goal.
Overhydration is seen in recreational athletes who achieve sweat rates
lower than fluid consumption, increasing the risk of hyponatremia.
Common signs of hyponatremia include altered mental status, mood
changes, confusion, muscular twitching, muscular weakness, headache,
swollen limbs.
Fluids containing both salt and carbohydrate should be consumed during
exercise, particularly if longer than 45 minutes and/or if high sweat rates
are achieved.
After exercise athletes should immediately initiate rehydration strategies
that include water, salt, and carbohydrate. The volume consumed should
be ∼125%–150% of the measured fluid deficit (i.e., the difference in weight
between pre- and postexercise), because water loss through sweat and
urination continues postexercise.
Alcohol is a diuretic and should be discouraged postexercise, at least until
after the athlete has achieved a state of euhydration.
 Summary

There is perhaps no other factor that so clearly has an impact on

performance than hydration state, and no nutritional substance than water
that can so quickly be inadequate to elevate the risk of serious illness.
Athletes in all sports can gain an immediate performance benefit by
assuring that physical activity begins, continues, and ends with hydration
state adequately maintained. To do this, athletes should practice
consuming appropriately constituted fluids on a fixed schedule rather than
by relying on thirst as the primary stimulus to drink. The thirst mechanism
fails to occur until a substantial amount of body water (about 2% of body
weight) has already been lost, assuring that athletes will perform in a
poorly hydrated state that will negatively affect performance.
Well-formulated sports beverages that contain a sodium (about 100–200
mg/240 mL) and carbohydrate (about 4%–8% carbohydrate solution) and
are appropriately consumed have been found to encourage fast
absorption, sustain blood volume, sustain sweat rates, and provide fuel to
the brain and muscles to minimize the impact of hydration deficits.
Athletes should find an appropriately formulated sports beverage that
tastes good while they are physically active, and that they are willing to
consume enough of to minimize body weight loss during exercise.
Athletes should become accustomed to a sports beverage to ensure
adequate gastric emptying, which is affected by fluid volume, osmolality,
pH, type(s) and concentration of carbohydrate, exercise intensity, fluid
temperature, environmental conditions, and the extent to which the
athlete is hypohydrated.
Entering physical activity in a well-hydrated state is important, because
improving hydration status while exercising is difficult during intense
activity because the maximal sweat rate is higher than the maximal
absorption rate for fluid.
After exercise is completed, the athlete should continue to drink to replace
any amount of fluid that was unreplaced during the exercise to return as
quickly as possible to a well-hydrated state. Athletes should be cautious to
not overconsume fluids because of the risk of hyponatremia.
Athletes should practice to find for themselves a refueling and hydration
plan that suits their individual needs, based on their state of
acclimatization, exercise intensity and duration, sweat fluid loss, and GI
tolerance. They should find an appropriately constituted sports beverage
for before, during, and after exercise, with the confidence of knowing that
an appropriate hydration strategy is critically important to performance
and recovery (146).
Before exercise athletes should strive to achieve euhydration by
consuming a fluid volume equivalent to 5–10 mL/kg body weight (∼2–4
mL/lb) in the 2–4 hours prior to exercise, with the goal of producing urine
 that is pale yellow and allowing sufficient time for excess fluid consumed to
be voided.
During exercise athletes should drink sufficient fluids to replace fluid losses
in a way that limits the total body fluid loss to no more than 2% of body
weight. Different sports, different sweat rates, and different environmental
conditions mandate that athletes find hydration strategies that are well
suited to them.

After exercise athletes typically finish with a fluid deficit, requiring that they
establish an appropriate strategy to achieve euhydration during the recovery
period. This generally involves consumption of water and sodium at a rate that
minimizes diuresis.

Practical Application Activity

1. Measure your body weight just before you begin to exercise.

2. Measure how much fluid (in oz) you consume during the exercise.
3. Measure your body weight (dry off first) right after you finish your
exercise.
4. The difference in weight is the fluid you should have consumed but did
not consume (16 oz = 1 lb). (If there was more than a 2% difference in
weight you have likely not benefited from the exercise as much as you
might have.)

Chapter Questions

2. On average, the body of a physically active adult is composed of

approximately ____ water weight.
a. 20.0%
b. 30.5%
c. 60.0%
d. 80.0%
3. The greatest proportion of total body fluid is found in the
a. ISF
b. Blood plasma
c. ECF
d. ICF
4. ISF refers to
a. Fluids in and around the heart muscle
b. Fluids that are mainly composed of anions rather than cations
c. Fluids surrounding cells but not part of the cell or plasma
d. Fluids in capillaries that nourish the periphery (toes, fingers, eyes, etc.)
5. The main cation in ECF is
a. Calcium
 b. Chloride
c. Potassium
d. Sodium
6. The primary cation in ICF is
a. Calcium
b. Chloride
c. Potassium
d. Sodium
7. ICF osmolarity is higher than ECF osmolarity, so what is the tonicity of the
blood?
a. Isotonic to the ICF
b. Hypotonic to the ICF
c. Hypertonic to the ICF
d. Hypertonic to the ECF
8. A heavily sweating athlete, particularly if he or she is well conditioned to the
environment, is likely to experience the following osmolarity change in the
blood:
a. Osmolarity increases
b. Osmolarity decreases
c. Osmolarity does not change
d. Osmolarity change is unpredictable
9. The greatest water loss that occurs when an athlete exercises intensely is
from
a. Kidneys (urine)
b. Lungs (air)
c. GI tract (feces)
d. Skin (sweat)
10. In athletes, the sensation of “thirst” is a perfect indicator that it is a good
time to consume fluids.
a. True
b. False
11. Of the following, which is present in the greatest concentration in sweat?
a. Lactate
b. Calcium
c. Magnesium
d. Sodium

Answers to Chapter Questions

1. c
2. d
3. c
4. d
5. c
6. b
7. a
8. d
9. b
10. d

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CHAPTER OBJECTIVES

Recognize the different components of body composition

and how these components may vary depending on level
of fitness.
Evaluate the different strategies available for assessing
body composition, the principles used in each method,
and the relative accuracy of each method.
Describe the hormones that influence weight and body
composition, and the dietary factors that can have an
impact on these hormones.
Demonstrate an understanding of the health risks
associated with obesity, and the exercise and dietary
strategies that are most likely to lower body fat level.
Recognize common risks associated with the
development of eating disorders in athletes and how
best to lower these risks in at-risk sports.
Evaluate the reasons why weight is not a good metric for
determining health risks and performance potential in
both athletes and nonathletes.
Describe how insulin production can be influenced by
multiple dietary factors including but not limited to the
consumption of sugars.
 Understand the limitations of using body mass index
(BMI) as a metric for assessing individual athletes.
Explain the female athlete triad and how this concept fits
into the larger organizational framework of relative
energy deficiency in sport (RED-S).

Case Study

Imagine an Olympian who was just behind the best

person on the swim team, and someone who was willing
to do anything to make that place hers. Everyone has an
inherited physique, and this powerhouse clearly had
inherited all the qualities (both good and bad) of her
genetic donors. She was on the short side of small and
had a “blockhouse” figure. Nevertheless, while
swimming her laps, there was no one better to look at:
great strokes, perfect flip turns, powerful starts off the
blocks, a rocket finish — and it all came together to
make her one of the best. Despite her national and
international competitive successes, she still was not
considered the best this country had to offer, and this
ate away at her psyche like nothing else could. To
improve, she spent more hours practicing, became more
careful about what she ate, and began bugging her
coach for more ideas on how to improve every part of
the stroke, even if the resultant improvement would be
miniscule.
She became so unhappy with herself that she found
fault with her appearance. “If only I were leaner” and “If
only I had less fat” were common interjections in her
conversations. But when you have someone who, for her
sport, is already in the 10th percentile for body fat
percent, it is hard to imagine that having less fat would
cause a competitive improvement. Nevertheless, she
began seeing herself as fat and took the only action she
could think of — dieting to the point of starvation to
make herself less fat.
During the regularly scheduled evaluations of the
national team swimmers, it was noticed that all of the
swimmers were comfortably walking around in their gym
shorts and T-shirts — all of them except the swimmer in
question. She had on two sweatshirts, gym pants, and a
jacket and was still shivering. It was obvious to all the
sports medicine staff that there was a problem, so a
body composition assessment was performed to
document the changes. As suspected, she not only had
lost weight but had lost more weight from her fat-free
mass (muscle) than from her fat mass, so she was less
able to move her body weight than before. Her coach
expressed concern that she had become impossible to
work with. Her starts were short, her turns had
deteriorated, and she no longer had a killer finish. All the
strength and skills that were at the core of her successes
had disappeared. Her coach was ready to increase her
training schedule (even though she was already
spending more hours in the pool and weight room than
anyone else) because he could not see how she could
compete in the next big competition given her poor state
of readiness.
When her diet was reviewed, it became clear that she
was trying to cover up an eating disorder. It would have
been impossible for her to have eaten what she reported
she ate and to have lost so much weight. It was decided
that, for her to return to the team, she would be required
to present a letter from a psychiatrist trained to work
with eating disorders, clearly stating that her continued
participation in competitive swimming would not place
her at risk for an eating disorder. In other words, if she
wanted to come back, she had to change what she was
doing and she had to convince an appropriate medical
 professional that this change would not be altered if she
returned to swimming.
Fortunately, this story has a happy ending. She did it.
She went home, went to counseling, learned what she
needed to do, accepted her physique as it was, ate
better, trained smarter, got her OK letter from her
physician, and became a star.

CASE STUDY DISCUSSION QUESTIONS

If you were working with competitive athletes who
believed that achieving a certain weight would make
them perform better, and the way in which they were
trying to achieve the desired weight was through
restrictive eating:

1. What would you tell them?

2. Would you discuss this issue with others who work
with the team (coaches, dietitians, exercise
physiologists, etc.) or would you try to go it alone?
3. Would you see if there are policies about the
appropriateness of talking to an athlete about their
weight?
4. If you believed an athlete had an eating disorder,
what would you do to help this athlete?
5. Who on the sports medicine team is qualified (if
anyone) to work with a psychological disorder?

Introduction

There is a clear interaction between physical activity and

nutrition, with an increased requirement for energy that
results from the higher rate of energy expenditure during
physical activity. Despite this exercise-associated
requirement, surveys assessing food and fluid intakes of
physically active people have found that they often fail to
satisfy the increased energy requirement (22, 66, 69). To
make this problem worse, it appears that physically active
people often supply the needed energy after it is most
needed (referred to as postloading), which can negatively
affect performance and also result in an unwanted body
composition change (29, 135).

Body Composition

Represents the major tissues that compose the human

body, including fat mass, lean mass, water, and bones.
Techniques for assessing body composition use different
assessment models, with a two-compartment model (fat
mass and fat-free mass) being the most common and a
four-compartment model (fat mass, lean mass, water
mass, and skeletal mass) being the most accurate.
Assessment strategies range from the most accurate and
most expensive (dual-energy x-ray absorptiometry [DXA],
multicurrent bioelectrical impedance analysis [BIA], and air
displacement plethysmography) to less accurate and less
expensive (skinfolds, BMI, and waist circumference).

Mass

Another word for weight that is commonly used in the

scientific literature. Weight of body fat is equivalent to
body fat mass, etc.

Important Factors to Consider

Much like humans, automobiles have finite storage of

fuel. For a car to run, the car fuel tank can never be empty
and it can never be overfilled. Letting the fuel tank go to
empty causes the car to stop. If you try to overfill an
automobile gas tank, the fuel has nowhere to go, but in
humans overfilling the tank results in more fuel storage (i.e.,
an increase in fat mass).
Now imagine that you want to take a car trip from New
York to San Francisco, but you are in a hurry and do not want
to stop to refuel every 350 miles, so you tell your car:
“Please take me to San Francisco, I promise I will give you all
the fuel you need for the trip once we get to San Francisco.”
It should be obvious to anyone that this postloading strategy
does not work for your car — and it does not work well for
physically active people.
An obvious problem in humans is to allow blood sugar to
drop, which can happen quickly with physical activity. Blood
sugar is the main fuel for the brain, so the brain increases
the production of cortisol, which breaks down muscle for
conversion to sugar. Blood sugar is improved, but at the cost
of losing muscle.

Consumption of inadequate energy may result in multiple

problems for the athlete, including the following:

Poor training benefits

Difficulties in maintaining fat-free (i.e., lean) mass
Lowering of metabolic rate
Increased difficulty with normal eating, leading to even
greater reductions in both energy and nutrient intakes
that may result in increased risk of disordered eating
and/or eating disorders
Increased risk of injury
Reduction in athletic performance

Consumption of excess energy may also result in multiple

problems for the athlete, including the following:

Higher total body mass

 Higher total fat mass
Unhealthy ratio of total fat mass to lean body mass
Cardiac insufficiency
Higher risk of type II diabetes
Higher risk of hypertension
Lower disease resistance
Dieting-associated adaptations that result in lower
energy expenditure
Increased risk of disordered eating and/or eating
disorders
Increased risk of injury
Reduction in athletic performance

Type II Diabetes

Associated with obesity, type II diabetes is a condition of

excess insulin production but with ineffective insulin (i.e.,
insulin resistance). Risk factors for metabolic syndrome
and type II diabetes are related (10).

Metabolic Syndrome

Represents a group of factors that elevate risk of

developing heart disease, diabetes, and stroke. Factors
include high abdominal obesity, high serum triglyceride
levels, low high-density lipoprotein cholesterol, and high
fasting blood sugar.

Several possibilities exist for why athletes fail to satisfy

total energy needs, including a poor understanding of what
foods and beverages are best to consume; inadequate
availability of foods and beverages before, during, and after
exercise; a sport-specific tradition that perpetuates
undesirable eating behaviors; and a tendency for athletes to
model behavior after those who have excelled in the sport
even if their food/beverage consumption behaviors are not
optimal (12). Many athletes also have a level of eating
anxiety, with a fear that eating exercise-appropriate foods
and beverages, which often contain sugars, will increase
body fat and weight (62, 84, 154). There may be confusion
with what to eat and drink because terms are often misused.
For example, high body fat does not mean high body weight,
leanness is not the same as thinness, and a higher weight
may be desirable if it is the result of more lean mass that
can improve the strength-to-weight ratio (12) (Figure 8.1).
The coach who insists that an athlete lose 5 lb may be
dismayed at the performance outcome if the majority of that
weight comes from muscle and not fat. This same athlete
who gained 5 lb of muscle and lost 5 lb of fat would have the
same weight, but the greater proportion of muscle would
serve to improve performance because of an improved
strength-to-weight ratio. This more lean athlete would also
appear smaller (a clear advantage in certain appearance
sports) because fat-free mass has a higher density than fat
mass (i.e., for the same weight, takes up less space) and
would likely also have better endurance because there is less
nonmuscle tissue to move. Put simply, the failure of many
physically active people to optimally consume energy may
be the direct result of using an inappropriate metric, weight,
as the sole measure of performance readiness. It also may
be due to a misunderstanding of energy thermodynamics,
the factors associated with the utilization of energy, as it
relates to humans. Correctly measuring and predicting body
composition, therefore, is critically important for helping
athletes achieve desired performances, particularly in sports
where athletes are judged on both aesthetics and skill (i.e.,
diving, gymnastics, figure skating) and in sports driven by
weight categories (i.e., wrestling, boxing) (1). Performing
body composition assessments requires consideration of
multiple associated factors, including (57) the following:
FIGURE 8.1: Obesity is not the same as overweight. BMI,
body mass index.

Fat-Free Mass

Body tissue that is not fat, including lean mass, skeletal

mass, and body water.

Fat Mass

The total weight of fat that a human has. For instance, if

someone weighs 100 lb, and 30 lb is fat, 30% of the weight
is fat (body fat percent) and 70 lb (70%) is fat-free weight
(fat-free mass).
 Subcutaneous Fat

It is typical for 50% of total body fat to express itself under

the skin (i.e., subcutaneously). Therefore, as is used with
skinfolds, measuring the thickness of subcutaneous fat
provides a prediction of total body fat.

Lean Mass

Lean mass represents lean tissue, including skeletal

muscle and organ mass, but not including skeletal mass
and fat mass.

Considering the appropriate reference model for

individual or group being assessed;
Determining the appropriate field or laboratory method
to use that will provide the needed information in a
minimally invasive, validated, and reliable way;
Understanding the potential health implications of the
results, including both total body fatness and fat
distribution;
Determining how best to make improvements in
musculature, body fat, or both.

Realizing that different people will have different

responses to any intervention that targets modification in
body composition.

Weight

Important Factors to Consider

The strategy for losing body fat mass while sustaining

body lean mass is different than the strategy to lose
weight. It is possible to lose lean body mass and gain fat
mass while losing weight. The ideal focus should be on the
following:

Avoiding recommendations that may lower lean mass

Avoiding recommendations that may increase fat mass

There is no question that weight is an important issue for

athletes because it influences the ease with which they can
perform required sport-specific skills (54). However, the
measurement of weight alone may provide a misleading
picture of whether the athlete is in a desirable state (Table
8.1). Athletes may increase the time and/or intensity of a
training regimen with the goal of improving performance, but
then inappropriately rely on changes in weight as a marker
of success. Imagine a football player who comes to training
camp at a weight much higher than the coach is accustomed
to seeing in this player. It may well be that the athlete
worked extremely hard during the off-season to increase
muscle mass, and the increase in weight is a result of more
muscle. Would the coach be wrong to tell that player that he
has to lose weight?

Table Weight and Body Composition “Realities”

8.1
Reality Humans are amazingly effective fat manufacturing
1 machines. Consume too much energy from food
and beverages and you make fat. Consume too
little energy from food and beverages, you lose
body mass — from fat mass and muscle, and in
many cases inadequate energy intake results in
higher body fat levels (29, 37, 39).
Reality Humans are always finding ways to become more
2 energy efficient. Exercise more and we eventually
 find a way to burn less energy to do this exercise
(8, 9, 21, 39, 109).
Reality For athletes, “weight” is the wrong measure for
3 virtually everything that it is commonly used for. It
is all about the ratio of fat mass to lean mass (73,
111, 145).
Reality The ___location and distribution of body fat is also
4 important. For example, central visceral fat
deposition is related to higher risk of disease such
as metabolic syndrome (101, 107, 125).
Reality Low-calorie diets are doomed to fail. Adaptive
5 thermogenesis leads to same weight on lower
energy intake, but the resultant weight has
relatively higher fat mass (14, 39, 120).
Reality There are many ways to increase insulin and make
6 more fat besides eating refined carbohydrates
(i.e., sugar), including letting yourself get really
hungry and/or eating large meals (5, 66, 72, 74,
88, 141, 155).
Reality The body’s reaction to an inadequate energy
7 intake is to lower body weight (mass), including
lowering the amount of tissue that needs more
energy, resulting in a greater loss of lean mass
than fat mass (36, 37, 107).
Reality A 3,500 calorie energy balance deficit does NOT
8 result in a 1 lb weight loss. This is because there
are a number of complex adaptive factors that
influence energy balance and body composition.
Although 3,500 calories of potential energy as
measured by a bomb calorimeter does equal 1 lb
of body fat, humans are not bomb calorimeters
(64).
Reality The commonly stated calories in, calories out
9 paradigm does not work as commonly applied in
24-hour units. Humans have a
 physiologic/endocrine system that reacts in “real
time” to multiple factors, including blood sugar,
stress, rate of energy utilization, and environment
(64, 96).

Gymnasts often reach their competitive peak during

adolescence, a time when fast growth is the normal biologic
expectation. Despite this expectation for growth, gymnasts
are sometimes weighed weekly to make certain that they are
maintaining their current weight. Ideally, the focus should be
on a training and nutrition program that will help to enhance
the strength-to-weight ratio, which involves improving the
lean body mass–to-weight ratio and may involve increasing
weight from an enlarged lean body mass. These are
examples of how weight is often used arbitrarily and wrongly.
Tracking the constituents of weight (fat, bone, muscle, water,
etc.) is far more logical and provides athletes with more
actionable information on whether the body is changing in a
desirable way. Importantly, the strategy for weight is
different than the strategy for losing fat while sustaining or
increasing muscle.

Ideal Weight
Ideal weight is considered to be a weight that is associated
with good health and is based mainly on height, as adjusted
for gender, age, build, and muscularity. As athletes typically
have greater muscle mass than nonathletes for any given
height, using ideal weight standards for athletes often
wrongly places them in an at-risk category because they
appear to be excessively heavy for their height. Standard
strategies for determining ideal weight for athletes should be
used cautiously and should not be the standard for
determining if an athlete’s weight is desirable.
Therefore, although not ideally used with athletes, the
following equations are provided for the reader to
understand the strategy used in determining ideal weight.
There are several commonly used predictive equations for
estimating the ideal body weight. However, these equations
are not appropriately used with athletes because of an
expected higher weight:height ratio than that for
nonathletes. The commonly used formulas for predicting
ideal body weight (Box 8.1) include those of Devine (31),
Robinson (132), and Miller (105).

Box 8.1 Commonly Used Formulas for Predicting

“Ideal” Body Weight

Devine Formula

Males: Ideal body weight (in kg) = 50 kg + 2.3 kg/inch

over 5 feet
Females: Ideal body weight (in kg) = 45.5 kg + 2.3
kg/inch over 5 feet

Robinson Formula

Males: Ideal body weight (in kg) = 52 kg + 1.9 kg for

each inch over 5 feet
Females: Ideal body weight (in kg) = 49 kg + 1.7 kg for
each inch over 5 feet

Miller Formula

Males: Ideal body weight (in kg) = 56.2 kg + 1.41 kg for

each inch over 5 feet
Females: Ideal body weight (in kg) = 53.1 kg + 1.36 kg
for each inch over 5 feet
Source: Pai MP. The origin of the “Ideal” body weight equations. Ann
Pharmacother. 2000;34(9):1066–9.
Body Mass Index
BMI, also referred to as Quetelet’s Index, is a calculation of
the weight-to-height ratio and may also be a useful tool for
categorizing the weight of populations/groups (Table 8.2).
However, it is not likely to be as useful for athletes. BMI,
while providing a measure of body mass (weight) relative to
height, fails to measure individual body fatness, which is the
marker of obesity. Athletes typically carry more muscle for
any given height and, because of this relative increase in
body density, may appear to be overweight or obese by BMI
standards, but may not be either overweight or obese.

Table 8.2 Body Mass Index (BMI) Categories

Classification BMI Category Risk of Developing Health
(kg/m2) Problems
Underweight <18.5 Increased
Normal 18.5–24.9 Least
weight
Overweight 25.0–29.9 Increased
Obese class I 30.0–34.9 High
Obese class 35.0–39.9 Very high
II
Obese class ≥40.0 Extremely high
III

BMI = Weight in kg/height in m2.

Source: National Institutes of Health, National Heart, Lung, and Blood Institute.
Clinical guidelines on the identification, evaluation, and treatment of overweight
and obesity in adults: the evidence report. Obes Res. 1998;6(Suppl 2):S51–210.

Using BMI on athletes is likely to create false positives.

That is, a large, lean athletic person may have a BMI >30,
but has low body fat and so is not obese. It has been found
that athletes are often incorrectly classified as obese when
based on BMI (41). It can also create false negatives. That is,
a thin, small person may have a BMI of ∼20, but a relatively
low lean mass and high body fat, so that person is obese
(111). As an illustration of this point, it has been found that
BMI fails to identify over a quarter of children with excess
body fat levels as obese (73).
The best strategy for BMI is to use it as it was intended,
as a measure of characterizing population obesity and
weight categories that are associated with health problems,
and not as a means of identifying individual obesity or
weight categories.

Circumferences
Despite the well-established relationship between higher
visceral fat (abdominal fat, trunk fat, fat surrounding the
organs) and cardiometabolic risk, the traditional measure for
assessing obesity risk (BMI) fails to provide a direct
estimation of visceral fat (117). There is increasing evidence
that taking waist circumference is a useful measure for
predicting health risks, including hypertension, elevated
blood lipids, type II diabetes, and cardiovascular disease. A
measure of lower cardiometabolic risk is to have a waist
circumference that is less than half your height (6). The
waist-to-hip ratio is also a way of estimating if excess body
fat is stored in the abdomen in both children and adults. The
widest part of the buttocks is used for the hip circumference,
and the waist circumference is taken above the hip bone. In
both men and women, the circumference of the waste should
be smaller than that of the hip. High risk in men is indicated
with a waist-to-hip ratio of 1.0+ and in women 0.85+ (146).

Body Mass Index

BMI, also referred to as Quetelet’s Index, was developed as

a means of predicting population obesity. It represents a
person’s mass in kilograms, divided by their height in
 meters squared (kg/m2). BMI categorizations include obese
(>30), overweight (25–30), normal (18.5–25), and
underweight (<18.5). Although often used as an
assessment of individual obesity, it can create both false
positives (i.e., it appears that someone has a high body fat
level and is obese, but is not because the extra weight is
from high muscle mass rather than high fat mass) and
false negatives (i.e., it appears that someone is not obese,
but is because although their weight is low, a high
proportion of weight is fat). BMI is not appropriately used
with athletes as a measure of fitness/obesity.

Obesity

An accumulation of body fat that exceeds the threshold for

maintaining good health and is associated with higher risk
for heart disease, type II diabetes, cancer, osteoarthritis,
and sleep apnea. Hyperplastic obesity represents obesity
that results from excess fat cell production and is
commonly associated with an excess number of fat cells
that are produced during a growth phase, such as
adolescence. Hyperplastic obesity is one of the dangers of
childhood obesity, as it is difficult to lower fat cell numbers
to lower obesity risk. Hypertrophic obesity represents
obesity that results from excess enlargement of existing
fat cells and is the most common form of adult-onset
obesity.

Anthropometric Ratios
Especially in children, anthropometric ratios that incorporate
height, weight, and age are used for the assessment and
prediction of protein-calorie malnutrition and/or failure to
thrive. Anthropometric ratios have also been used to identify
young athletes who possess good characteristics for specific
sports (2). As many young children are increasingly involved
in high-level sport, some simple measures that can identify if
the child is satisfying energy/nutrition requirements are
important to understand.

Weight/Age
This is the most widely used method for assessment of
malnutrition in children. Put simply, the ratio intends to
assess whether the child’s weight for their age is
appropriate. A child with a low weight/age may be
malnourished and/or have an illness.

Height/Age
Height is a more stable growth parameter than weight
because height is irreversible, whereas weight can go up or
down. A relatively long period on a deficient diet is needed
for height to become sufficiently retarded, and a relatively
long time is required for height to return to normal after a
period of malnutrition. Therefore, height/age is not
considered an indication of the present nutritional status of
the child, but may be a method for assessing chronic
malnutrition or a long-term illness.

Weight/Height
Weight can change rapidly, whereas height is relatively
stable. Therefore, this ratio is a measure of the present
nutritional status of a child, with low weight/height an
indication of acute/short-term/current malnutrition.

Weight/Height/Age
At each age during normal growth and development, a
certain amount of weight is associated with any given
height. Using standard growth charts, it is relatively easy to
determine if a young athlete is deviating from their
established percentile in standard growth charts. As an
example, rapidly going from the percentile the young athlete
is typically near to another lower or higher percentile may be
an indication of an energy imbalance and/or illness.

Visceral Fat

The fat tissue around the organs (i.e., viscera). This fat
protects the organs from sudden concussion and also
protects the organs from sudden temperature shifts. Also
referred to as abdominal fat, high visceral fat is associated
with higher risk of type II diabetes, insulin resistance, and
inflammatory diseases that include cancer.

Waist Circumference

As a measure of central obesity (high body fat carried on

the trunk), waist circumference (also referred to as waist
girth) has been shown to be a good measure for health
risks associated with obesity.

Body Composition

Changing weight and body composition is not as

straightforward as often believed. It is common for people to
think that energy restriction (i.e., dieting) is an unpleasant,
yet effective, strategy for achieving weight loss and
improving body composition (Table 8.3). The common logic
behind dieting suggests that the caloric intake is
proportionate to the person’s weight, so a 25% reduction in
energy intake should result in a 25% reduction in weight. The
reality, however, is that energy expenditure following weight
loss is lower than would be expected by the amount of
weight that was lost (64, 96, 129, 135). This means that the
adjustment in energy expenditure to inadequate intake is
greater than the mathematical expectation because a
higher-than-expected reduction in metabolic mass (e.g., lean
mass) occurs, which results in a return to the original weight,
but with a lower energy intake. Put simply, low energy
intake, relative to energy requirements for energy balance,
causes a reduction in fat-free mass that forces an even
greater reduction in energy consumption to sustain weight.
The body’s reaction to an inadequate energy (caloric) intake
is to reduce the highly metabolically active tissues like
muscle that use energy (calories). This is a perfectly logical
survival strategy, as the body attempts to survive the
inadequate consumption of energy by lowering the need for
energy. Because food is the carrier of more than just energy
(calories), the reduction in food intake also diminishes
vitamin and mineral exposure, increasing malnutrition risk
and related disease risks.

Table 8.3 Terms Commonly Associated With

Weight and Body Composition
Terms Definition
Static (linear) Assumes that a change in one side of the
energy energy balance equation (e.g., energy
balancea intake) does not change or influence the
other side of the equation (e.g., energy
expenditure).
Dynamic Assumes that numerous biologic and
(nonlinear) behavior factors regulate and influence
energy both sides of the energy balance equation.
balancea Thus, a change in factors on one side of the
equation (e.g., energy intake) can and does
influence factors on the other side of the
equation (e.g., energy expenditure).
Dietary The energy content of food by weight (kcal
energy or kJ/g).
density
Table 8.3 Terms Commonly Associated With
Weight and Body Composition
Terms Definition
Thermic effect Energy required digesting, metabolizing, or
of food storing energy as fat or glycogen.
Energy fluxb The rate of energy conversion after
absorption from food into body tissues for
use in metabolism or its conversion into
energy stores.
PAc Physical activity. Bodily movement that
enhances health such as walking, dancing,
biking, and yoga.
Exercisec PA that is planned, structured, repetitive,
and performed with the goal of improving
health or fitness.
Health-related Cardiovascular or muscular fitness focused
fitnessc on the reduction of chronic disease risk.
Moderate- Moderate PA is an intensity of exercise
vigorous PAc similar to walking at 3.0 miles/h, whereas
vigorous PA is an intensity of exercise
equivalent to running a 10-minute mile.
Weight- PA such as walking, jogging, running,
bearing PA d hiking, dancing, stair climbing, lifting
weights, jumping, playing tennis,
basketball, or soccer.
Body The percentage or amount of fat and fat-
composition e free (mineral, protein, and water) in bone,
muscle, and other tissues in the body.
 Table 8.3 Terms Commonly Associated With
Weight and Body Composition
Terms Definition
Compensatory Partial or complete compensation, through
behaviorf diet, for the energy expended in exercise
(e.g., eating back energy expended during
exercise by increasing energy intake),
thereby negating body weight loss because
of increased PA. Decreasing PA could also
be a compensatory behavior.

Source: Manore MM, Larson-Meyer DE, Lindsay AR, Hongu N, and Houtkooper L.
Dynamic energy balance: An integrated framework for discussing diet and
physical activity in obesity prevention–is it more than eating less and exercising
more? Nutrients 2017; 9(905): doi: 10.3390/nu9080905

Logic also suggests that a 25% increase in energy intake

will lead to a proportionate increase in weight. In fact, when
people are overfed to gain weight, the amount of weight gain
is, at least initially, closely proportionate to the amount of
overfeeding (32, 49, 76, 88, 131). These studies strongly
suggest that we have homeostatic mechanisms during
periods of energy deficits that help us maintain our weight,
which may be a survival-of-the-species mechanism that
helps humans survive periods of famine. We also appear able
to store energy effectively (as fat) during periods of excess.
This may also be a survival-of-the-species mechanism that
enables us to store energy when we are lucky enough to
have excess food available.
It is increasingly clear that obesity development is
complex and associated with numerous factors (115):

Poor maintenance of energy balance

Insufficient physical activity
Living in an environment that fails to support a healthy
lifestyle, including
Safe places to walk
 Affordable gyms
Exhaustive work schedules
Oversized food portions
Poor access to or excessively expensive healthy
foods, including fresh fruits and vegetables
Chronic food advertising that encourages
consumption of high-calorie and/or high-sugar foods
Disease states, including conditions that result in low
energy metabolism (e.g., hypothyroidism) or loss of
metabolic mass (e.g., high cortisol production)
Use of medications that stimulate weight gain, including
corticosteroids and antidepressants
Emotional factors (e.g., boredom, anger) that may result
in overeating
Age-related loss of muscle
Poor sleep patterns

Energy Balance
Because major energy balance surpluses and energy balance
deficits appear to activate homeostatic mechanisms, a
possible means of making a desired change in weight and
body composition is to avoid major energy balance shifts.
Exercise should be at the core of any desired body
composition change that increases lean mass and decreases
fat mass. But such a change may be easier to achieve if the
energy balance deficits and energy balance surpluses over
the course of a day are never too large at any time. It has
been suggested that a desired body composition is easier to
achieve when energy balance remains within ±300–400 kcal
bounds (11–13, 25, 29). It has also been found that, of
female athletes with similar 24-hour energy availability and
energy balance, those spending more time in a catabolic
state were more likely to develop menstrual dysfunction
(45). Eating frequency is likely to play a role in the
maintenance of energy balance (29, 72). Because the
standard three-meal-a-day schedule forces athletes to
consume a large amount of food at each meal to obtain the
needed energy, this pattern may not be ideal for athletes
with large energy requirements (12, 13, 29, 72). It may be
far easier, for instance, to stay in a near-energy-balanced
state throughout the day on a more frequent pattern that
dynamically matches expenditure.
Getting energy balance right is difficult because it is
complex. The energy in side of the balance scale involves all
the factors associated with the intake of energy, including
meal size (i.e., caloric load of the meal), meal frequency, diet
quality, and factors that can influence the total absorption
and speed of absorption of the consumed foods. The energy
out side of the equation involves the metabolism of the
individual, the quality of the diet consumed, physical
activity, and meal frequency. In addition, the thermic effect
of food (i.e., the energy that must be invested to derive
energy from the food consumed) may also be influenced by
the energy out factors. Although seemingly a small influence
on total energy out, the average thermic effect of food,
which averages about 10% of the total calories consumed,
can be higher or lower (±2%), depending on diet quality,
activity, and meal frequency (Figure 8.2). There is evidence
that more frequent eating increases the thermic effect of
food (i.e., more calories are burned in the process of deriving
energy from food) than eating the same calories in fewer
eating opportunities (46, 59, 149). In addition, energy
balance is influenced by numerous hormones and chemicals
that affect appetite, satiety, and metabolic rate (68).
FIGURE 8.2: Energy balance is complex. (From Guyenet SJ,
Schwartz MW. Regulation of food intake, energy balance, and
body fat mass: implications for the pathogenesis and
treatment of obesity. J Clin Endocrinol Metab.
2012;97(3):745–55; Hall KD, Heymsfield SB, Kemnitz JW,
Klein S, Schoeller DA, Speakman JR. Energy balance and its
components: implications for body weight regulation. Am J
Clin Nutr. 2012:95(4):989–94; Loh K, Herzog H, Shi Y-C.
Regulation of energy homeostasis by the NPY system. Trends
Endocrinol Metab. 2015;26(3):125–35.)

Two common energy balance feedback systems involve

the hormones leptin and ghrelin. As an example of these
energy balance feedback mechanisms, which under ideal
circumstances serve to sustain the body tissues in a healthy
state, see Figure 8.3. These hormones have precisely
opposite effects, with leptin decreasing food intake and
ghrelin increasing food intake. It should be no surprise that
impaired leptin sensitivity and/or production is associated
with obesity, and excess ghrelin production is also
associated with obesity (133, 160).
FIGURE 8.3: The energy balance feedback mechanisms of
leptin and ghrelin. Leptin and ghrelin have opposing effects
on body weight. (From Klok MD, Jakobsdottir S, Drent ML. The
role of leptin and ghrelin in the regulation of food intake and
body weight in humans. Obes Rev. 2007;8(1):21–34; Shintani
M, Ogawa Y, Ebihara K, et al. Ghrelin, and endogenous
growth hormone secretagogue, is a novel orexigenic peptide
that antagonizes leptin action through the activation of
hypothalamic neuropeptide Y/Y1 receptor pathway. Diabetes.
2001;50(2):227–32).

Traditional View of Energy Balance

The traditional view of energy balance involves a
macroeconomic (i.e., daily) view of the human system: A 24-
hour energy intake that equals a 24-hour energy expenditure
results in perfect energy balance, a state that is associated
with weight stability (Figure 8.4).
FIGURE 8.4: Traditional view of energy balance.

It is also understood that a positive energy balance (i.e.,

relatively more energy consumed than expended) mandates
that the excess energy be stored, resulting in a higher
weight, and that a negative energy balance (i.e., relatively
less energy consumed than expended) mandates that the
difference in energy must be provided by body tissues,
resulting in lower weight (96, 102). This traditional view of
energy balance implies that a significant reduction in energy
intake (commonly referred to as dieting) results in weight
loss that is associated with an improved body profile and
body composition. However, there are complications in
determining energy balance that make it difficult to
understand whether the expected energy balance outcomes
will occur. These issues include the following (63, 64, 97,
129):
 Leptin

A satiety hormone, it is produced mainly by adipose (fat) cells

to inhibit hunger if fat cell mass becomes enlarged. It has the
effect of lowering food intake, increasing energy expenditure,
increasing fat catabolism, decreasing plasma glucose, and
decreasing body fat mass. Poor leptin production is associated
with increased obesity. Ghrelin and leptin have opposing
functions.

Ghrelin

The appetite-stimulating hormone, it is produced mainly in the

small intestine and increases with fasting and/or low blood
sugar. It has the effect of increasing food intake, lowering
energy expenditure, lowering fat catabolism, increasing plasma
glucose, and increasing body fat mass. Leptin and ghrelin have
opposing functions.

There are few longitudinal studies that help us fully

understand the long-term impact of energy balance
deviations on body composition and weight.
Both biologic and psychological factors influence energy
balance, but these are rarely studied together to better
understand their interactive effects.
There remain weaknesses in our understanding of how
different exercise that varies in amount, intensity, pattern,
timing, endurance, and resistance may differentially impact
energy balance, body composition, and weight.
There are large individual differences on how changes in
energy balance impact weight and body composition
outcomes, making it difficult to know, with certainty, how
different individuals will respond to a protocol that was
viewed as generally effective for groups.
Current strategies for acquiring energy intake and energy
expenditure information have a great deal of error associated
 with them.

A calorie is not necessarily a calorie with proportionally

different macronutrient intakes, as macronutrient composition
may influence both body fat and body protein mass. The
traditional view of energy balance should immediately raise
concerns because the human endocrine system does not wait
until the end of the day to determine if the energy provided
during the previous 24 hours was delivered in a way that satisfied
tissue requirements. The endocrine system works in real time,
with insulin, ghrelin, leptin, and cortisol responses based on the
current energy balance state of affairs (64, 129).
The often-used mathematical relationship between energy
imbalance and weight change is 3,500 kcal = 1 lb of body fat
(14,644 kJ = 0.454 kg). That is, a negative energy balance
resulting in a 3,500 kcal deficit, regardless of the time frame (1
day, 1 week, 1 month, etc.) will result in a 1-lb lowering of fat
weight. It is also thought that a positive energy balance resulting
in a 3,500 kcal surplus will lead to a 1-lb increase in fat weight.
However, there is an increasing body of evidence that these
predicted calorie-to-weight outcomes do not stand up to scrutiny.
This evidence suggests that anyone failing to adequately satisfy
energy needs is most likely to experience a return to the original
weight, but the resultant weight will have a lower fat-free mass
and higher fat mass (38, 96, 135, 159) (Figure 8.5).
FIGURE 8.5: Different densities of fat tissue and muscle tissue.

It is clear that there is a dose–response relationship between

levels of physical activity and the amount of weight that is lost.
The American College of Sports Medicine’s position statement on
physical activity and weight loss has concluded that 150 minutes
of physical activity per week promotes minimal weight loss and
that greater levels of physical activity result in greater levels of
weight loss (4). However, the loss of weight, per se, may be
misleading, because it fails to differentiate between the loss of
fat mass and fat-free mass (64). In addition, because the
currently popular weight control strategy of exercising more and
eating less may result in a severe negative energy balance that
lowers more lean mass than fat mass, a leading obesity
researcher has said: “Therefore, the mere recommendation to
avoid calorically dense foods might be no more effective for the
typical patient seeking weight reduction than would be a
recommendation to avoid sharp objects for someone bleeding
profusely” (120). It has been found that exercise-trained men and
women often consume insufficient energy, resulting in negative
health consequences (68). Weight cycling, where weight loss is
followed by a regaining of weight, is a common feature of low-
calorie diets. To make matters even worse, the common weight
cycling experienced by people who are on severely energy-
deficient diets increases both cardiovascular disease and renal
disease risks (38). Ideally, energy balance should be sustained in
a range that helps to sustain or increase lean mass while
sustaining or lowering fat mass (29) (Figure 8.6).

FIGURE 8.6: Weight cycling associated with low-calorie diets

increases risks of cardiovascular and renal disease. FR,
glomerular filtration rate. (From Dulloo AG, Montani JP. Dieting
and cardiometabolic risks. Obesity Rev. 2015:16(Suppl 1):1–6.)

Insulin

A hormone made by the β cells of the pancreas, which monitor

blood glucose. As blood sugar rises, it is detected by the
 pancreas and results in the production of insulin. The insulin
allows body tissues to take up sugar, thus lowering blood sugar
and providing an important energy source to the cells. A
sudden rise in blood sugar results in excess insulin production
(hyperinsulinemia), resulting in excess energy leaving the blood
and entering the cells. Hyperinsulinemia is associated with
obesity and may also occur from consumption of a high-calorie
meal and/or consumption of foods after blood sugar has been
allowed to become excessively low.

An article assessing the metabolic adaptations in “The Biggest

Loser” competition, and the subject of a New York Times article,
illustrates the weight-cycling problems experienced by those who
lose weight through low-calorie diets coupled with an increase in
physical activity (51, 81). The 14 participating contestants lost an
average of 128.3 lb (58.3 kg) that was associated with
significantly lower average resting metabolic rate (−610
kcal/day). Six years later, the majority (90.2 lb; 41.0 kg) of the
weight lost was regained, with a significantly lower resting
metabolic rate (−704 kcal/day) and lower energy metabolism
(−499 kcal/day). These findings strongly imply that weight may
be an inappropriate marker for understanding the success of a
diet, as the loss of weight resulting from inadequate energy
provision appears to downregulate metabolic (i.e., lean) mass as
the body attempts to adapt to the inadequate energy provision.
This adaptive thermogenesis appears to make weight gain
inevitable, with studies suggesting that the majority of the
regained weight is fat mass (36, 37, 39). Following a strategy that
lowers fat mass while sustaining or increasing lean mass is likely
to be a far healthier long-term strategy for controlling obesity.
The traditional view of energy balance (i.e., energy in; energy
out), despite being a standard feature of most books and book
chapters that discuss issues related to weight, has never been
found to be correct (63, 94). It has also been pointed out that it is
a fallacy to think that small changes in lifestyle have the capacity
to reverse obesity and show that walking to use 100 kcal more
each day should result (if using 3,500 kcal = 1 lb fat) in 50 lb of
weight loss in 5 years, but the actual loss is typically only ∼10 lb
(64). An online model presented by the U.S. National Institutes of
Health has incorporated this point by including new set point
plateau norms (http://bwsimulator.niddk.nih.gov). This system
finds that a 40 kcal/day permanent reduction in energy intake
should result in ∼20 lb of weight loss in 5 years, but the actual
predicted weight loss is only 4 lb because the body has a
compensatory response that is not considered in the standard
(i.e., 3,500 kcal = 1 lb body fat) energy balance prediction.

Hormonal Response to Energy Balance Shifts

It is important to consider the hormonal alterations that occur in
the human system as it attempts to adjust to wide shifts in
energy balance. Insulin, through its effect on cell membranes, is a
major regulator of blood sugar. When insulin is produced, insulin
makes it possible for blood glucose to enter the cell so that the
cell has the energy (glucose) to undergo normal metabolic
processes. If excess insulin is produced, too much glucose leaves
the blood and enters the cell. Because cells have no facility to
metabolize this excess energy, the cells create fat from the
glucose and shuttle the fat out of the cell for storage as tissue
fat. In simple terms, too much insulin production is associated
with greater fat storage (body fat rises).
Relatively large doses of refined/simple carbohydrates may
result in hyperinsulinemia (excess insulin production), which
unlike a normoinsulinemic response (normal insulin production)
fails to shut down the appetite-stimulating hormone ghrelin (17,
80, 132). The continued high presence of ghrelin results in
sustained appetite and greater food consumption that could
produce a high positive energy balance, which could result in
higher weight. Without a stimulus to increase muscle (i.e.,
appropriate exercise), this excess energy consumption could
result in a higher level of stored body fat. It is important to note,
however, that the simple/refined carbohydrate explanation for
hyperinsulinemia is likely to be incomplete and potentially
misleading, as there are multiple causes of hyperinsulinemia in
addition to the consumption of high glycemic meals (Table 8.4).
For instance, an infrequent eating pattern that allows blood sugar
to drop below normal levels may also result in a hyperinsulinemic
response at the next eating opportunity (16, 43). Insulin is
produced exponentially to the caloric load of the food consumed,
so eating an excessively large meal (regardless of its
composition) would also result in excess insulin production with
the concomitant increase in fat and, because of the associated
maintenance of ghrelin, more total energy intake and weight (24,
151). Higher total body fat or higher abdominal fat, regardless of
the food consumed, is also associated with hyperinsulinemia and
all of its sequelae (42, 126). Although it is true that refined, high
glycemic carbohydrates play a special role in insulin production,
there are multiple other causes of hyperinsulinemia that are
independent of macronutrient distribution, and these causes
cannot be ignored if attempting to understand how energy
balance dynamics influence weight and body composition.

Table 8.4 Factors That Can Result in Excess Insulin

Production
1. A high bolus A high consumption of high glycemic foods,
intake of simple including refined/processed grains, sugary
refined beverages, and/or high-sugar foods, are
carbohydrate quickly absorbed and induce a fast and high
and/or sugars insulin response.
2. Consumption Insulin is produced exponentially to the caloric
of any large content of the meal consumed. Therefore, the
meal net insulin production of four 500 kcal meals is
lower than the net insulin production of two
1,000 kcal meals, even though the total
caloric intake is the same.
3. Consumption Normal blood sugar ranges from 80 to 120
of mg/dL, and if blood sugar is allowed to go
foods/beverages below this level (a common occurrence with
following a long skipped meals or exercise longer than 30 min
period without that is unsupported with a carbohydrate
eating that containing sports beverage), the next meal is
results in low likely to result in a high insulin response
blood sugar regardless of the meal’s composition.
4. Having a high Individuals with excess fat contributing to total
body fat level mass are likely to be chronically
 hyperinsulinemic, making it even more
important to avoid points 1–3 above.

Source: Benardot D. Energy thermodynamics revisited: energy intake strategies for

optimizing athlete body composition and performance. Pensar en Movimiento: Revista
de Ciencias del Ejercicio y la Salud (J Exerc Sci Health). 2013;11(2):1–13.

Adaptive Thermogenesis

Refers to the decrease in energy expenditure below the level

that may be predicted from energy expenditure, body weight,
and lean mass in response to an inadequate energy intake.

An additional potential problem is that the calculation of

energy balance using the 24-hour traditional view makes the
assumption that the time of day used to assess the prior 24 hours
is irrelevant. The typical data collection strategy for such an
assessment is to ask a client/athlete for the immediate prior 24-
hour energy intake and expenditure regardless of the time of day
the client is with you, with the assumption that energy balance at
that precise point of time is the same for the entire 24 hours that
preceded it. However, the within-day energy balance curve is not
flat, so the time of day that the client/athlete is assessed creates
differences in the energy balance calculation (Figure 8.7). Also,
meals are not always consumed at the same times. A later dinner
that is consumed early in the 24-hour assessment period could
lead to two dinners being included in the same analysis period,
resulting in an apparent large 24-hour energy balance surplus. An
early dinner early in the 24-hour assessment period and a late
dinner late in the same 24-hour assessment period could exclude
both dinners and make it appear as if the client is in a chronic
energy balance deficit. The resulting 24-hour energy balance
conclusion would, therefore, be entirely different for the same
person, depending on the time of day the evaluation took place.
FIGURE 8.7: Energy balance fluctuates over the course of a day.
Because of this, the same person, on the same day, would
appear as if he or she had an entirely different energy balance
depending on the time of day.

24-Hour Energy Balance

The ratio of energy consumed over 24 hours versus the energy

expended over 24 hours, and represents the traditional way
that energy balance has been measured in humans. However,
recent studies suggest that wide fluctuations in energy balance
during the day (i.e., in real time) may result in the loss of lean
tissue or an increase in fat mass, even if 24-hour energy
balance appears to be good.

It is possible for a person to appear to be in nearly perfect

energy balance at the end of a 24-hour assessment period, but to
have arrived at this point with extremely large energy balance
surpluses or deficits that could have an impact on body
composition. A source of concern with the traditional model for
energy balance is the failure to consider that the pattern of
energy consumption is an important factor in weight and body
composition. This model assumes that a person requiring 2,000
kcal/day (8,368 kJ/day) to satisfy energy requirements could
consume that energy without regard to meal size or eating
frequency, and the energy balance influence on weight or body
composition would be the same. This person could, for instance,
have a 2,000 kcal breakfast and eat nothing else the remainder
of the day to satisfy the energy requirement; they could have a
2,000 kcal dinner and eat nothing else prior to that dinner; or
they could have four 500 kcal meals during the day. The 24-hour
macroeconomic model assumes that the endocrine system only
takes action at the point of assessment and that the outcomes in
body composition and weight would be the same, but they are
not. The large breakfast would cause the person to spend the
majority of the day in an energy balance surplus, with excess fat
storage the likely outcome; the large dinner would cause the
person to spend the majority of the day in an energy balance
deficit, with catabolism of lean tissue and a relatively higher fat
storage; and the frequent meal eater is more likely to sustain the
metabolic mass and the fat mass.
A study of the association between hourly energy balance and
body composition in four different groups of elite athletes
illustrates the importance of avoiding wide shifts in energy
balance during the day (29). This study found that large within-
day energy balance deficits were associated with higher body fat
levels (Figure 8.8). An example of this can also be found in an
assessment of an elite athlete, whose ending energy balance was
very close to perfect, but who achieved a large energy balance
deficit while arriving at the end-of-day energy balance point
(Figure 8.9). The corrective action was to adjust the consumed
energy during the day to avoid the large energy balance deficit
while maintaining total energy intake as it was (12). At no time
was the recommendation made to increase or lower total energy
intake, but rather to change the timing and amount of foods
consumed to better sustain energy balance throughout the day
and positively influence the hormone/endocrine response.
FIGURE 8.8: Large within-day energy balance deficits are
associated with higher body fat percent. Athletes who sustained
smaller deviations from perfect energy balance over the course
of 24 hours had lower body fat levels. (From Deutz R, Benardot D,
Martin D, Cody MM. Relationship between energy deficits and
body composition in elite female gymnasts and runners. Med Sci
Sports Exerc. 2000;32(3):659–68.)
FIGURE 8.9: Maintaining energy balance as a strategy for
improving body composition. (From Benardot D. Timing of energy
and fluid intake: new concepts for weight control and hydration.
ACSM Health Fit J. 2007;11(4):13–9.)

As demonstrated by several studies, the traditional 24-hour

energy balance model is not capable of considering within-day
fluctuations in energy balance. It was found that muscle
breakdown occurs with inadequate real-time fuel provision as an
adaptation to the inadequate energy availability and as a
consequence of higher cortisol production (72, 74). Infrequent
eating and large bolus meals result in higher body fat storage,
even if total caloric intake is the same, largely as a result of
greater insulin production from the larger meals (29, 48). Insulin,
blood sugar, and leptin are better controlled with frequent
smaller feedings that dynamically match energy requirement (66,
88). The exerciser who fails to satisfy the dynamic need for
energy and develops low blood sugar will go into a state of
gluconeogenesis. This will result in the likely breakdown of lean
tissue to release alanine to the liver where the alanine–glucose
cycle can manufacture glucose to, among other things, sustain
normal brain function. An early study found that after only 40
minutes of strenuous activity, free serum alanine could increase
by 60%–90% or even more if the exercise occurs with low blood
sugar (47). Studies have also found that cortisol is elevated if
exercise proceeds with a failure to consume a carbohydrate
beverage, likely resulting in a negative within-day energy balance
and in low blood sugar (118). Cortisol is known to be catabolic to
both bone and muscle, resulting in higher stress fracture risk and
higher body fat percent (23, 33, 74). One must ask why an
athlete would exercise in a way that breaks down muscle and
bone when the goal is to reduce exercise-associated risks and
enhance muscle function. Yet, if the traditional 24-hour energy
balance view is followed, this is all too possible. As illustrated in
Table 8.5, there are multiple hormonal problems that occur when
negative energy balance occurs.

Table 8.5 Negative Energy Balance and

Hormonal Changes
Tissue/Organ Hormone/Compound Expected Change
Adipocytes and Leptin Decreased
hypothalamus
Adrenal Cortisol Increased
Gastrointestinal tract Ghrelin Increased
Liver Plasma glucose Decreased
IGF-1a Decreased
IGFBP-1b Increased
Pancreas Insulin Decreased
(fasting)
Increased (eating)
Thyroid Total T3c Decreased
a
Insulin-like growth factor-1.
b
Insulin-like growth factor binding protein-1.
c
Triiodothyronine.
Sources: Laughlin GA, Yen SSC. Hypoleptinemia in women athletes: absence of a diurnal
rhythm with amenorrhea. J Clin Endocrinol Metab. 1997;82(1):318–21; Loucks AB,
Callister R. Induction and prevention of low-T3 syndrome in exercising women. Am J
Physiol. 1993;264(5):R924–30; Loucks AB, Heath EM. Induction of low-T3 syndrome in
exercising women occurs at a threshold of energy availability. Am J Physiol.
1994;266(3):R817–23; Loucks AB, Verdun M, Heath EM. Low energy availability, not
stress of exercise, alters LH pulsatility in exercising women. J Appl Physiol.
1998;84(1):37–46; Stafford DEJ. Altered hypothalamic-pituitary-ovarian axis function in
young female athletes. Treat Endocrinol. 2005;4(3):147–54.
Real-Time View of Energy Balance
In studies of both athlete and nonathlete populations, dietary
trends that coincide with the steep obesity velocity curve include
larger food portion sizes, consumption of fast foods with hidden
fats, and decreased meal frequency (72, 82). All of these have an
influence on ghrelin and leptin. Decreased meal frequency is
associated with greater daily energy consumption, possibly from
an upregulation of appetite and/or a tendency for greater fat
consumption found that visible fats in meals resulted in a lower
total energy intake than hidden fats because of altered sensory
signals (140, 155). It was also found that meal skipping has an
influence on obesity. They assessed a large sample of people who
did not typically skip breakfast as children or adults (n = 1,359),
those who skipped breakfast only in childhood (n = 224), those
who skipped breakfast only in adulthood (n = 515), or those who
skipped breakfast in both childhood and adulthood. Skipping
breakfast is associated with a severe energy balance deficit. The
chronic breakfast skippers had significantly higher fasting insulin,
serum low-density lipoprotein, and waist circumference. Even
when adjusting for diet quality, these differences persisted. These
data imply that humans do not adapt to poor eating behaviors
that fail to sustain energy balance.
It has also been found that the increased energy intake
associated with infrequent eating is not matched with higher
activity, resulting in a higher body fat level (15, 52). Franko et al.
(52) found, after studying girls between the ages of 9 and 19 for
over 10 years, that the subjects who consumed 3+ meals on
more days had lower overweight and obesity rates than girls with
lower meal frequency. Berkey et al. (15), studying a cohort of
more than 14,000 boys and girls, found that eating breakfast
(i.e., increasing eating frequency) was an important strategy for
avoiding obesity.
Avoiding hyperinsulinemia, either through preventing hunger
(associated with eating when in a severely low blood sugar state
and a direct result of infrequent eating and poor within-day
energy balance) or eluding the consumption of high glycemic
foods, is useful in controlling the appetite-stimulating hormone
ghrelin. Anderwald et al. (5) found that ghrelin was unchanged in
type II diabetics following insulin treatment, but a rise in serum
insulin that occurs following a meal had the effect of suppressing
ghrelin and reducing appetite in nondiabetics. In an assessment
of a small group of young adult males, it was also found that the
postmeal drop in ghrelin is likely due to the rise in insulin, but
that this relationship does not exist with the hyperinsulinemia
associated with insulin resistance (141). In a group of 278 healthy
French schoolchildren between the ages of 6 and 8 years, it was
found that skipping breakfast and consuming sugar-sweetened
beverages while watching television were likely factors in
unsuppressed ghrelin, hyperinsulinemia, or both, and that these
behaviors were associated with significantly higher BMI, sum of
four skinfolds, and waist circumference (71). Put simply,
producing excess insulin sustains appetite through sustained
ghrelin.
A concern with the macroeconomic view of energy balance is
the assumption that an energy balance achieved at the end of a
24-hour period is perfectly sustained for the entire 24 hours that
precede it. However, there are natural peaks and valleys in
energy balance throughout the day, and it has been found that
wide deviations from perfect energy balance during a 24-hour
period are associated with higher body fat percent, even if
energy balance is achieved at the end of that 24-hour period. A
recent review of studies assessing the relationship of protein
intake and sarcopenia found a similar result, with the suggestion
that sustaining a steady intake of high-quality protein (between
25 and 35 g/meal) at standard three-meal intervals throughout
the day is far more effective at maintaining or increasing muscle
mass than the common postloading that many athletes do,
resulting in excessively large end-of-day energy and protein
intakes (121). A reassessment of athlete protein intakes using
this model is warranted, as it appears that many athletes with
relatively high protein intakes exceeding 2–3 g/kg/day may
actually have inadequate protein intakes when maximal protein
utilization rates (∼30–35 g protein per meal) are considered. The
extremely high single-meal protein and energy intakes seen in
some athletes, often at levels exceeding 100 g protein and 4,000
kcal, provide protein and energy at levels that are metabolically
inefficient and more likely to increase fat mass than muscle
mass. Once again, the 24-hour model for energy/nutrient intake
and expenditure fails to optimally provide actionable information.

Relative Energy Availability in Sport

Energy deficiency has long been reported in athletes, and in
particular it has been widely prevalent in athletes in weight-
sensitive sports, including gymnastics, wrestling, diving, and
figure skating (110). Energy deficiency can occur as a result of
several factors, including intentionally restricting energy intake to
make a certain weight class or lean physique, or because of an
eating disorder, a sport-associated disordered eating pattern, or
from a simple misunderstanding of how a failure to supply the
needed energy can compromise health and performance.
Sustaining an energy-deficient diet during physical activity may
place an athlete in a catabolic state that results in precisely what
they wish to avoid: a loss of muscle mass and an increase in fat
mass (29). In 2014, the International Olympic Committee (IOC)
introduced a new term to describe this failure of adequately
supplying needed energy: relative energy deficiency in sport
(RED-S), and described problems faced by all physically active
people who fail to supply the fuel required for the activity. RED-S
includes a broad range of potential health and performance
consequences for both males and females who are physically
active (110) (Figure 8.10).
FIGURE 8.10: Disease risks and performance issues associated
with relative energy deficiency in sport (RED-S). (From Mountjoy
M, Sundgot-Borgen J, Burke L, et al. The IOC consensus
statement: beyond the Female Athlete Triad—Relative Energy
Deficiency in Sport (RED-S). Br J Sports Med. 2014;48:491–7.)

Relative Energy Deficiency in Sport

Also referred to as RED-S, this represents the ratio of energy

consumed and expended in real time, to determine if athletes
have sufficient energy available to perform a given athletic
task. RED-S is associated with poor health, increased injury risk,
and poor performance.

Energy deficiency and its consequences have been the focus

of numerous studies in recent years, with some studies
suggesting that athletes participating in sports with weight
classifications or lean physiques are at risk, including female
distance runners, figure skaters, gymnasts, divers, and swimmers
(27). Studies have found that a surprisingly large cross-section of
athletes experience components of RED-S, but these athletes and
those who work with them are unaware of the health and
performance consequences they may experience (110).
RED-S, besides compromising performance through a
reduction in fat-free mass and an increase in fat mass, may also
increase illness frequency and nutrient deficiency, including
anemia (110). Failure to adequately supply energy over the long
term may affect metabolic rate, immunity, protein synthesis,
growth and development, and cardiovascular health while also
negatively affecting psychological, endocrine, hematologic, and
gastrointestinal well-being. Menstrual dysfunction and lower bone
mineral density are well-established negative consequence of
poorly satisfying energy needs (35, 137, 142). An increase in
cortisol, as a result of physiologic and/or psychological stress that
is associated with poor energy availability, can also negatively
affect bone mineral density (53). Athletes with lower bone
mineral density are at greater risk of stress fractures and related
musculoskeletal injuries.
The within-day energy balance and within-day energy
substrate studies, coupled with the poor predictive ability of the
traditional 24-hour energy balance model, suggest that a new
within-day energy balance model should be used (Figure 8.11).
This model considers both time spent in a catabolic and anabolic
energy balance state, and the magnitude of the energy balance
surpluses and deficits to predict body composition and weight
outcomes. Importantly, by incorporating time spent in different
energy balance zones, this model may be more useful in
predicting the endocrine response to energy balance
inadequacies and surpluses, which may aid in reducing health
and performance risks in athletes.
FIGURE 8.11: A new model for energy balance assessment.
(From Benardot D. Energy thermodynamics revisited: energy
intake strategies for optimizing athlete body composition and
performance. Pensar en Movimiento: Revista de Ciencias del
Ejercicio y la Salud (J Exerc Sci Health). 2013;11(2):1–13.)

This model also enables the consideration of an important

understanding of energy imbalances: The body’s reaction to an
inadequate energy intake is to reduce the tissue that needs
energy. Ideally, there should be a dynamic relationship between
the need for energy and nutrients, and the provision of energy
and nutrients to optimize body composition, weight, and
performance. Athletes who spend the majority of time in a near-
energy-balanced state are likely to reduce energy balance–
related problems described in RED-S, with the suggestion that
athletes address how energy is provided over the day and around
exercise sessions (29, 45, 110). Those who spend more time in a
large energy balance surplus are likely to increase body fat
levels, and those who spend more time in a large energy balance
deficit are likely to have difficulty sustaining muscle and could be
at risk for more RED-S health- and performance-related problems.

Assessment of Body Composition

 Important Factors to Consider

There are many methods available for the assessment of

body composition but all of these methods have some error
associated with them, with some methods having lower
error than others, and some methods are more portable
and less expensive than others.
It is important to find a method that can be used with your
population repeatedly, so that a trend of change can be
assessed. For instance, skinfolds do not provide as accurate
a prediction of body fat percent as DXA, but skinfold
calipers are portable and, with time and training, a
practitioner can take skinfolds on a subject repeatedly to
obtain a valuable assessment of how body fat is changing.
Ultimately, this may be more valuable information to a
practitioner than a single measure that cannot be taken
more than once or twice a year because of cost or the
inability of the athlete to go to the lab or clinic.

The body is composed of different components (water, muscle,

fat, bone, nerve tissue, tendons, etc.), and each has a different
density (18) (Table 8.6). From a functional standpoint, tissues are
grouped together into those that are mainly fat (fat mass), which
has little water associated with it, and those that have little fat
(fat-free mass), which has a great deal of water associated with
it. The fat-free mass is also commonly but inaccurately referred
to as lean mass (123). More recently, because of new techniques
and improvements in estimating body composition, bone mineral
density (skeletal mass) has been included as a third commonly
assessed component of body composition. But for the purpose of
this book, the components of body composition generally are
referred to as fat mass (the amount of mass in the body that is
mainly fat) and fat-free mass (the amount of mass in the body
that is mainly free of fat).

Table 8.6 Important Terms for Body Composition

Assessment
Fat mass Also referred to as body fat, adipose tissue, or
stored fat. This represents the total weight of
fat that contributes to total body weight.
Lean mass This refers to all of the body weight that is not
fat mass. Fat-free mass is defined as lean body
mass minus the bone mass.
Percent body This represents the total fat mass (i.e., total
fat weight of fat) of a person divided by the
person’s total body mass (i.e., total weight).
Obesity Defined as having too much body fat. The
common determination for obesity is through
calculation of BMI (i.e., a BMI of 30 or greater is
considered “obese”). However, this may be
misleading because it fails to differentiate
between fat and muscle weight. Therefore, a
highly muscled person may be defined as
overweight (high weight for height), but would
not be unhealthy.
Overweight Defined as weighing too much for your height.
This is often based on height/weight tables, but
may be misleading because it fails to
differentiate between fat and muscle weight.
Therefore, a highly muscled person may be
defined as overweight (high weight for height),
but would not be unhealthy.
Body fat Body fat that is distributed around the abdomen
distribution or poses greater health risks than fat stored in
fat patterning other areas.
Android-type This refers to excess fat primarily in the
obesity abdomen and surrounding the organs (i.e.,
apple-shaped obesity). It is associated with
glucose intolerance, diabetes, and higher
cardiovascular risk and is considered to have
higher health risk than gynoid-type obesity.
Gynoid-type This refers to excess fat around the hips and
obesity thighs (i.e., pear-shaped obesity) and is
 associated with lower disease risk than android-
type obesity.
Anthropometry Refers to the scientific study of measurements
and proportion of the human body. Common
anthropometric measures taken for the
assessment of body composition include height,
weight, and circumference. These are often
converted to ratios (e.g., BMI) as a predictor of
body composition and obesity risk.

BMI, body mass index.

The fat mass is composed of essential fat and storage fat. The
essential fat is a required component of the brain, nerves, bone
marrow, heart tissue, and cell walls that we cannot live without.
Storage fat, on the other hand, is an energy reserve that builds
up in fat (adipose) cells underneath the skin (subcutaneous fat)
and around the organs (visceral or interabdominal fat). Average
healthy men and women do have ∼11%–15% of total body
weight from storage fat. Combining the essential fat and storage
fat compartments, normal body fat percent for males is ∼15%
(3% essential; 12% storage), whereas normal body fat percent for
females is 26% (15% essential; 11% storage) (78, 157). (Please
note that different methods for assessing body composition have
method-specific standards. The values listed here are to provide
the relative differences of body fat distributions in males and
females.)
There is historical evidence that a body fat percent of 17%–
22% is needed to maintain a normal menstrual cycle in most
women (77). There is also evidence that physiologic and/or
psychological stress is a trigger for disrupting the reproductive
system (130). However, a closer look at both the body fat and
stress hypotheses for disturbing normal menstrual function is not
likely to be correct. There is strong evidence to suggest that
energy availability, not body fatness or stress, is the primary
regulator of female reproductive function. Women falling below
an energy balance that ranges from 20 to 30 calories of lean
body mass per day (i.e., if energy consumption minus energy
expenditure falls below 20–30 calories of lean mass per day) are
at significantly higher risk of menstrual dysfunction (67, 91). In
addition, these data strongly suggest that women consuming 45
calories/kg of lean body mass are resistant to developing
menstrual dysfunction regardless of body fat level or physical
stress. Given the large number of normally menstruating athletic
females who are lean (i.e., who have relatively low body fat
levels), the energy availability hypothesis is more logical.
Females with an eating disorder, dysmenorrhea (abnormal
menses), and low bone density have a condition referred to as
the female athlete triad (116). These are related conditions, as
inadequate energy intake (typical of eating disorders) is
associated with both abnormal menstrual function and low bone
density. Inadequate energy intake results in lower estrogen, and
estrogen suppresses osteoclasts, cells that break down bone.
Without this suppression, it is difficult to increase bone mineral
density. The IOC consensus statement on RED-S described earlier
refers to multiple physiologic problems that occur in all athletes
who fail to satisfy, in real time, the dietary energy required for
health, daily activity, growth, and sporting activities (143). These
include problems with metabolic rate, menstrual function, bone
health, immunity, protein synthesis, and cardiovascular health,
all of which are caused by RED. Importantly, athletes who fail to
adequately satisfy energy requirements are likely to lose fat-free
mass and experience a relative increase in fat mass, which
requires body composition assessment to discern. Monitoring
weight alone will miss these important changes in body
composition.

Eating Disorder

A general term for a psychometric disorder that is associated

with abnormal eating behavior, often associated with loss of
mass. These disorders include anorexia nervosa, anorexia
athletica, and binge eating disorder. Athletes in aesthetic sports
or sports where “making weight” is a traditional component of
a sport are considered at high risk.

Female Athlete Triad

A triad of conditions that exist simultaneously, including an
eating disorder, dysmenorrhea (amenorrhea or
oligomenorrhea), and low bone mineral density (osteoporosis or
osteopenia). Females competing in aesthetic sports or sports
where “making weight” is a traditional component of a sport
are considered at risk.

There are multiple means for assessing body composition.

Commonly used methods, discussed in this chapter, include the
following:

Multiple skinfolds: Using a skinfold caliper, a double thickness

(derived from pinching and measuring the subcutaneous fat)
of different areas of the body is measured. The skinfold
values are included in a prediction equation with weight, age,
and gender to predict percent body fat.
Densitometry (underwater or hydrostatic weighing): Fat mass
is less dense than lean mass, and a lower density will make a
person more buoyant in water and weigh less in water than
when compared with their out-of-water weight. The difference
in out-of-water weight and in-water weight is a function of
body density and has been used to predict body composition.
Air displacement plethysmography: Similar to hydrostatic
weighing principle, a less dense person (i.e., someone with a
greater proportion of body fat) will displace more air than
someone of the same weight with a higher density. The
measurement of displacement of air can be used to predict
body composition.
Ultrasound: Using an ultrasound wave, this system measures
the thickness of different tissues by assessing the time it
takes for sound to bounce back from the interface between
the subcutaneous fat layer and the muscle layer, and the
muscle layer and bone. The thickness of these tissue layers
can be used to predict body composition.
Bioelectrical impedance: Electrical current(s) pass through
different segments of the body. The difference between the
original electrical energy and the ending electrical energy,
after it has passed through a body segment, is a measure of
 how much the electrical current has been impeded. Fat tissue
has almost no water, so is a poor conductor of electrical
current (i.e., it has high impedance), whereas fat-free tissue
has a great deal of water and so is an excellent conductor of
electrical current. Therefore, measuring bioelectrical
impedance has been used to predict body composition.
DXA: A lower-energy and higher-energy x-ray pass through
the body, and the amount of x-ray energy that has passed is
read by a detector. Higher tissue densities (bone density is
greater than muscle density; muscle density is greater than
fat density) absorb relatively more of the low-energy x-ray
than the high-energy x-ray. The difference in x-ray absorption
is a function of the tissue density and has been used to
predict body composition relatively accurately.

Other methods for assessing body composition include the

following:

Total body water (D2O): Total body water in humans on

average is ∼65% of body weight and varies by age, gender,
and body fatness. Individuals with relatively higher fat-free
mass have more body water than individuals with relatively
higher fat mass. Total body water can be estimated by
providing a known dose of water that is made from deuterium
rather than hydrogen (D2O vs. H2O). The deuterated water
evenly distributes itself throughout the entire body water,
and then a sample of body water is analyzed to determine
the ratio of D2O to H2O. Higher relative D2O (i.e., a higher
concentration) suggests lower total body water, which is
associated with lower fat-free mass and has been used to
predict body composition.
Total body potassium (K40): Potassium40 is a naturally
occurring isotope of potassium and represents 0.012% of
total body potassium. This isotope gives off a unique γ-
radiation wave that is readable and can be differentiated
from other isotope waves. The concentration of potassium
(the primary intercellular electrolyte) in fat-free mass is
known, so by measuring K40 by using a whole-body γ-
radiation counter, it is possible to predict total body
potassium, which can be used to predict fat-free mass. By
knowing total mass and fat-free mass, body fat mass can be
predicted using a two-component model of body composition.
Infrared interactance: This method is based on the principle
that tissues of different density will absorb and/or reflect
infrared light differently. Higher density tissues (i.e., fat-free
mass) absorb less light and reflect more light than lower
density tissues (i.e., fat mass). The difference in light
absorption/reflection can be measured and has been used to
predict body composition.
Creatinine excretion: For a given height there is an
expectation that humans excrete creatinine, which is a
normal nitrogenous metabolic by-product of fat-free mass
respiration. Therefore, assuming normal kidney function, the
amount of urinary creatinine excreted in a 24-hour period is a
measure of fat-free mass, with higher creatinine levels
associated with higher fat-free mass. By knowing total mass,
creatinine excretion can be used to predict body composition.
3-Methylhistidine excretion: This method is similar to
creatinine excretion, except that 3-methylhistidine excretion
is specific to skeletal muscle respiration. That is, greater
amounts of urinary 3-methylhistidine excretion are associated
with higher skeletal muscle mass.
Total body electrical conductivity: This method is based on
the fact that water is a conductor of electricity and fat-free
mass contains more water than fat mass. A body is inserted
into a tube that has a measured electromagnetic field. The
amount of disruption in the electromagnetic field is a function
of how much fat mass the person has. Higher fat mass
creates a greater measured reduction in the electromagnetic
field than lower fat mass, and this measurement has been
used to predict body composition.
Computed tomography (CT scan): Using x-rays, the CT scan
produces sectional scans (slices) of the body. The images can
be assessed for different densities and can also provide
information of fatty infusion in lean tissue. However, this
method is limited by cost and by high exposure to x-ray
radiation.
 Magnetic resonance imaging: A magnetic field passing
through the body produces an image of the relative
conductance/resistance to the electrical field created by
different tissues. The resultant images allow differentiation of
fat mass and fat-free mass, providing information on body
composition.

Each method has a different cost and a different standard

error of measurement. Some methods are appropriate for
laboratory/clinical assessment, whereas others can be used in the
field. Regardless of the method, each method attempts to
measure relative body fatness (i.e., how much body fat a person
has) and relative body fat-free mass (the difference between the
fat mass and all the body mass). Some methods can provide
information on where the fat mass and fat-free mass are held in
different amounts, and some methods can also provide
information on bone density and total body water. (See Table 8.7
for the theoretical contributors to mass in a relatively lean man
and a relatively lean woman.)

Table 8.7 Theoretical Contributors to Total Body

Mass
Body Lean Man (%) Lean Woman (%)
Component
Water 62 59
Fat 16 22
Protein 16 14
Minerals 5–6 4–5
Carbohydrate <1 <1

Lean mass is mainly water and protein, but also includes

minerals and stored carbohydrate (glycogen). The main
constituents of the fat-free mass include soft tissues muscle, the
heart, and other organs but do not include skeletal (bone) tissue
(58). The water content of the fat mass is below 10% (77, 158).
Athletes typically have a larger lean mass and a lower fat mass
than nonathletes do, so well-hydrated athletes have a higher
proportion of total weight that comes from water.
 Using the two-component fat mass to lean body mass model
of body composition, the combined weight of fat mass and lean
mass equals total body weight. Because weight by itself fails to
discriminate between the two components, it is considered to be
an inappropriate measure of body composition. Therefore, the
statement “My weight is increasing, so I must be getting fat” is
common but incorrect. It is possible for an athlete to increase the
fat-free (i.e., muscle) mass without increasing the fat mass.
Clearly, there would be an increase in weight, but not fat weight.
It is also possible for an athlete to maintain weight but
experience changes in fat or lean mass. This could be either
desirable or undesirable depending on which element is
increasing. A high strength-to-weight ratio shows an increase in
lean mass (strength) with a maintenance or lowering of fat mass
(weight) equaling total weight. This scenario is obviously
desirable. However, should an athlete increase the fat mass while
lowering the lean mass, strength is lost and the strength-to-
weight ratio decreases or is low. Assessing these aspects of body
composition has become a standard tool for the evaluation of
body changes that occur as a result of time, training, and
nutritional factors.
Body composition assessment generally results in obtaining a
value referred to as body fat percent, or the proportion of total
weight that is made up by the fat mass. Assuming an athlete
weighs 150 lb and has a body fat percent of 20%, it means that
30 lb (150 × 0.20 = 30) is fat weight and 120 lb is lean weight. If
this athlete experiences a reduction in body fat percent to 15%
while maintaining weight, this would mean that 22.5 lb (150 ×
0.15 = 22.5) is fat weight and 127.5 lb is lean weight. This
increase of 7.5 lb in lean weight and reduction in fat weight
means the athlete is now smaller (pound for pound, lean mass
takes up less space than fat mass because it has a higher
density), which should enable the athlete to move more quickly
and more efficiently than before. However, if this 150-lb athlete
were to maintain weight but increase fat mass while reducing the
fat-free mass, potential speed and efficiency of movement would
be reduced. For all of these reasons, weight is a poor measure for
predicting athletic success. This example also emphasizes the
importance of assessing changes that occur in both the fat-free
and fat mass, because understanding changes in both
compartments is necessary for understanding the potential
impact on performance.
Because reporting on fat mass (i.e., body fat percent) may be
considered undesirable by many athletes, practitioners should
consider emphasizing the positive. For instance, an athlete with a
percent body fat of 25% may wish to lower this value to 20%. As
a sports medicine practitioner you should consider asking them
to increase fat-free mass from 75% to 80%. All too often athletes
who are told to lower body fat percent resort to calorie-restricted
diets to achieve the fat loss. This is typically counterproductive,
as more lean mass is lost than fat mass. Therefore, changing the
focus to increasing fat-free mass rather than lowering fat mass
could help athletes strategize on how to best satisfy the energy
needs of an ever larger fat-free mass, with the side benefit of
reducing the risk of the athlete developing one of the RED-S
health/performance risks.

Purpose of Body Composition Assessment

A high fat-free-mass-to-fat-mass ratio is often synonymous with a
high strength-to-weight ratio, which is typically associated with
athletic success. However, there is no single ideal body
composition for all athletes in all sports. Each sport has a range
of fat-free mass and fat mass associated with it, and each athlete
in a sport has an individual range that is best for him or her.
Athletes who try to achieve an arbitrary body composition that is
not right for them are likely to increase health risks and will not
achieve the performance benefits they seek. Therefore, the key
to body composition assessment is the establishment of an
acceptable range of lean and fat mass for the individual athlete,
as well as the monitoring of lean and fat mass over regular time
intervals to ensure the stability or growth of the lean mass and a
proportional maintenance or reduction of the fat mass. As
indicated earlier, there should be just as much attention given to
changes in lean mass (both in weight of lean mass and proportion
of lean mass) as the attention traditionally given to body fat
percent.
 Athletes wishing to lower body fat levels should also be aware
of the best physical activities to achieve this goal. “Aerobic” or
low-intensity training, which is so often used as a fat-loss exercise
regimen, may not be the most effective means of achieving this
goal. It has been found that high-intensity exercise training was
significantly more effective at reducing total abdominal fat and
abdominal subcutaneous fat than low-intensity exercise training
(70). High-intensity winter sports, for instance, are associated
with lower body fat percent and higher lean mass than less
intense activities (103). Care must be taken, however, to avoid
low blood sugar during high-intensity exercise, as low blood sugar
is a predictor of high cortisol production, which is associated with
a loss of fat-free mass, a loss of bone mass, and higher body fat
percent (105). Whatever dietary and exercise strategy is used,
periodic assessment of body composition will help an athlete
understand if the desired goal is being achieved.

Importance of Body Composition to Performance

Athletic performance is, to a large degree, dependent on the
athlete’s ability to sustain power (both anaerobically and
aerobically) and the athlete’s ability to overcome resistance or
drag (86). Both of these factors are interrelated with the athlete’s
body composition. Coupled with the common perception of many
athletes who compete in sports where appearance is a concern
(swimming, diving, gymnastics, skating, etc.), attainment of an
“ideal” body composition often becomes a central theme of
training. Besides the aesthetic and performance reasons for
wanting to achieve an optimal body composition, there may also
be safety reasons. An athlete who is carrying excess weight may
be more prone to injury when performing difficult skills than the
athlete with a more optimal body composition. However, the
means athletes sometimes use in an attempt to achieve an
optimal body composition are often counterproductive.
Low-calorie diets and excessive training often result in such a
severe energy deficit that, while total weight may be reduced,
the constituents of weight also change, commonly with a lower
muscle mass and a relatively higher fat mass. The resulting
higher body fat percentage and lower muscle mass inevitably
result in a performance reduction that motivates the athlete to
follow regimens that produce even greater energy deficits. This
downward energy intake spiral may be the precursor to eating
disorders that place the athlete at serious health risk. Therefore,
although achieving an optimal body composition is useful for
high-level athletic performance, the processes athletes often use
to attain a desirable body composition may reduce athletic
performance, place them at a higher injury risk, and increase
health risks.
The mind-set that many people have that food, regardless of
the amount and type, produces fat is unhealthy. A much healthier
(and from the point of view of an athlete, more appropriate)
mind-set is that food is the provider of energy and the nutrients
associated with burning energy. Athletes would not think of trying
to run their automobile without fuel, as they are certain it would
not run. Athletes should also imagine that putting fuel (food) in
their bodies to make their muscles run is normal and desirable.
Within reasonable bounds, having a relatively low body fat
percentage may aid athletic performance. It occurs by improving
the strength-to-weight ratio: for a given weight, more of it is
represented by lean mass that is power-producing and less of it
by fat mass that represents stored fuel. It also helps by lowering
the resistance, or drag, an athlete has as she or he is going
through the air, swimming in water, or skating on ice; the smaller
the body profile, the less resistance it is likely to produce.
Less resistance, or drag, is so important for some sports
(typically the faster you go the greater the importance of drag
reduction) that performance techniques are based on reducing
drag. Speed skaters, for instance, spend the entire race bent over
to reduce wind resistance. Cyclists wear special streamlined
helmets and clothing, position their bodies on the bicycle to
reduce drag, and even strategize about the best time to sprint
ahead of the cycle in front of them. Going too soon can lead to
premature exhaustion because it takes a great deal more energy
to go the same speed if you are the one facing wind resistance. A
gymnast who weighs 110 lb and is 5 feet tall with a body fat
percentage of 15% will have a lower wind resistance (i.e., less
drag) tumbling through the air than a gymnast with the same
weight and height but with a body fat percentage of 20%. For
some sports, however, this may make little or no difference. It is
hard to imagine how a power lifter would have a problem with
wind resistance, and linemen on football teams are more
interested in moving mass than going fast over a distance
(although quickness helps). In sports where being aerodynamic
helps, body composition could make a big difference. The reason
for this is something many of us have already experienced:
pound for pound, fat mass takes up more space than fat-free
mass because it is less dense than fat-free mass.

How Body Composition Is Estimated

You cannot tell about a person’s body composition by weighing or
simply observing the person. There are many thin people who
have lost so much lean mass that they actually have a relatively
high body fat percent. (They are not lean.) There are also many
large people whom you might assume are obese but who are
actually relatively lean. Even with modern equipment and
sophisticated equations it is extremely difficult (if not impossible)
to accurately measure body fat percentage and to accurately
repeat that measure. It is important to consider that all the
techniques available for measuring/estimating body composition
are estimates of what the body contains. Because each technique
uses a different means of estimating body composition, cross-
comparisons between techniques should not be made. For
instance, an athlete with an initial body composition assessed
using skinfold calipers last year should not have that value
compared with the body composition assessed using BIA today. It
would be misleading to use these values as a means of
determining how this athlete’s body composition has changed
over time.
Ideally, athletes should be assessed several times over equal
time periods to obtain a trend line for how body composition is
changing, because the trend is likely to be more important than
the absolute value (113). Imagine measuring an athlete whose
body composition looks fine, so you have no reason to intervene.
What if, however, high body fat level was lower on the previous
measure and even lower on the measure before that, and this
athlete has also lost some lean mass over the same time period.
As another example, an athlete appears to have a high level of
body fat, initiating a counseling session to help the athlete lower
the fat mass. What if, however, the athlete had a higher body fat
level several months earlier that was reduced still further 1
month before the current measure? This athlete is obviously
doing something right, and it would be a pity to intervene in a
strategy that is already working. By taking several measures, the
health professional has a much better idea of how the athlete is
changing and whether an intervention is warranted.
It may be useful to assess the predominant ___location of body
fat, as fat stored in different areas is associated with differential
health risks. For instance, abdominal body fat poses greater
health risks than fat stored in other areas. If health risk
assessment, rather than performance, is the focus of the body
composition assessment, then a method should be selected that
can identify where the preponderance of fat is stored.
The ultimate purpose of body composition assessment is to
determine the ratio of fat mass to fat-free mass. This is referred
to as a two-compartment model (1. fat mass; 2. fat-free mass).
However, some methods of body composition assessment have
the capacity to provide more information on what constitutes the
fat-free mass. For instance, in a three-compartment model body
composition assessment, the information includes fat mass, and
the fat-free mass is divided into the protein mass and bone
(skeletal) mass. A four-compartment model provides even more
information on the fat-free mass, with information on fat mass,
water mass, protein mass, and skeletal (bone mineral) mass
(Figure 8.12).
FIGURE 8.12: Two- and four-compartment body composition
assessment models. A. Weight alone (one-compartment model;
often used). B. Fat weight and fat-free weight (two-compartment
model; often used). C. Muscle, bone, skin, blood, organ, and fat
weight (six-compartment model; rarely used with hard-to-obtain
technology). D. Water, protein, bone mineral, and fat weight
(four-compartment model; preferred strategy with available
technology). (From Lohman TG. Applicability of body composition
techniques and constants for children and youths. Exerc Sport Sci
Rev. 1986;14:325–57.)

Methods for Predicting Body Composition

Skinfolds
Skinfold calipers, which vary in cost from free to $500, are used
to measure a double thickness of skin and the fat layer under the
skin (Figure 8.13). This fat layer (called subcutaneous fat)
represents ∼50% of a person’s total body fat. Therefore,
measuring the subcutaneous fat layer provides a measurement
that can be used to predict total body fat level.
FIGURE 8.13: Basic skinfold technique. (From Thompson WR,
editor. ACSM’s Resources for the Personal Trainer. 3rd ed.
Baltimore (MD): Lippincott Williams & Wilkins; 2010. p. 286.)

The basic rules for taking skinfold measures are as follows:

Take skinfold measurements on the right side of the body

(most skinfold equations were developed from measurements
on the right side).
Do not take measurements when the subject’s skin is moist
(ensure that the skin is dry and has no lotion). Also do not
take measurements immediately after exercise or when the
person being measured is overheated because the shift of
body fluid to the skin will inflate normal skinfold size.
To reduce error during the learning phase, skinfold sites
should be precisely determined, marked, and verified by a
trained instructor. The largest source of error in skinfold
testing is inaccurate site selection.
Firmly grasp the skinfold with the thumb and index finger of
the left hand and pull away.
Hold the caliper in the right hand, perpendicular to the
skinfold and with the skinfold dial facing up and easily
readable. Place the caliper heads ¼–½ inch away from the
fingers holding the skinfold. Try to visualize where a true
double-fold of skin thickness is and place the caliper heads
there.
Read the caliper dial to the nearest 1 mm within 4 seconds.
During the measurement, ensure that the left thumb and
forefinger maintain the shape of the skinfold.

Take a minimum of two measurements at each site (at least 15

seconds apart). If the two values are within 10% of each other,
take the average. Multiple different body composition prediction
equations are available for the general population, and there are
also several equations available for athletes. Using an equation
that is specific to the person you are measuring (i.e., male,
female, athlete, nonathlete) yields more accurate results. Also,
equations using a greater number of skinfold measurements are
more accurate. For instance, an equation may require height,
weight, age, triceps skinfold, and abdomen skinfold, whereas
another equation may require height, weight, age, and skinfolds
at the triceps, subscapular, midaxillary, suprailiac, abdomen, and
mid-thigh sites (Table 8.8).
Commonly used body fat percent prediction equations for use
with skinfolds are found in Box 8.2.

Box 8.2 Commonly Used Skinfold Equations for

Predicting Body Density

Men

Seven-Site Formula (chest, midaxillary, triceps,

subscapular, abdomen, suprailiac, thigh)
Body density = 1.112 − 0.00043499 (sum of seven
skinfolds) + 0.00000055 (sum of seven skinfolds)2 −
0.00028826 (age) [SEE 0.008 or ∼3.5% fat]
Three-Site Formula (chest, abdomen, thigh)
Body density = 1.10938 − 0.0008267 (sum of three
skinfolds) + 0.0000016 (sum of three skinfolds)2 −
0.0002574 (age) [SEE 0.008 or ∼3.4% fat]
Three-Site Formula (chest, triceps, subscapular)
Body density = 1.1125025 − 0.0013125 (sum of three
skinfolds) + 0.0000055 (sum of three skinfolds)2 −
0.000244 (age) [SEE 0.008 or ∼3.6% fat]

Women

Seven-Site Formula (chest, midaxillary, triceps,

subscapular, abdomen, suprailiac, thigh)
Body density = 1.097 − 0.00046971 (sum of seven
skinfolds) + 0.00000056 (sum of seven skinfolds)2 −
0.00012828 (age) [SEE 0.008 or ∼3.8% fat]
Three-Site Formula (triceps, suprailiac, thigh)
Body density = 1.0994921 − 0.0009929 (sum of three
skinfolds) + 0.0000023 (sum of three skinfolds)2 −
0.0001329 (age) [SEE 0.009 or ∼3.9% fat]
Three-Site Formula (triceps, suprailiac, abdominal)
 Body density = 1.089733 − 0.0009245 (sum of three
skinfolds) + 0.0000025 (sum of three skinfolds)2 −
0.0000979 (age) [SEE 0.009 or ∼3.9% fat]
SEE, Standard error of estimation.
Source: American College of Sports Medicine. Exercise prescription for individuals
with metabolic disease risk factors. In: ACSM’s Guidelines for Exercise Testing and
Prescription. 10th ed. Philadelphia (PA): Wolters Kluwer; 2017.

Table 8.8 Skinfold Sites and Measurement

Procedures
Abdominal Vertical fold; 2 cm to the right side of the
umbilicus
Triceps Vertical fold; on the posterior midline of the
upper arm, halfway between the acromion and
olecranon processes, with the arm held freely to
the side of the body
Biceps Vertical fold; on the anterior aspect of the arm
over the belly of the biceps muscle, 1 cm above
the level used to mark the triceps site
Chest/pectoral Diagonal fold; one-half the distance between the
anterior axillary line and the nipple (men), or
one-third of the distance between the anterior
axillary line and the nipple (women)
Medial calf Vertical fold; at the maximum circumference of
the calf on the midline of its medial border
Midaxillary Vertical fold; on the midaxillary line at the level
of the xiphoid process of the sternum. An
alternate method is a horizontal fold taken at
the level of the xiphoid/sternal border on the
midaxillary line
Subscapular Diagonal fold (45-degree angle); 1–2 cm below
the inferior angle of the scapula
Suprailiac Diagonal fold; in line with the natural angle of
the iliac crest taken in the anterior axillary line
immediately superior to the iliac crest
Thigh Vertical fold; on the anterior midline of the thigh,
 midway between the proximal border of the
patella and the inguinal crease (hip)
Procedure

All measurements should be made on the right side of the

body with the subject standing upright.
Caliper should be placed directly on the skin surface, 1 cm
away from the thumb and finger, perpendicular to the
skinfold, and halfway between the crest and the base of the
fold.
Pinch should be maintained while reading the caliper.
Wait 1–2 s before reading caliper.
Take duplicate measures at each site and retest if duplicate
measurements are not within 1–2 mm.
Rotate through measurement sites or allow time for skin to
regain normal texture and thickness.

Source: American College of Sports Medicine. Exercise prescription for individuals with
metabolic disease risk factors. In: ACSM’s Guidelines for Exercise Testing and
Prescription. 10th ed. Philadelphia (PA): Wolters Kluwer; 2017.

A new equation for predicting body composition from skinfolds

for men has been validated using DXA (7). The new equation
produces a relatively low standard error (2.72%) and is strongly
correlated with DXA when used with a generally fit male
population. No similar DXA-validated skinfold equations are
currently available for women. This DXA criterion equation uses
seven skinfold sites, including chest, midaxillary, triceps, thigh,
subscapular, suprailiac, and abdomen, with the following formula:

It is important to mention the values that are derived from

skinfold equations and used to predict body fat percentage. Many
equations used with athletes are intended to be used with the
general nonathlete population. Because athletes are considerably
leaner than the average nonathlete, the body fat results derived
from skinfold equations are unrealistically low and, therefore, not
accurate. However, the derived value can be used as a baseline
to determine change over time if the same technique and same
equation are used to follow-up values. It is inappropriate to
compare the first value with one that was obtained using a
different set of skinfolds and a different equation or to compare
the skinfold-derived body composition value with values derived
from other methods.

Ultrasound
The principle of ultrasound is based on the reflection of sound
from the skin to the interface between muscle and fat. As the
ultrasound passes through different tissue densities, a portion of
the sound wave is reflected back. The time it takes for the sound
to reflect back is a function of the thickness of the tissue it has
passed through (Figure 8.14). This technique provides a tissue
depth of the subcutaneous fat layer and the underlying muscle
layer, thereby providing a measure of relative body fatness.
Assuming the operator is experienced and skilled, studies have
found that ultrasound is a reliable, accurate, and safe method for
the measurement of subcutaneous fat and muscle thickness
(156). Knowing the optimal sites to measure, as determined by
fat patterning, is important for obtaining reliable results using
ultrasound (112). A recent study applying a standardized
ultrasound technique for measuring subcutaneous fat used eight
measurement sites and produced high measurement accuracy
and reliability in groups ranging from lean to obese (144). The
ultrasound device is relatively inexpensive and does not induce
any electrical and radiation wave that could be considered
potentially unsafe.
FIGURE 8.14: Ultrasound. The ultrasound device both emits and
receives ultrasound signals. A portion of the emitted signal
“bounces” off the interface of fat and muscle, and off the
interface of muscle and bone. The device analyzes the time it
takes for the signal to “bounce” back from each tissue interface,
which is a measure of tissue thickness (i.e., the longer it takes,
the thicker the tissue). Note: As ultrasound cannot pass through
air and bone has air, ultrasound used for body composition
assessment cannot be used as a measure of bone thickness/size.

Hydrostatic Weighing (Hydrodensitometry)

This is the classic means for determining body composition and
applies what is known as Archimedes’ principle. Archimedes was
a Greek mathematician, engineer, and physicist who discovered
formulas for determining the area and volume of different shapes
and the principle of buoyancy. In essence, this principle states
that, for an equal weight, lower density objects have a larger
surface area and displace more water than higher density objects
(Figure 8.15).
FIGURE 8.15: Hydrodensitometry represents underwater
weighing of a subject following Archimedes’ principle: The weight
of a subject is equal to the weight of the fluid that the subject’s
body displaces. As fat mass has a lower density than lean mass,
a subject with greater fat mass will displace more water because
the subject is “larger” than a leaner person of the same weight.
In practice, out-of-water weight is compared to in-water weight.
The greater the difference in weight, the greater the body fat
level. (From Plowman S, Smith D. Exercise Physiology for Health
Fitness and Performance. 5th ed. Philadelphia (PA): LWW (PE);
2017.)
 From a body composition standpoint, this principle is applied
in the following way:

1. The subject is weighed on a standard scale to get a “land”

weight.
2. Using specialized equipment, the subject’s lung volume is
estimated (the subject blows into a tube).
3. The subject sits on a chair that is attached to a weight scale.
4. The chair and weight scale are positioned over water and the
chair is slowly lowered into the water.
5. When the subject is lowered into the water just below the
chin, they are asked to fully exhale and completely lower
their head into the water to be completely immersed.
6. While immersed, “underwater weight” is read off the scale
that is attached to the chair the subject is sitting on.

Subjects weigh less in water than out of water because body

fat (regardless of the amount present) makes the subject more
buoyant. The difference between in-water weight and out-of-
water weight is a function of how much body fat the subject has.
A very obese subject with a high level of body fat would appear
light in water relative to land weight. Because lung volume is
measured prior to taking the water weight, there is an
adjustment for the buoyancy that can be attributed to the air in
the lungs. To minimize the lung-air effect, the subject is asked to
exhale prior to full submersion, but there is always some air
remaining in the lungs that is referred to as residual volume.
The potential for error using hydrodensitometry is great. The
percent of water in fat-free mass is assumed to be 73.2%, but
studies indicate that it varies between 60% and 92%. This
creates a potential error in estimating percent body fat of
between 4% and 22% (153). There is also an assumption that the
density of fat mass is fixed at 0.90 g/cm3 and the density of fat-
free mass is fixed at 1.10 g/cm3, but it is established that the
densities of body fat and fat-free mass vary between individuals.
Other potential sources of error include the following:

Athletes have higher bone densities than nonathletes,

potentially causing an underestimation of body fat.
 Older people have lower bone densities than younger people,
potentially causing an overestimation of body fat.
The trapped gas in the gastrointestinal tract can only be
estimated.

Nevertheless, this technique is useful for determining the

change in body composition over time if the technicians
performing the measurements are effective at replicating the
measurement procedure. It is also a useful means of determining
the body composition of a population, because the errors
associated with the technique will average themselves out over
many measurements.

Air Displacement Plethysmography

The BOD POD Gold Standard Body Composition Tracking System
(COSMED) is used to determine body composition via air
displacement body density. Because fat mass is less dense than
lean mass, fat displaces more air for the same weight of lean
mass. This is the same principle of measurement as underwater
weighing (hydrodensitometry), but with air displacement instead
of water displacement, the BOD POD measures a subject’s mass
and air volume, from which their whole-body density is
determined. The measure involves assessment of pressure
changes with injection of a known volume of air into a closed
chamber, with a larger body volume displacing greater air
volume and resulting in a greater increase in pressure. Using
these data, body fat and lean muscle mass can then be
calculated. There are clear advantages over hydrodensitometry
measurements, providing higher subject acceptability, greater
precision, and eliminating residual long volume as an issue
(Figure 8.16).
FIGURE 8.16: A. In a Bod Pod a subject sits in an enclosed
container. Body composition is assessed by measuring the
amount of air that has been displaced by the subject. B. BOD
POD. Similar to the strategy for assessing body composition using
hydrodensitometry, the BOD POD assesses air displacement
versus water displacement as a measure of relative body fatness.
(From McArdle WD, Katch FI, Katch VL. Exercise Physiology. 8th
ed. Philadelphia (PA): LWW (PE); 2014; McCrory MA, Gomez TD,
Bernauer EM, Molé PA. Evaluation of a new air displacement
plethysmograph for measuring human body composition. Med Sci
Sports Exerc. 1995;27:1686.)

This technique has been found to be valid and reliable for

body composition determination, correlating well with DXA.
However, it has been found that results consistently overestimate
fat-free mass and underestimate fat mass (4, 98). In a study of
test–retest reliability of 283 women, there was no significant
mean difference between the first and second tests, suggesting
that the BOD POD would be an excellent device for determining
body composition change over time (152).

Bioelectrical Impedance Analysis

Water is a good conductor of electricity, and most body water is
found in the lean mass. Fat, which is essentially anhydrous (has
almost no water in it), impedes the electrical flow, hence the
name "BIA." The greater the impedance of electrical current, the
greater the amount of fat the electrical current has confronted.
Regardless of the BIA equipment used, the principle behind the
technique is the same. If you know the beginning level of energy
(electricity) that enters the system and you can measure the
level of energy that exits the system, you know how much of the
energy has been impeded in the system. Because muscle, as a
result of the water and electrolytes it contains, is an efficient
conductor of electricity and fat is an efficient insulator (therefore
it impedes) of electricity, the greater the impedance, the greater
the level of fat. If you start with 100 units of electricity going into
your system and 80 units of electricity coming out of the system,
you have more water and muscle than someone who has 100
units going in and 60 units coming out.
There are several types of BIA equipment, ranging from simple
to highly sophisticated. On the simple end of the spectrum, BIA
scales have the subject stand on an electronic weight scale, and
an electrical current runs from the right foot, up the right leg,
down the left leg, and out the left foot. There is also a handheld
device that runs a current from one hand to the other (Figure
8.17). The measured impedance (i.e., the difference between the
beginning and ending electrical current) is used to predict fat
mass. The least expensive devices use a single electrical current,
making these systems highly susceptible to differences in
hydration state. For instance, if a relatively lean person is
dehydrated at the time of the measurement, the electrical
current will not be as efficiently conducted (i.e., there will be
greater impedance) because of lower body water and the person
will appear to have a higher fat mass than they actually have.
More sophisticated devices use multiple electrical currents that
traverse all parts of the body. An obvious weakness of devices
that do not measure the entire body is that the prediction of total
body fatness is based on the portion of the body assessed, which
may not be representative of the body fat level of other parts of
the body.
FIGURE 8.17: Different bioelectrical impedance analysis (BIA)
devices measure different parts of the body. The portion of the
body the current passes through determines the portion of the
body that is assessed. A. With the BIA scale, the current passes
from one foot to the other, so the body composition of both legs
and lower pelvis is measured. B. With the handheld BIA device,
the current passes from one hand to the other, so the body
composition of both arms and upper chest is measured. C. With
the hand-to-foot BIA device, the current passes from one hand to
the foot on the same side of the body, so the body composition of
one entire side of the body below the neck is measured. D. With
the BIA device connected to both feet and hands, the current
traverses the entire body, enabling a body composition measure
of the whole body below the neck. (A, from Drench Fitness
[Internet], 2018. Available from: http://www.drenchfit.com/.
Accessed May 4, 2018; B, from Plowman S, Smith D. Exercise
Physiology for Health Fitness and Performance. 5th ed.
Philadelphia (PA): LWW (PE); 2017; C, from Kraemer WJ, Fleck SJ,
Deschenes MR. Exercise Physiology. Philadelphia (PA): LWW (PE);
2011; D, from Premier Integrative Health Center for Personalized
Medicine. Inbody scale. Available from:
http://www.premierintegrativehealthkc.com/inbody-scale/.
Accessed May 4, 2018.)

Some newer and more expensive ($5,000–$25,000) BIA

models are capable of providing segmental body composition
(arms, legs, abdomen) that is useful for determining muscular
symmetry and determining the ___location of fat storage. These
models also use multiple current technologies that create far less
error with different hydration states than single-current models. A
validation study comparing a newer eight-mode multicurrent BIA
device (i.e., a device that measures the entire body by running
currents between each hand, between each foot, and between
each hand and foot) found that there were no significant
differences between DXA and the BIA device for fat mass, percent
body fat, and total fat-free mass (75). It is important to note that
the BIA device used induces multiple currents, making it more
accurate with different degrees of dehydration. With less
expensive devices that induce a single current, the state of
hydration may pose a significant error in the derived values. With
these devices it is critically important that the person having a
BIA measurement taken be in a well-hydrated state, and anything
that can compromise hydration should be avoided 24 hours prior
to an assessment (drinking alcohol, exercising, consuming large
amounts of coffee, and spending time outside in hot and humid
weather). It has been noted that there are no athlete-specific BIA-
associated equations currently available for predicting body
composition in this population (108). Although newer multicurrent
BIA systems are likely to produce results similar to those
observed with DXA, there are likely to be differences in athletes
than in the general population that have not yet been fully
addressed with BIA.

Dual-Energy X-Ray Absorptiometry

DXA is widely considered to be the most accurate means of
predicting body composition, and it is generally considered the
current gold standard for this purpose. It does have certain
limitations, however, in that it is not portable and the cost is in
excess of $100,000. The information you can derive from a full-
body scan on an athlete is invaluable, including bone density,
body fat percentage, lean body mass, fat mass, and the
distribution of fat and lean mass in the arms, body trunk, and
legs. The standard error of estimation for soft tissue (muscle and
fat) is <1.5%, and for bone it is <0.5%, providing highly reliable
and repeatable results (26) (Figure 8.18).
FIGURE 8.18: Dual-energy x-ray absorptiometry is capable of
assessing both whole body and regional body composition and
bone mineral density. A. Dual-Energy X-Ray Absorptiometry
involves having the subject lie on a table. Low level x-rays of
known intensity pass through the subject and the remaining x-
rays not absorbed by body tissues are read by the arm above the
subject. Higher tissue densities absorb greater amounts of x-ray,
allowing for accurate assessment of body composition. B. The
results of a DXA scan can display both skeletal tissue and soft
tissue (muscle and fat), and compare densities against
established standards. C. Different parts of the skeleton known to
be at higher risk of low bone density can also be assessed,
including the femoral neck (sight of osteoporotic hip fractures),
and the lower spine (sight of osteoporotic compression fractures).
(A, from Kraemer WJ, Fleck SJ, Deschenes MR. Exercise
Physiology. Philadelphia (PA): LWW (PE); 2011; B and C, from
Aktolun C, Goldsmith S. Nuclear Oncology. Philadelphia (PA): LWW
(PE); 2015.)

The DXA procedure was originally developed to determine the

bone mineral content and density of bone. The subject lies on the
DXA table for ∼20 minutes, and the pencil-beam x-rays pass
through the subject and are measured by the analyzer and
interpreted by a technician using device-specific software
programs. Because metal has such a high density, the subject is
asked to remove all jewelry and must wear clothing that contains
no metal. The resultant value is translated into a density value
for bone, lean, and fat tissue.
DXA works by passing two x-ray beams through the subject
and measuring the amount of x-ray that has been absorbed by
the tissue it has passed through. One beam is a high-intensity
beam and the other one is a low-intensity beam, so the relative
absorbance of each beam is an indication of the density of the
tissue it has passed through. The higher the tissue density, the
greater the reduction in x-ray intensity. DXA systems filter the x-
ray so that only a very small proportion of the original x-ray
passes through the subject. Depending on body thickness, a
subject having a DXA scan will receive between 0.02 and 0.05
mREM of radiation. By comparison, typical background
nonmedical radiation that most people receive ranges between
0.5 and 0.75 mREM. The induced radiation is so low that a person
would require ∼800 full-body DXA scans before receiving the
same level of radiation received from a single standard chest x-
ray. Because of the low radiation induction, DXA is approved by
the Food and Drug Administration as a nonmedical screening
device to predict body composition. X-ray devices are typically
reserved as medically related diagnostic instruments because of
the amount of radiation they impart, but not so for DXA. Because
DXA is widely considered to be the gold standard for body
composition assessment, other methods (skinfolds, BIA, BOD
POD, etc.) are validated based on DXA findings (85).

Why Body Composition Changes

Body composition changes, and this change is by altering what
and when food is consumed and the amount and intensity of the
exercise performed. Because energy is considered precious by
the human system, a failure to use energy-requiring tissues
causes them to be lost. The general rule for fat-free mass that
illustrates this adaptation, including bone mass, is “use it or lose
it.” An example of this adaptation is what happened to early
astronauts (before preactivated vitamin D was developed) when
in outer space. They quickly demineralized their bones and lost
muscle because the gravity-free environment of outer space
eliminates the need for having strong gravity-resisting muscle
and bone. The same outcome can be seen when people are
bedridden because of illness or injury. Both bone mass and
muscle mass are rapidly reduced because they “cost calories”
and are not required when lying in bed. It is important to consider
that body tissues are alive and attempt to adapt to the current
situation. If you exercise in a way that requires more muscle to
make that exercise easier, then the body adaptation is to
increase musculature. If you put less stress on muscle by
exercising less, then the muscle is lost.
Influences on body composition relate to genetic
predisposition, age, gender, type of activity, amount of activity,
nutrition, and the gut microbiome.

Genetic Predisposition
People have different inherited body types, and each type has a
different predisposition toward accumulating more or less fat
(136). Different body types (i.e., somatotypes) have different
body compositions. Endomorphs (large trunk, short fingers,
shorter legs) have a predisposition toward higher body fat
percentages, and ectomorphs (long legs, long fingers, shorter
trunk) have a predisposition toward a slender build with less body
fat (119, 139). There are clear differences in the susceptibility
individuals have in becoming obese, even when living in the
same environment, strongly suggesting that genetic
predisposition plays an important role (40). Because the genetic
composition cannot change, the most people can hope to do is to
optimize what nature has provided.

Age
People generally develop a lower lean mass and higher fat mass
after the age of 30. Older men were found to weigh 8.2 kg less
than middle-age men, mainly from having lower lean tissue (19).
The age-related drop in lean mass is even larger when older
individuals are compared with younger individuals. By age 65–70
the average male has lost 12 kg of lean mass when compared
with age 25, and the average female has 5 kg less (50). Because
energy metabolism drops about 2% for each decade after age 30,
it gets progressively more difficult to maintain a desirable weight
and body composition. However, although this age-related
change in body composition is normal, it is not a mandate. It has
been clearly shown that a good diet and regular physical activity
can keep you lean (56).

Gender
All other things being equal (i.e., equal weight-to-height ratios),
women have a higher body fat percentage and lower lean mass
than men (55). This gender difference is primarily a manifestation
of the different biologic functions of men and women. Because
women convert some of the testosterone they produce to
develop a uterus, less testosterone is available to develop
muscles (44). Despite this difference, it is certainly possible for
women to enlarge the muscle mass through regular resistance
activity and proper eating.

Type of Activity
Different types of activities place different stresses on the system
and, as you would expect, the body responds differently to these
stresses. The standard exercise for reducing body fat percentage
is aerobic exercise, but there is good evidence that any type of
activity (including anaerobic activity) will reduce the body fat
percentage and improve exercise capacity (20, 60). High-
intensity activity may result in a greater increase in lean body
mass while reducing body fat mass, resulting in lower health risks
and better body composition with a minimal impact on weight
(124). Nevertheless, this shift in body composition is still likely to
make the person appear slightly smaller, because, pound for
pound, fat weight takes up more space than lean mass weight.
Low-intensity activity, on the other hand, appears to reduce body
fat percentage with minimal impact on lean body mass, resulting
in weight reduction. When energy expenditure (calories burned)
is equivalent, both anaerobic and aerobic activity appear to
equally lower body fat.

Amount of Activity
The greater the volume of exercise, the greater the potential
benefits in desirably altering body composition and reducing
health risks. There are, of course, limits to training. Excess
training may result in overtraining syndrome, which negatively
affects both body composition and health. In all training
protocols, activity must be supported by an adequate intake of
energy. Increasing the time of activity without also increasing the
amount of energy intake causes a breakdown of muscle mass to
support energy needs and may have multiple negative outcomes
(110). In addition, overtraining, although it will not necessarily
lead to a reduction in lean body mass, causes an increase in
muscle soreness and reduces muscular power and endurance.
Therefore, the amount of activity should be carefully balanced
with adequate energy intake and with adequate rest to ensure
maintenance of muscle mass and athletic performance (95).

Nutrition
Numerous nutritional factors can have an impact on body
composition, including consumption of too much energy (the fat
mass will enlarge), too little energy (the lean mass will become
smaller), or at the wrong times (fat mass may enlarge and/or lean
mass becomes smaller, depending on how the energy is
delivered) (110, 116). A failure to consume an adequate level of
these nutrients (B-vitamins, zinc, iron, etc.) may also reduce an
athlete’s ability to properly burn fuel, thereby limiting the
capacity to use fat during exercise.

Gut Microbiome
New data strongly imply that the gut microbiome (i.e., the
volume and makeup of the bacteria in the gastrointestinal tract)
has an impact on the acquisition of nutrient and on energy
metabolic pathways (30). These findings demonstrate how
important it is to have a healthy gut for lowering obesity risk and
related disorders. Early results suggest that microbiota
transplantation in males with obesity-related metabolic syndrome
lowers obesity and improves insulin sensitivity to lower health
risks (65).

Common Issues With Body Composition Assessment

Body composition assessment has become an important part of
athlete assessment. The amount of muscle and fat that an
athlete has can be predictive of performance, and bone mass
assessment is important for understanding if developmental
problems exist or if the athlete is at risk for stress fracture. A
periodic assessment of body composition also helps the athlete
understand if the training regimen is causing the kinds of
physical changes that are being sought. However, there are
important considerations when assessing body composition.

Desirable Body Composition Change Is Possible

Body composition may change through changes in diet and
exercise, but diet and exercise should be considered together
when making changes. Changing an exercise protocol without
making appropriate changes in food/beverage intake is likely to
cause unpredictable problems in achieving the desired body
composition. If an athlete is increasing training in a training
regimen, it is necessary to increase energy intake to support the
increase in energy expenditure. Athletes putting themselves in a
severe energy-deficit state by increasing exercise and
maintaining or lowering energy intake are likely to lower
metabolic rate, increase fat storage, and cause a breakdown of
muscle to support energy needs. Eating too much is also likely to
increase fat storage. It is best to maintain energy intake
throughout the day, so athletes should be careful about
consuming enough energy to support exercise, rather than
making up for an energy deficit at the end of the day.

Keeping Information Private

Athletes often compare body composition values with other
athletes, but this comparison is not meaningful and may drive an
athlete to change body composition in a way that negatively
affects both performance and health. Health professionals
involved in obtaining body composition data should be sensitive
to the confidentiality of this information. They should also explain
to each athlete that differences in height, age, and gender are
likely to result in differences in body composition, without
necessarily any differences in performance. Strategies for
achieving privacy and helping the athlete put the information in
the proper context include the following:

Obtain body composition values with only one athlete at a

time, to limit the chance that the data will be shared.
Give athletes information on body composition using phrases
such as “within the desirable range” rather than a raw value,
such as saying, “your body fat level is 18 percent.”
Provide athletes with information on how they have changed
between assessments, rather than offering the current value.
Increase the focus on muscle mass and decrease the focus on
body fat.
Use body composition values as a means of helping to
explain changes in objectively measured performance
outcomes.

Comparing Body Composition Results Using Different

Methods
Different methods for assessing body composition produce
different standard results. Therefore, it is inappropriate to
compare the results from one method with the results of another.
If athletes are being evaluated to determine body composition
change over time (an appropriate use of body composition
assessment), this comparison should only be made if the same
method has been used for the entire assessment period. For
instance, the difference in two DXA scans taken several months
apart provides valuable information on how body composition has
changed in an individual, as does the difference in two skinfold
assessments. However, the difference between body composition
values from a DXA scan and skinfold equation is not useful in
determining change. Even within methods, the same prediction
equations should be used to determine if an athlete’s body
composition has changed between measurements.

Seeking an Arbitrarily Low Level of Body Fat

Most athletes would like their body fat level to be as low as
possible. However, athletes often try to seek a body fat level that
is arbitrarily low (so low that it has nothing to do with the norms
in the sport or their own body fat predisposition), and this can
increase the frequency of illness, increase the risk of injury,
lengthen the time the athlete needs before returning to training
following an injury, reduce performance, and increase the risk of
an eating disorder. Body composition values should be thought of
as numbers on a continuum that are usual for a sport. If an
athlete falls anywhere on that continuum, it is likely that factors
other than body composition (training, skills acquisition, etc.) will
be the major predictors of performance success. Seeking
arbitrarily low body fat levels and/or weight is a particular
problem for athletes in sports where making weight is a common
expectation. Wrestlers, in particular, make dangerous efforts —
sometimes leading to death — to lower body fat levels and
weight in order to be more competitive.

Excessive Frequency of Body Composition Assessment

Athletes who are assessed frequently (frequent weight and/or
skinfolds taken) are fearful of the outcome, because the results
are often (and inappropriately) used punitively. Real changes in
body composition occur slowly, so there is little need to assess
athletes weekly, biweekly, or even monthly. Assessing body
composition two to four times each year is an appropriate
frequency to determine and monitor body composition change. In
some isolated circumstances when an athlete has been injured or
is suffering from a disease, such as malabsorption, fever,
diarrhea, or anorexia, it is reasonable for a physician to
recommend a more frequent assessment rate to control for
changes in lean mass. Coaches who have traditionally obtained
weight and/or body composition values weekly, biweekly, or
monthly should shift their focus to a more frequent assessment of
objective performance-related measures.

Summary

The assessment of body composition can be a useful tool in

helping the athlete and coach understand the changes that are
occurring as a result of training and nutritional factors. Health
professionals involved in obtaining body composition data should
focus on using the same technique with the same prediction
equations to derive valid comparative data over time. Care
should be taken that body composition values are used
constructively as part of the athlete’s total training plan. Ideally,
the emphasis should be on a periodic monitoring of the athlete’s
body composition to determine change of both the lean and fat
mass. Many athletes are sensitive about body fat, so care should
be taken to use body composition values in a way that enables
their constructive use in the athlete’s general training plan.
Be cautious about making recommendations that are based on
a single body composition measurement. It is possible that a
single measurement may suggest that an athlete is overfat.
However, if that athlete had an even higher body fat level 1 or 2
months earlier, they are already doing something that is making
a desirable change in body composition. Were an intervention to
occur it could inadvertently change that successful strategy. The
same might be true for an athlete who, on a single measure,
appears to be relatively lean, causing no intervention to occur.
But what if that athlete has been experiencing a steady increase
in body fat levels? This would never be known if only a single
measure was taken. Therefore, the key to successful body
composition measures is to take several measures at the same
time intervals, perhaps monthly, each time using the same
equipment to determine an accurate trajectory of change before
any intervention takes place.
The Position Statement of the American College of Sports
Medicine, The Academy of Nutrition and Dietetics, and the
Dietitians of Canada on Nutrition and Athletic Performance makes
some important points related to weight and body composition
for athletes, including the following (147):

In three out of six studies of male and female athletes,

negative energy balance (losses of 0.02%–5.8% body mass;
over five 30-day periods) was not associated with decreased
performance. In the remaining three studies where
decrements in both anaerobic and aerobic performance were
observed, slow rates of weight loss (0.7% reduction in body
mass) were more beneficial to performance compared to fast
rates (1.4% reduction in body mass), and one study showed
that self-selected energy restriction resulted in decreased
hormone levels.
Although it is clear that the assessment and manipulation of
body composition may assist in the progression of an athletic
career, athletes, coaches, and trainers should be reminded
that athletic performance cannot be accurately predicted
solely based on body weight and composition. A single and
rigid optimal body composition should not be recommended
for any event or group of athletes.
Nutrition goals and requirements are not static. Athletes
undertake a periodized program in which preparation for
peak performance in targeted events is achieved by
integrating different types of workouts in the various cycles of
the training calendar. Nutrition support also needs to be
periodized, taking into account the needs of daily training
sessions (which can range from minor in the case of “easy”
workouts to substantial in the case of high-quality sessions
[e.g., high-intensity, strenuous, or highly skilled workouts])
and overall nutritional goals.
Nutrition plans need to be personalized to the individual
athlete to take into account the specificity and uniqueness of
the event, performance goals, practical challenges, food
preferences, and responses to various strategies.
The achievement of the body composition associated with
optimal performance is now recognized as an important but
challenging goal that needs to be individualized and
periodized. Care should be taken to preserve health and long-
term performance by avoiding practices that create
unacceptably low energy availability and psychological
stress.
Some nutrients (e.g., energy, carbohydrate, and protein)
should be expressed using guidelines per kilogram of body
mass to allow recommendations to be scaled to the large
range in the body sizes of athletes. Sports nutrition
guidelines should also consider the importance of the timing
of nutrient intake and nutritional support over the day and in
relation to sport rather than general daily targets.
There is ample evidence in weight-sensitive and weight-
making sports that athletes frequently undertake rapid
weight loss strategies to gain a competitive advantage.
However, the resultant hypohydration (body water deficit),
loss of glycogen stores and lean mass, and other outcomes of
pathologic behaviors (e.g., purging, excessive training,
starving) can impair health and performance.
An individualized diet and training prescription for weight/fat
loss should be based on assessment of goals, present training
and nutrition practices, past experiences, and trial and error.
Nevertheless, for most athletes, the practical approach of
decreasing energy intake by ∼250–500 kcal/day from their
periodized energy needs, while either maintaining or slightly
increasing energy expenditure, can achieve progress toward
short-term body composition goals over ∼3–6 weeks.
Athletes may choose to excessively restrict their fat intake in
an effort to lose body weight or improve body composition.
Athletes should be discouraged from chronic implementation
of fat intakes below 20% of energy intake because the
reduction in dietary variety often associated with such
restrictions is likely to reduce the intake of a variety of
nutrients such as fat-soluble vitamins and essential fatty
acids, especially n-3 fatty acids.
Athletes who frequently restrict energy intake, rely on
extreme weight loss practices, eliminate one or more food
 groups from their diet, or consume poorly chosen diets may
consume suboptimal amounts of micronutrients and benefit
from micronutrient supplementation. This occurs most
frequently in the case of calcium, vitamin D, iron, and some
antioxidants. Single-micronutrient supplements are generally
only appropriate for correction of a clinically defined medical
reason (e.g., iron supplements for iron deficiency anemia).
Where significant manipulation of body composition is
required, it should ideally take place well before the
competitive season to minimize the impact on event
performance or reliance on rapid weight loss techniques.
Among other responsibilities, it is the role of the sports
dietitian to provide assessment of nutrition needs and current
dietary practices, including the following:
Energy intake, nutrients and fluids before, during, and
after training and competitions
Nutrition-related health concerns (eating disorders, food
allergies or intolerances, gastrointestinal disturbances,
injury management, muscle cramps, hypoglycemia, etc.)
and body composition goals
Food and fluid intake as well as estimated energy
expenditure during rest, taper, and travel days
Nutritional needs during extreme conditions (e.g., high-
altitude training, environmental concerns)
Adequacy of athlete’s body weight and metabolic risk
factors associated with low body weight
Supplementation practices
Basic measures of height, body weight, etc., with
possible assessment of body composition

Practical Application Activity

There is a common myth that going on an energy-restricted

diet will help you achieve a more desirable weight, but if this
energy restriction results in large energy balance deviations
during the day (i.e., a large number of hours in a RED), then
this strategy is likely to be counterproductive. Assess your own
diet to assess energy balance as follows:

1. Predict your hourly resting energy expenditure (REE) using

the Harris–Benedict equation, modified by Mifflin et al.
(104) for your gender:

Men Hourly REE = ((10 × weight in kg) + (6.25 ×

height in cm) − (5 × age in years) + 5)/24
Women Hourly REE = ((10 × weight in kg) + (6.25 ×
height in cm) − (5 × age in years) − 161)/24

Source: Mifflin MD, St Jeor ST, Hill LA, Scott BJ, Daugherty SA, Koh YO. A new
predictive equation for resting energy expenditure in healthy individuals. Am J
Clin Nutr. 1990;51(2):241–7.

2. Using the relative energy expenditure (MET value) scale

below, predict your hourly and total daily energy
expenditure. (Take the hourly REE and multiply it by the
activity factor that comes closest to your activity for each
hour of the day.) Using this strategy will give you the hourly
energy intake (food/beverage consumed) and hourly
energy expenditure (activity intensity).

Factor Description
1 Resting, Reclining: Sleeping, reclining, relaxing
1.5 Rest +: Normal, average sitting, standing,
daytime activity
2.0 Very Light: More movement, mainly with upper
body. Equivalent to tying shoes, typing, brushing
teeth
2.5 Very Light +: Working harder than 2.0
3.0 Light: Movement with upper and lower body.
Equivalent to household chores
3.5 Light +: Working harder than 3.0; Heart rate
faster, but can do this all day without difficulty
4.0 Moderate: Walking briskly, etc. Heart rate faster,
sweating lightly, etc., but comfortable
Factor Description
4.5 Moderate +: Working harder than 4.0. Heart rate
noticeably faster, breathing faster
5.0 Vigorous: Breathing clearly faster and deeper,
heart rate faster, must take occasional deep
breaths during sentence to carry on conversation
5.5 Vigorous 1: Working harder than 5.0. Breathing
noticeably faster and deeper, and must breathe
deeply more often to carry on conversation
6.0 Heavy: You can still talk, but breathing is so hard
and deep you would prefer not to. Sweating
profusely. Heart rate very high
6.5 Heavy 1: Working harder than 6.0. You can barely
talk but would prefer not to. This is about as hard
as you can go, but not for long
7.0 Exhaustive: Cannot continue this intensity long,
as you are on the verge of collapse and are
gasping for air. Heart rate is pounding

Begin End Activity Activity Food/Drink Food/Drink

Hour Hour Factor Description Description Amount
****Begin Example****
12 7 1.0 Sleep
AM AM
7 AM 8 1.5 Nothing Whole 3
AM special wheat
waffles
(frozen
Kellogg)
Maple syrup 2
tablespoons
1% milk 1 cup
Orange juice 1.5 cups
(from
concentrate)
Coffee 2 cups
Begin End Activity Activity Food/Drink Food/Drink
Hour Hour Factor Description Description Amount
1% milk for 2
coffee tablespoons
10 11 5.0 Jog 30 min Gatorade 16 oz
AM AM
12 1 PM 1.5 Nothing Medium size 1 sandwich
noon special beef
sandwich
white bread,
mayonnaise,
lettuce, and
tomato
Coffee 2 cups
Artificial 2 packets
coffee
creamer
Apple pie 1 slice
(small)
5 PM 6 PM 4.0 Walk 1 h Water 16 oz
7 PM 8 PM 1.5 Nothing Lasagna Large plate
special with ground
beef and
cheese
Lettuce Medium
salad with size salad
tomatoes
and
cucumbers
Blue cheese 1
salad tablespoon
dressing
Red wine 1 medium
glass
10 11 1.5 Nothing Popcorn (air 100 calorie
PM PM special popped; no pack
butter)
 Begin End Activity Activity Food/Drink Food/Drink
Hour Hour Factor Description Description Amount
***End Example***

3. Determine if your total daily energy consumption closely

satisfies your total daily energy expenditure.
4. Using this strategy and a spreadsheet (assess energy
balance for each hour of the day), you can also determine
the within-day energy balance deviations that you
experience, following the strategies of Deutz et al. (29),
Fahrenholtz et al. (45), and Torstveit et al. (150).
5. See if you can find a way to distribute your food/beverage
consumption so you can maintain an hourly energy balance
that maintains shifts that do not exceed ±400 calories of
energy balance.

Chapter Questions

1. Low energy availability is defined as a(n):

a. Energy expenditure that routinely exceeds energy intake in
real time
b. Low energy intake caused by an eating disorder
c. Hormonal disruption that results in the delayed uptake of
glucose
d. Reduced metabolic rate because of self-imposed starvation
2. When comparing energy inadequacy and energy excess, both
have all of these problems except:
a. Increased injury risk
b. Reduced athletic performance
c. Increased risk of disordered eating
d. Higher risk of type II diabetes
3. Of the following, which is associated with lower food intake,
higher energy expenditure, and higher fat catabolism?
a. Leptin
b. Insulin
c. Ghrelin
d. a and c
4. Of the following, which is most likely to lower ghrelin?
a. A large breakfast about 2 hours after waking up
b. A moderately sized meal before blood sugar is allowed to go
below normal
c. A good breakfast, lunch, and dinner
d. A large meal to ensure blood sugar is sufficient to satisfy
tissue requirements plus enough to stimulate a high insulin
response
5. Decreased meal frequency is associated with:
a. Lower total daily energy consumption
b. Higher total daily energy consumption
c. No difference in total daily energy consumption
d. Reduced appetite
6. The current method of body composition assessment with the
lowest standard error is:
a. BIA
b. Hydrostatic weighing
c. DXA
d. BOD POD
7. Meal skipping is an effective weight loss strategy.
a. True
b. False
8. Studies suggest that a 40 kcal/day permanent reduction in
energy intake results in about a _____ lb weight loss in 5 years.
a. 20
b. 10
c. 4
d. 0
9. Humans are extremely effective at storing fat.
a. True
b. False
10. An expectation of exercise is that:
a. Doing the same exercise at the same intensity and duration
will continually improve fitness
b. Humans adapt to the same activity and will increase energy
efficiency doing that activity
c. The weight and body composition outcomes of exercise are
unpredictable
d. It will always result in a muscle mass increase
Answers to Chapter Questions

1. a
2. d
3. a
4. b
5. b
6. c
7. b
8. c
9. a
10. b

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CHAPTER OBJECTIVES
Comprehend the importance of delivering oxygen to cells for
optimal cellular respiration and athletic performance.
Identify the nutrients closely associated with manufacturing
red blood cells (RBCs).
Recognize the substances associated with iron storage and
delivery.
List the nutrients associated with protecting cells from
oxidation reactions and how they function as antioxidants.
Analyze the relationship between oxygen uptake and VO2max
as it relates to exercise intensity.
Recall the molecules that form reactive oxygen species
(ROS) and are potentially damaging to cells.
Know the diseases associated with insufficient iron and
excess iron.
Identify the possible causes of iron deficiency in athletes and
nutritional strategies that could help to resolve the
deficiency.
Identify the causes of ROS-related oxidative stress and the
nutritional countermeasures that can be followed to
minimize the stress.
Understand reduction–oxidation (REDOX) reactions and how
they are involved in normal metabolic functions.
 Case Study

John was an elite swimmer who made the decision to start

competing in triathlons. In his first triathlon, John predictably
came in first after the swim portion, but lagged terribly
behind in the bike and running portions of the race. He was
not dissuaded, however, from continuing to pursue becoming
an elite triathlete. John did everything imaginable to improve
the running and biking portions of the race, including
investing in a top-notch racing bike and hiring coaches who
showed him how to train, improve his form, and strategize
each portion of the race. All of these, coupled with a superb
training program, helped him improve with each race, and he
slowly moved up in the rankings. He did so well that the time
on his last triathlon qualified him to enter the biggest race of
the year. He had 2 months to prepare, and he was leaving no
stone unturned in getting ready for the most important
competition in his career. Of course he was also looking at
optimal nutrition strategies for fueling/hydration and had
developed some excellent pre-, during-, and postevent
strategies to make sure his muscles were ready going into
the race, stayed in an optimal state during the race, and
recovered well after the race.
There were many choices of what to do, but he found a
talented sports dietitian who provided him with the perfect
nutritional strategy. Because this was a really important race
and John wanted every imaginable edge, he kept an open
mind to other options. He read an article about how physical
activity increases muscle soreness because of oxidative
stress, and that taking a combination of the fat-soluble
vitamin E and the water-soluble vitamin C supplements, both
powerful antioxidants, would reduce exercise-associated
muscle soreness and improve performance. He thought there
could be no harm in taking these benign vitamin
supplements, and that they could only help his athletic
mission, so he started taking daily supplemental doses of the
vitamins a couple of months before this important race. Of
 course, he was also training harder and longer at the same
time he was taking the supplements, so he was convinced
that the increased muscle soreness he felt was surely
attributable to the training — thank goodness he was taking
the supplements, because the muscle soreness would have
been bad without them.
Race day arrived and John raced pretty well, but not as
well as he had hoped. So, he kept up his training and
nutrition regimen (including the supplements) to do better
next time. Then he saw the summary results of a research
study that took place at the very race in which he had hoped
to excel. The study found that taking antioxidant
supplements actually increased markers of oxidative stress
and muscle soreness! He remembered what his sports
dietitian told him: “More than enough is not better than
enough.” This was good advice that he is now following.

CASE STUDY DISCUSSION QUESTIONS

1. Why do you believe so many athletes are predisposed to

taking supplements?
2. What messages would you give them to help them
understand that “more than enough is not better than
enough?”
3. Why would taking high doses of antioxidant vitamins
actually make muscle soreness worse than if they were
not taken?

Introduction

Acquiring oxygen through pulmonary ventilation (breathing) is an

important first step in the transportation of oxygen from inspired
air to the delivery of oxygen into body cells. The next step is the
exchange of oxygen and carbon dioxide between the lungs and
blood, which is followed by the transportation of oxygen and
carbon dioxide bound to hemoglobin in RBCs. Finally, there is an
exchange of oxygen and carbon dioxide between the RBCs in
capillaries and tissue cells (51).
Athletes can only be successful if their body systems are fully
capable of capturing sufficient oxygen, moving oxygen through
the blood to tissues, and efficiently using the oxygen by having
sufficient oxidative enzymes in mitochondria. They must also
have efficient excretion of carbon dioxide, a by-product of
oxygen utilization, and must also have sufficient antioxidants
available in tissues to deal with the potentially negative side
effects of excess oxygen exposure. Each function just mentioned
has a nutritional component, including:

Sufficient protein and energy, so that the tissues can store

iron (ferritin) and deliver iron (transferrin) for the formation
of hemoglobin.
Vitamins B12 and folic acid, which are involved in RBC
formation. RBCs contain hemoglobin, which is the iron-
containing and oxygen/carbon dioxide–carrying protein.
Iron has a critical role as part of hemoglobin (in RBCs) and
myoglobin (in tissues). Hemoglobin is the iron-containing
protein in RBCs responsible for delivering oxygen from the
lungs to tissues and removing carbon dioxide from tissues.
Myoglobin is an iron-containing protein used for storing iron
in tissues. Approximately 70% of iron is found in hemoglobin
and myoglobin. A large number of enzymes, including
cytochrome enzymes, contain iron primarily for oxidative
phosphorylation (the process of obtaining energy from
energy substrates). Iron is stored in the protein complex
ferritin. The protein transferrin carries iron in the blood for
storage, mainly in the liver, skeletal muscle, and
reticuloendothelial cells that line the liver, spleen, and bone
marrow. Exceeding the storage capacity for iron results in
the formation and deposit of hemosiderin, which is not
functionally available to cells. Iron overload disorder results
from excess hemosiderin, which is associated with tissue
damage. An associated disorder, hemochromatosis, results
from excess iron absorption, which may also be associated
with tissue damage.
 Copper, as part of the protein ceruloplasmin, which is
involved in transferring iron from the transport protein
transferrin to the RBC oxygen-carrying protein hemoglobin.
β-Carotene, vitamin C, vitamin E, and selenium, which are
antioxidant nutrients needed for protecting cells from
oxidation reactions.

Physical activity may increase the rate of energy utilization by

20–100 times, depending on intensity, above the energy
expended in a resting state, creating an enormous demand for
oxygen in metabolically active tissues (18). This chapter reviews
the nutrient relationships associated with the utilization of
oxygen, the potential tissue damaging effects from ROS that are
associated with physical activity, and the role that oxygen
delivery has on human performance.

Oxygen Uptake

Every body cell requires oxygen to survive, and it is through the

air we breathe that the oxygen and other gases are supplied.
Inspired air is composed of 20.95% oxygen and other gases
(Table 9.1). Gas exchange in the lungs occurs in the 150 million
alveoli humans have in each bronchi (75). The inspiratory
capacity, or the maximal amount of air that can be breathed in
through normal expiration, is ∼3.6 L (3.8 quarts) for the average
adult male, and ∼2.4 L (2.5 quarts) for the average adult female
(Figure 9.1).
The oxygen diffused into the lung alveoli passes into the
blood through capillaries and enters the iron-containing
hemoglobin in RBCs. RBCs then carry the oxygen to tissues. At
the same time that oxygen is being delivered through the alveoli,
carbon dioxide in the blood (a by-product of energy metabolism)
passes to the alveoli and is exhaled (Box 9.1).

Box 9.1 The Contents of the Air We Breathe

 Nitrogen — 78.09%
Oxygen — 20.95% (lower than this amount at high
altitudes)
Argon — 0.93%
Carbon dioxide — 0.039%
Water vapor — 1% at sea level; 0.4% average
Source: Cotes JE, Chinn DJ, Miller MR. Lung Function: Physiology, Measurement and
Application in Medicine. 6th ed. London: Blackwell Publishing; 2006.

FIGURE 9.1: The diaphragm moves down to pull air into the
lungs and pushes up to push air out of the lungs. Lung alveoli
capture the oxygen in air and transport the oxygen to the
hemoglobin in red blood cells. (From Anatomical Chart Company.
Anatomy of the Heart Anatomical Chart. 2nd ed. Philadelphia
(PA): LWW (PE); 2005.)
 The oxygen content of air is ∼20.95%, and the oxygen
content of the expired air after exercise is 13.6%–16%,
suggesting that a relatively small proportion of inspired oxygen
is captured by the lungs (86). The typical water content of air is
0.5%, whereas the water content of expired air is ∼6%,
illustrating why the more rapid respiration during physical
activity is a major route of water loss in athletes.

Table 9.1 Altitude Adjustments to Measured

Hemoglobin Concentrations
Altitude (Meters Measured Hemoglobin Adjustment (g/dL)
Above Sea Level)
<1,000 0
1,000 −0.2
1,500 −0.5
2,000 −0.8
2,500 −1.3
3,000 −1.9
3,500 −2.7
4,000 −3.5
4,500 −4.5

Source: World Health Organization. Haemoglobin concentrations for the diagnosis of

anaemia and assessment of severity. Vitamin and Mineral Nutrition Information
System. Geneva, World Health Organization, 2011. (WHO/NMH/NHD/MNM/11.1)
Available from: http://www.who.int/vmnis/indicators/haemoglobin.pdf. Accessed 6th
August, 2017.

Important Factors to Consider

The oxygen content of dry air is ∼21% atmospheric

pressure.
Inspired oxygen pressure is ∼50% lower at an altitude of
5,500 m (the height of Mount Blanc) and 30% of that at
sea level at an altitude of 8,900 m (the height of Mount
Everest) (73).
 Athletic performance is affected by how well the heart and
lungs can provide an adequate supply of oxygen to working
muscles. This is demonstrated by the following (8, 24):

Greater oxygen delivery capacity improves VO2max, whereas

lower oxygen delivery capacity lowers VO2max.
The improvements seen in VO2max from athletic training
result from enhanced cardiac output, which is associated
with improved oxygen delivery.
Muscles with enhanced blood flow are able to acquire and
use more oxygen, resulting in better muscle function and
enhanced performance (Figure 9.2).

FIGURE 9.2: Greater oxygen using capacity is seen in highly

trained vs. nontrained subjects. During submaximal cycle
ergometer exercise, trained subjects reach a steady-state
 VO2 faster than untrained subjects, reducing the oxygen
deficit and, therefore, lactate production. (From McArdle WD,
Katch FI, Katch VL. Essentials of Exercise Physiology. 4th ed.
Philadelphia (PA): LWW (PE); 2011.)

As exercise intensity increases, so does the rate of cellular

respiration. High-intensity exercise may cause a 25-fold increase
in the demand for oxygen in working muscles, which is satisfied
through the increase in the rate and depth of respiration.
Interestingly, a lower blood pH is associated with a rise in carbon
dioxide, rather than the higher need for oxygen that is the
trigger for the higher respiration rate. Chemoreceptors in the
medulla oblongata of the brain detect the lower pH when carbon
dioxide is elevated, which stimulates the motor nerves
controlling the intercostal and diaphragm muscles to increase
their activity (24). When lactate (i.e., lactic acid) begins to
accumulate in the blood at a faster rate than can be removed
(typically the result of intense exercise), the blood pH begins to
decrease (i.e., it becomes more acidic), and this also results in
faster respiration (33). Diseases affecting the lungs, such as
pneumonia, asthma, emphysema, bronchitis, chronic obstructive
pulmonary disease, and lung cancer, compromise an individual’s
ability to obtain sufficient oxygen and excrete sufficient carbon
dioxide (108). (Exercise-induced asthma [EIA] is discussed later
in this chapter.)

Nutrients Associated With Oxygen Delivery

A number of minerals, vitamins, and protein carriers provide for
the delivery and cellular utilization of oxygen. These nutrients
work together as a team to capture oxygen from the
environment, transport oxygen through the blood, transport
oxygen from the blood to the cells for metabolic actions, and
remove the metabolic by-products of oxygen-related metabolic
activities. One of the primary energy metabolic by-products
removed is carbon dioxide:
Iron
Iron is a critical element in the delivery of oxygen to working
tissues. It is part of RBC hemoglobin, muscle myoglobin, and
enzymes involved in electron transfer for energy metabolism.
(See Chapters 2, 3, and 4 for more information on energy
metabolism, oxidative phosphorylation, and the electron
transport chain, respectively.) Iron exists in two oxidation states:
ferrous (Fe2+) or ferric (Fe3+). In a neutral pH (i.e., neutral
acidity), iron is typically found in the ferric (Fe3+) form, whereas
in an acidic environment, iron is found in the ferrous (Fe2+) form.
Aside from transporting oxygen in hemoglobin, iron is also found
in cytochromes and iron–sulfur-containing proteins as part of
oxidative phosphorylation, which is the enzyme-based metabolic
pathway cells use to oxidize nutrients and form adenosine
triphosphate (ATP) energy. Excess iron (i.e., iron not part of
hemoglobin, myoglobin, or enzymes) is toxic and can increase
the risk of liver and colon disease. Severe toxicity of iron causes
ferrous iron to generate hydroxyl free radical from hydrogen
peroxide, resulting in ROS tissue damage and related muscle
soreness.

Reactive Oxygen Species

Commonly abbreviated as ROS, these are chemically reactive

molecules that contain oxygen and may result in tissue
damage if tissues are not adequately protected with
antioxidants. Examples include hydrogen peroxide, superoxide,
hydroxyl radical, and singlet oxygen. Although ROS are
naturally formed by-products of oxygen-related metabolism,
excess formation of ROS is tissue damaging.

Hemoglobin is a high priority for the human system. Should

low iron availability cause hemoglobin to drop, the iron in
myoglobin and iron-containing enzymes are scavenged with the
goal of maintaining RBC hemoglobin. Because of this, it is
possible for athletes to experience a performance reduction even
if measured hemoglobin and hematocrit (the two most common
measures of iron status) appear to be in the normal range. It is
important, therefore, that ferritin (stored iron) also be measured
as a normal component of a blood test intended to screen for
iron status (Table 9.1). It is important to note that there is no
universally accepted minimum value on the serum ferritin level
associated with iron deficiency or iron depletion. The generally
used minimum values for serum ferritin that are associated with
iron deficiency/depletion range from <10.0 ng/mL to <35 ng/mL
(74, 103).
Should an iron deficiency anemia occur, the anemia is
characterized by small RBCs (microcytic cells), RBCs that are
light in color (hypochromic cells), and an inadequate number of
RBCs. This condition is referred to as a microcytic hypochromic
anemia (Figure 9.3).

FIGURE 9.3: Iron deficiency anemia is characterized by smaller,

lighter in color, and fewer in number RBCs. A. Iron deficiency
anemia is characterized by an insufficient number of red cells
(anemia) that are small (microcytic) and low in color
(hypochromic) from low hemoglobin concentration. B.
Megaloblastic anemia is characterized by an insufficient number
of red cells (anemia) that are large (macrocytic) and low in color
(hypochromic) from dilution of hemoglobin in the cells. The
cause is vitamin B12 and/or folic acid deficiency. C. Sickle cell
disease is characterized by an insufficient number of red cells
(anemia) that are misshapen (sickle cell). This is a
genetic/inherited condition. D. Normal RBCs are normally
concentrated (i.e., normal hematocrit), normally shaped
(normocytic), and have a normal bright red color
(normochromic). RBCs, red blood cells. (From Porth C. Essentials
of Pathophysiology. 3rd ed. Philadelphia (PA): LWW (PE); 2011.)

Anemia

A general term to describe insufficient RBCs with limited

hemoglobin, resulting in reduced oxygen-carrying capacity. The
common dietary cause is insufficient iron consumption, but
anemia may also be the result of insufficient vitamin B12,
folate, or protein. It may also be caused by loss of blood as is
typical in a woman’s menstrual period, but may occur with any
chronic bleeding from the gastrointestinal (GI) tract or loss of
iron in the urine. Additional anemia risks that athletes face are
associated with foot-strike and other sources of intravascular
hemolysis, periods of rapid growth (i.e., the adolescent growth
spurt), training at high altitudes, and increased iron losses via
sweat, urine, and feces (28).

Transferrin
Transferrin is a blood glycoprotein (combination of carbohydrate
and protein) that is the main carrier of free iron in the blood.
Each transferrin molecule has the capacity to carry two
molecules of ferric (Fe3+) iron. Transferrin is a two-way
transporter that is not only capable of carrying iron to the bone
marrow, spleen, and liver for storage but also capable of carrying
iron to form hemoglobin in new RBCs (55). It is a molecule with a
relatively short half-life that can be measured as an indicator of
recent protein status. Low blood transferrin may indicate protein
or energy malnutrition, which results in inadequate synthesis of
transferrin by the liver. It should be noted that transferrin can
also be synthesized by the brain (22). Low blood transferrin may
also result from excess protein loss through the kidneys
(proteinuria), an infection, or cancer. A high blood transferrin
level is an indicator of iron deficiency. Athletes with low blood
transferrin may have impaired production of hemoglobin that
can lead to anemia, even with ample iron body stores, whereas
high transferrin may be an indicator of iron deficiency anemia. In
addition to its iron-carrying capacity, transferrin is associated
with body immunity by limiting the amount of free iron and ROS
creation, which is associated with tissue inflammation, and
lowering the amount of free iron required by bacteria for survival
(6).

Ceruloplasmin
Ceruloplasmin, which represents 90% of the total plasma copper,
is a copper-containing protein involved in transferring iron from
transferrin to hemoglobin in the formation of new RBCs, and in
transferring iron from deteriorated RBCs for inclusion into newly
formed RBCs (106). Copper deficiency results in low
ceruloplasmin that can result in low RBC anemia (microcytic
hypochromic anemia), because of an inability to transfer iron for
the formation of hemoglobin. This poor transfer capacity may
result in iron overload disease, referred to as hemochromatosis,
with iron accumulating in the pancreas, liver, and brain, resulting
in neurologic disorders (42). It is important to note that copper
deficiency is a relatively uncommon clinical disorder, with those
most at risk of deficiency including premature infants, children
recovering from malnutrition, people with any malabsorption
syndrome (i.e., celiac disease, sprue, and any surgical shortening
of the small intestine), and cystic fibrosis (11, 12). There is also
some indication that, because of competitive absorption, excess
zinc consumption may result in copper deficiency (68, 95).
Although athletes have a greater requirement for iron and
associated nutrients to increase the manufacture of healthy
RBCs, there are no data to suggest that the athletic endeavor
increases the risk of copper deficiency.

Vitamin B12 (Cobalamin)

Vitamin B12 is a cobalt-containing vitamin that, as a result, is
also referred to as cobalamin. Two primary functions of vitamin
B12 are the formation of new RBCs and the preservation of a
healthy nervous system. Although a deficiency is uncommon in
adults, deficiencies are seen in people over the age of 60, or in
any condition that impairs the gastric production of intrinsic
factor, which is needed for vitamin B12 absorption (21). Pure
vegans and vegetarians who consume few animal products are
considered at higher risk of vitamin B12 deficiency because the
vitamin is more easily obtained from animal products (72). The
vegetarian athlete is at even greater risk of anemia because of
the combination of marginal vitamin B12 status (vegetables are a
poor source, and meats are a good source of B12) coupled with
the faster exercise-associated RBC breakdown experienced by
athletes (7, 99). Poor vitamin B12 availability when RBCs are
being formed results in cells with weak membranes. These
poorly formed cells, called megaloblasts, are fragile and live
approximately half as long as a normal RBC (60 days vs. 120
days) (35). The shortened life of these cells requires a constantly
faster production of red cells to maintain normal oxygen-carrying
capacity (Figure 9.4).
FIGURE 9.4: Sports anemia/dilutional pseudoanemia. The
differential in blood volume and red cell concentration becomes
noticeable after 3–5 days of an increase in exercise
duration/intensity. After some time, blood volume ceases to
increase and red cell production catches up, to remove the
appearance of anemia.

However, this faster required level of RBC production cannot

be maintained, eventually resulting in anemia. The anemia
resulting from vitamin B12 deficiency is referred to as pernicious
anemia because it develops slowly over several years (5).
Pernicious anemia is a megaloblastic, hypochromic anemia, with
RBCs that are large, misshapen because of a poorly formed
membrane and low in color (the hemoglobin is spread out over a
larger cell area, diluting the color) (44).

Folate
The vitamin folate refers to both the naturally occurring folates
in food and also folic acid, which is the synthetic form used in
supplements and in fortified foods. Folate, vitamin B12, and
vitamin C are all vitamins involved in protein metabolism, so are
important in hemoglobin and RBC synthesis and protein carrier
(i.e., transferrin) synthesis. Importantly, folate, in conjunction
with vitamin B12, is required for the production of RBCs (44).
Folate is also involved in nerve tissue development and, in
pregnant females with good folate status, is known to nearly
eliminate the risk of neural tube defects in newborns (26, 114).
The anemia associated with inadequate folate is similar to that
produced by a deficiency of vitamin B12 (megaloblastic,
hypochromic anemia), and the resulting reduced oxygen-carrying
capacity is equally severe. Although vitamin B12 is obtained
primarily from animal sources, folic acid can be obtained from
folate-fortified foods, fresh fruits, fresh vegetables, and legumes.
Folate has been fortified in the food supply, primarily cereal
grain products, since 1998, dramatically reducing the risk of
developing folate deficiency as a factor in reduced oxygen
delivery (26).
 Vitamin B12

Also referred to as cobalamin, a cobalt containing water-

soluble vitamin, it is involved in the formation of RBCs. It not
only is derived in the diet from animal-based foods, but can
also be obtained from fermented foods (soy tofu, etc.).
Insufficient B12 results in megaloblastic anemia because of
large, fragile RBCs with a shorter life span. The large cells also
make it difficult to oxygenate peripheral tissues, including the
brain.

Folate

Folate is the generic term used to refer to both naturally

occurring folates in food and folic acid, which is the synthetic
form of the vitamin used in fortified foods and supplements. It
is also referred to as vitamin B9. Where a distinction is
necessary, folates is used to refer to the forms found in foods
and the body tissues, whereas folic acid is used to refer to the
form in supplements or fortified foods. Where no distinction is
needed, the term folate is used. Folates are mainly derived
from fresh fruits and vegetables. When consumed, it works
with vitamin B12 to form new RBCs, without which the red cells
are large and fragile (megaloblasts). Deficiency results in
megaloblastic anemia, and women who initiate a pregnancy
without sufficient folate are at risk of having a baby with a
neural tube defect (anencephaly or spina bifida). To lower this
risk, the United States has been fortifying the food supply with
folic acid. (For more information, see Chapter 5 on vitamins.)

Oxygen–Nutrient Performance Relationship, Causes of

Anemia, and Related Disorders
Iron deficiency and/or iron deficiency anemia impairs muscle
function and diminishes muscular work capacity (41, 58). There
is also no question that physical activity can alter blood-iron
status and that blood-iron status can also alter physical activity
performance. A number of studies have found that athletes,
regardless of sport, are at higher risk of anemia than the
nonathlete population (45). Those athletes most at risk for iron
deficiency appear to be distance runners, vegetarians, and
regular blood donors (78, 103). One study assessing 747 athletes
and 104 untrained controls found that endurance athletes had
lower hemoglobin and hematocrit levels, perhaps from a greater
degree of foot-strike hemolysis (96). A study of female volleyball
players also found that a high proportion were at risk from
inadequate dietary intakes of iron, with 13% of the players
diagnosed with iron deficiency anemia (9). Virtually all studies
show a greater incidence of iron deficiency and iron deficiency
anemia in athletes compared with nonathletes, suggesting that a
significant proportion of athletes are performance compromised
(48). There are a number of possibilities related to iron
deficiency in athletes.

Sports Anemia (Dilutional Pseudoanemia)

When athletes begin an intensive exercise program, they
experience a rise in both blood volume and RBCs. However,
because the blood volume increases at a faster rate than the
RBCs, it appears that the athletes have anemia (97). Because
this condition is transient (eventually the concentration of red
cells becomes normal), it is referred to as a dilutional
pseudoanemia, sports anemia, or athletic anemia (36).
Although it is common for athletes to have hemoglobin
concentrations that are ∼1 g/dL below normal, the athletes still
typically experience an increase in RBCs that is associated with
an increase in oxygen-carrying capacity (30). It is for this reason
that this condition is referred to as a pseudoanemia (i.e., not a
true anemia). In fact, athletes do better as a result of the
increased plasma volume and red cells because of a more
efficient cardiac stroke volume and greater oxygen delivery to
working muscles (38).
It is most often seen in endurance athletes, but can be
observed in any athletes experiencing increases in training
intensity. It is the most common anemia in male athletes (97).
When it occurs, hemoglobin concentration appears to be reduced
by 1.0–1.5 g/dL, but this reduction is dilutional and occurs
despite an increase in RBCs. It is actually a beneficial adaptation
to training because the expanded plasma volume helps to
maintain sweat rates while lowering cardiac stress (97) (Figure
9.5).

FIGURE 9.5: Redox reactions — relationship between donor

(reducing agent) and receiving (oxidizing) agents. LDH, lactate
dehydrogenase. (From McArdle WD, Katch FI, Katch VL. Exercise
Physiology. 8th ed. Philadelphia (PA): LWW (PE); 2014.)

Foot-Strike Hemolysis or Exertional Hemolysis

Anemia has many causes including hemolysis, or the abnormal
breakdown of RBCs either in the blood vessels (intravascular
hemolysis) or in the tissues (extravascular hemolysis). There are
multiple causes of hemolysis, including the sudden compression
of RBCs caused by foot-strike or compressed muscles
experienced by athletes. With foot-strike or exertional hemolysis,
red cells circulating in capillaries through the bottom of the feet
or from compressed muscles are crushed (31). It is important to
note that exertional hemolysis may occur in all athletes,
including swimmers, and cyclists, suggesting that foot-strike
hemolysis commonly experienced by runners is only one of the
mechanisms associated with faster red cell breakdown (93, 101).
The faster RBC breakdown from hemolysis may make it more
difficult for athletes to maintain a normal concentration of RBCs,
which may increase anemia risk. However, the iron released
from hemolyzed RBCs is normally rebound to hemoglobin to
produce new red cells, so although the risk of anemia is greater,
exertional hemolysis should be considered an additional risk
factor in the development of anemia, as it would rarely result in
anemia by itself (117).

Sports Anemia

A dilutional pseudoanemia that occurs when the intensity of an

exercise program is increased. As an adaptation to the
exercise, blood volume is increased at a rate faster than RBCs
can be increased, resulting in what appears to be anemia.

Hemolysis

Hemolysis is the rupturing of RBCs from bacteria, sickle cell

disease, parasites, and external pressure on tissues (i.e., foot-
strike hemolysis). The greater breakdown of RBCs, regardless
of the cause, may result in anemia.

Loss of Iron in Urine

A chronic loss of RBCs in the urine (hematuria), a condition
brought on by frequent high-intensity and long-duration practice
sessions, may contribute to anemia, a problem that would clearly
lower athletic performance. Athletes should be careful, therefore,
to take in sufficient nutrients though consumption of good
quality foods to replace lost nutrients. Luckily, the process of
producing new RBCs (erythropoiesis) appears to be remarkably
resilient in the face of exercise stress. Assuming sufficient
nutrient availability that includes iron, folate, and vitamin B12,
humans are capable of producing a large number of new RBCs
(32). Some athletes try to enhance erythropoiesis by taking the
drug erythropoietin, but this blood-doping technique is illegal
and has the potential for increasing blood viscosity, with
subsequent thrombosis and potentially fatal results (97).

Hematuria

Blood (heme) in the urine (uria), which is seen in athletes but

is not common. Hematuria may be the result of vigorous
exercise, but is also associated with infection of the urinary
tract and other more serious diseases. Hematuria increases
the risk of anemia.

Data from past studies indicate that the higher prevalence of

hematuria in athletes has multiple causes, including (2, 49):

Foot-strike hemolysis
Renal ischemia (restriction of blood supply to the kidney,
often caused by dehydration in athletes)
Hypoxic kidney damage
Release of a hemolyzing factor
Bladder or kidney trauma
Nonsteroidal anti-inflammatory drug (NSAID) intake
(common NSAIDs include aspirin, tylenol, etc.)
Dehydration
Increased circulation rate
Myoglobinuria release
Peroxidation of RBCs
Sickle cell anemia

Ferritin
Ferritin is an intracellular protein that stores and releases iron
and is referred to as “storage iron” (110). Athletes with higher
exercise durations and workloads appear to have a lower level of
ferritin, suggesting that athletes are at higher risk of
compromised iron status than are nonathletes and that higher
exercise durations may be associated with even greater iron
status risk. Endurance athletes who put in large numbers of
training hours (and miles) are therefore at highest risk of poor
iron status even though they rely most on aerobic metabolic
processes to achieve their endurance (93, 101). A multistudy
comparison of serum ferritin values in female athletes involved
in different sports has found that between 18% and 57% of the
measured athletes had values suggesting iron depletion (1). It
has been suggested that iron requirements for all female
athletes may be 70% higher, or 13.8 mg/day, than the estimated
average requirement (for adult females = 8.1 mg/day) (27).

Diet
Restrictive food intakes, which are commonly observed among
athletes involved in weight classification or aesthetic sports,
typically fail to adequately supply vitamins and minerals. There
is real risk, therefore, that athletes in “make-weight” or
“appearance” sports may be at higher risk for developing
performance deficits associated with lower oxygen delivery. Iron
deficiency, even without anemia, reduces muscle work potential,
and iron deficiency anemia makes matters worse because of a
further reduction in oxygen-carrying capacity. It should be clear
that a failure to supply nutrients, in addition to iron, may also
compromise oxygen delivery. Magnesium deficiency increases
oxygen requirements needed to perform submaximal exercise,
thereby reducing endurance performance (58). The only
reasonable and appropriate way for weight-conscious athletes to
ensure adequate nutrient exposure to avoid nutrient deficiencies
that could compromise oxygen delivery and performance is to
eat foods with a high nutrient density (i.e., more nutrients per
calories delivered). It is also important that these athletes have
iron status regularly monitored (23).

Gender
Female athletes are at greater risk of poor iron status that may
result in iron deficiency from insufficient dietary iron intake,
menstruation, increased iron losses associated with hemolysis,
sweating, GI bleeding, and exercise-induced acute inflammation
(10, 66). The effects include reduced athletic performance and
impaired immune function. Female athletes should consider
either consuming more iron-rich foods (including red meats) or
taking iron supplements under the supervision of a physician.
Importantly, female athletes should have regular annual
screening for iron status that includes hemoglobin, hematocrit,
and ferritin. The goal of the screening is to intervene prior to the
development of a frank iron deficiency anemia, which can have
profoundly negative effects on health and performance (1).

Exercise-Induced Asthma
Oxygen delivery to working tissues is critically important for
athlete performance, so any condition that compromises
breathing and limits the oxygen that can be brought into the
body is an important consideration. An area of particular interest
for athletes is EIA, which affects a significant proportion of the
athlete population (19, 20). EIA is an airway obstruction that
occurs as a result of exercise (either during or after) and may
occur in people who do not suffer from chronic asthma (13). The
prevalence of EIA in athletes is not fully established, but there
are published reports of a 42.5% prevalence in collegiate
athletes, a 55% prevalence in cross-country skiers, and a 12%
prevalence in basketball players (17, 54, 112). Symptoms may
begin within 5–20 minutes after the initiation of exercise and
include:

Coughing and wheezing

Tight chest with some chest pain
Shortness of breath
Early and severe fatigue

These symptoms are most obvious immediately after

stopping exercise and usually dissipate within an hour.

Causes of Exercise-Induced Asthma

The causes of asthma-related chronic lung inflammation are not
well established, but there appears to be a genetic component,
suggesting that some people are born with a predisposition to
having asthma. A trigger is required to cause asthma, and in EIA
the trigger appears to be a large volume of cold and dry air that
is moved into lungs (13). EIA may also be associated with
“mouth breathing” when exercising in cold and dry
environments, and the chlorine in pools may also serve as a
trigger for EIA. Because of this, sports requiring continuous
activity with faster breathing, particularly in cold weather, are
most likely to induce EIA (19, 20). The sports commonly
associated with EIA include:

Long-distance running
Soccer
Hockey
Cross-country skiing
Downhill skiing
Hiking
Swimming
Figure skating

Studies suggest that the highest population prevalence of EIA

appears to be in skiers (55%), competitive figure skaters (30%–
55%), swimmers (48%), cross-country skiers (50%), and
Canadian professional football players (56%) (54, 43, 61, 82, 94,
113).

Recommended Treatment for Exercise-Induced Asthma

Recommended nonpharmacologic treatment for EIA includes the
following (13, 40, 53):

1. Understand that EIA is a chronic condition, so knowing the

triggers may help in avoiding a severe EIA response.
2. Become well conditioned for the activity that induces EIA.
Athletes who are well-conditioned and acclimated to the
environment can exercise at lower breathing rates at any
given work intensity and, therefore, are less likely to suffer
from EIA.
3. If possible, avoid exercising in cold and dry air. If the sport
mandates exercising outside in these conditions (as, for
instance, in cross-country skiing), athletes can try covering
the mouth and nose with a scarf or ski mask to warm and
humidify the breathed air.
 4. A warm-up period is important, with the intensity of the
warm-up dependent on how each athlete responds to EIA.
5. A well-planned cool-down period may diminish the severity
of EIA by slowing airway changes.
6. Avoid exercise on days when asthma symptoms from other
conditions, such as hay fever or food allergies, are present.

It is possible for athletes to use drugs to treat EIA during a

sanctioned competition, but they must first obtain permission to
do so from the World Anti-Doping Association (WADA,
https://www.wada-ama.org) for internationally sanctioned
events, or the International Olympic Committee (IOC,
https://www.olympic.org/fight-against-doping) Medical
Commission for Olympic games. In general, athletes must meet
specific criteria that are established as the result of standardized
exercise challenge tests from certified laboratories to be given
permission to use drugs for the control of EIA (20). Because the
drugs used for asthma are constantly being developed and are
changing, athletes and physicians must be aware of the current
regulations published by WADA and the IOC. The regulations for
treating EIA with drugs may change, so the athlete and those
involved in treating the athlete should stay abreast of the current
regulations through referring to the WADA and IOC Web sites.
Athletes taking drugs to resolve asthma symptoms who have not
followed the proper certification procedures may be sanctioned
for doping and removed from competition.

Oxidative Stress

Cells are constantly manufacturing free radicals, which are

molecules with one or more unpaired electrons, and nonradical
derivatives of oxygen, such as hydrogen peroxide, as part of
normal metabolic processes. These free radicals and the
nonradical derivatives of oxygen are referred to as ROS, which
can increase dramatically with higher energy metabolism
associated with exercise (90). Oxidative stress occurs when
the production of ROS exceeds the body tissue capacity to
neutralize them (62, 70). ROS cause damage to cells because
their radical movement inside cells destroys them, producing
“clinkers” (dead cells). The major ROS in humans include
superoxide and nitric oxide. Both are highly reactive and can
initiate reactions to form other ROS. Superoxide rapidly forms
hydrogen peroxide, which is responsible for most hydrogen
peroxide in cells, and superoxide and nitric oxide both also
rapidly form other ROS (80).

Oxidative Stress

A system imbalance between ROS and the tissue ability to

minimize the tissue-damaging effects of ROS. A balance of
antioxidants is an important strategy for reducing oxidative
stress.

The body inhibits ROS production through antioxidant

vitamins and minerals (see Box 9.2). The minerals work to
regulate enzyme activity so as to diminish ROS production,
whereas vitamins accept ROS to remove them from the cellular
environment, thereby limiting their potential hazards inside the
cell. Early studies of vitamin E, a fat-soluble antioxidant vitamin
found mainly in vegetable oils, initially showed promise in
reducing ROS (98). However, athletes should be cautious about
thinking that a greater than normal amount of a vitamin is better
than normal amount in diminishing the effects of ROS. There has
been a recent concern that vitamin E and vitamin C
supplementation, by itself, may place the pool of antioxidants
out of balance, thereby diminishing the overall defenses humans
have to prevent ROS (71). A reasonable strategy is to avoid this
imbalance by regularly consuming foods that contain a variety of
antioxidants rather than taking a single antioxidant vitamin
supplement. In doing so, the sensitive balance between the
antioxidants can remain intact while increasing the antioxidant
presence to provide an improved defense against ROS (Table
9.2).
 Antioxidant

Common nutrient antioxidants include β-carotene, vitamin C,

vitamin E, and selenium. Antioxidant phytochemicals showing
preventive and/or therapeutic effects in humans include
lycopene, allicin, flavonols, curcumin, resveratrol, flavonoids,
and quercetin (118). Other endogenous antioxidants present in
tissues include glutathione (GSH) and superoxide dismutase
(SOD). They function to inhibit the damaging oxidation of ROS.

Box 9.2 Iron-Associated Terminology

Ferritin

Ferritin is an iron-storage protein found in the liver, spleen, and

bone marrow, with only a small amount in the blood. The
amount in the blood is thought to be proportionate to the
amount stored in the liver, spleen, and bone marrow, so a
blood ferritin test is an indicator of the amount of stored iron.
The lower the ferritin level, even within the “normal” range,
the more likely a client is iron deficient.

Normal ferritin values:

Adult males: Min: >10–35 ng/mL; up to 300 ng/mL
Adult females: Min: >10–35 ng/mL; up to 120 ng/mL

Note: ng/mL = nanograms per milliliter

Hematocrit

Hematocrit is the proportion of whole blood that is composed

of RBCs and is often referred to as the number of RBCs per unit
of blood.

Normal hematocrit values:

Adult males: 42%–52%
 Adult females: 36%–48%

Hemochromatosis

Hemochromatosis is an iron overload disease caused by

uninhibited iron absorption. It can result in liver damage if the
iron concentration is not lowered.

Hemoglobin

Hemoglobin is the iron-containing, oxygen-carrying protein in

RBCs.

Normal hemoglobin values:

Adult males: 13.8–17.2 g/dL
Adult females: 12.1–15.1 g/dL

Note: Initial exposure to higher altitude results in a lowering of

plasma volume with a related increase in hemoglobin
concentration. Remaining at higher altitude results in a gradual
increase in both hemoglobin and blood volume that results in
greater oxygen-carrying capacity (103). It is important to have
sufficient iron stores (ferritin) for these adaptive changes to
occur. See Table 9.1 for altitude-associated adjustments to
measured hemoglobin concentrations.

Hemosiderosis

Hemosiderosis is a disease condition that results from excess

iron in the body, often from blood transfusions. It is often seen
in individuals with thalassemia.

Serum Iron

Serum iron represents the total amount of iron in the blood

serum.

Normal serum iron values:

 Adult males: 75–175 mcg/dL
Adult females: 65–165 mcg/dL

Total Iron Binding Capacity

The total iron binding capacity (TIBC) test measures the

amount of iron the blood could carry if transferrin were fully
saturated with iron molecules. Because transferrin is produced
by the liver, the TIBC can be used to monitor liver function and
protein status nutrition.

Transferrin

The transferrin test is a direct measurement of the protein

transferrin (also called siderophilin) in the blood. The
saturation level of transferrin can be calculated by dividing the
serum iron level by TIBC.

Normal transferrin values:

Adult males: 200–400 mg/dL
Adult females: 200–400 mg/dL

Note: Normal transferrin saturation values are between 30%

and 40%.

REDOX reactions include reactions involving the transfer of

electrons between different chemicals. The chemical from which
the electron is stripped is oxidized, whereas the chemical to
which the electron is added is reduced. An easy way to
remember REDOX is the term OIL RIG, where Oxidation Is Loss of
electrons; Reduction Is Gain of electrons. REDOX reactions are
important to many life functions, including photosynthesis and
respiration (87) (Figure 9.5).
The relative balance between the volume of oxidants and the
volume of antioxidants is the determinant of REDOX balance. A
higher level of oxidants relative to antioxidants leads to oxidative
stress. However, it is important to consider that an
overabundance of antioxidants relative to oxidants also results in
cellular stress. A balance between the two is key to sustaining
muscle function and reducing muscle soreness. Because ROS
production is likely to occur as a result of exercise, cellular
antioxidant defenses are produced to inhibit ROS overproduction,
which occur mainly inside cell mitochondria and cytosol (39).
These cellular antioxidant defenses are produced by tissues, but
they may also be provided through the diet. Together, these
dietary and cellular defenses work to suppress excess ROS.
Small amounts of the free radical superoxide are produced
during the formation of ATP, resulting in some ROS (56). Because
there is a significant increase in the metabolic rate of exercising
humans, it is expected that ROS would rise proportionately to
the increase in energy metabolism and the formation of ATP.
Interestingly, the exercise-associated rise in ROS production
appears related to exercise intensity but not to total energy
expenditure associated with exercise, suggesting that the
mitochondria may not be the only important source of ROS (4). It
was found that markers of oxidative damage were highest
following maximal intensity activity, and lower intensity activity
had lower oxidative damage markers (83).
Nutrient imbalances can also cause difficulties with immune
function. Excess vitamin E negatively affects the immune
system, but inadequate levels of this vitamin, iron, selenium,
zinc, calcium, and magnesium can also create immune
deficiencies (16, 55, 59, 69). All this information points to the
importance of maintaining a balance of all the nutrients rather
than consuming high levels of one or two with the hope of
inducing a desirable cellular protective effect.

Table The Antioxidant Nutrients

9.2
Nutrient Recommended Recommended Functions
Intake for Men Intake for
Women
Table The Antioxidant Nutrients
9.2
Nutrient Recommended Recommended Functions
Intake for Men Intake for
Women
Vitamin C 90 mg/d 75 mg/d Vitamin C
scavenges reactive
oxidants in
leukocytes and in
lung and gastric
mucosa, and it
reduces lipid
peroxidation in
cells.
Vitamin E 15 mg/d 15 mg/d Vitamin E mainly
prevents the
peroxidation of
lipids.
Selenium 55 mcg/d 55 mcg/d Selenium functions
through
selenoproteins,
which form oxidant
defense enzymes.
The dietary
reference intake is
based on the
amount needed to
synthesize
selenoprotein
glutathione
peroxidase.
 Table The Antioxidant Nutrients
9.2
Nutrient Recommended Recommended Functions
Intake for Men Intake for
Women
β- (900 mcg/d) (700 mcg/d) 12 mcg of β-
Carotenea carotene can form 1
mcg of retinol
(vitamin A). The
human nutrient
requirement is for
vitamin A, not β-
carotene. However,
β-carotene is more
than just a
precursor to the
production of
vitamin A. Besides
being an important
biomarker for the
intake of fresh fruits
and vegetables, it
also has important
antioxidant
properties.
a
Represents the generally recommended intake level, but is not the recommended
dietary allowance.

It is important to consider that oxidative metabolic processes

are constantly working, even during events that are primarily
anaerobic. The anaerobic athlete who just completed a 10-
second high-intensity sprint has something in common with a
gymnast who just completed a 90-second floor routine: the need
to breathe a large volume of air (oxygen) to recharge the fuels
they will need for the next bout of high-intensity exercise (107).
Iron is a primary element for transporting oxygen to working
tissues and carbon dioxide away from working tissues, making it
a critically important nutrient for athletes. Despite this, iron is
the most common nutrient deficiency, and athletes may be at
even greater risk for iron deficiency than the general public
because of multiple reasons, including foot-strike hemolysis,
intravascular hemolysis, and increased iron loss in sweat, urine,
and feces (103).

Reactive Oxygen Species in Cells

Enzyme Antioxidants
Enzymes within skeletal muscles contain antioxidants, including
the following:

SOD: Converts superoxide (a highly reactive ROS) to the less

reactive ROS, hydrogen peroxide. Mitochondria contain
manganese-containing SOD, whereas the cell cytosol
contains a copper- and zinc-containing SOD.
Catalase (CAT): Once ROS are converted to hydrogen
peroxide, CAT works to further neutralize hydrogen peroxide
to water.
Glutathione peroxidase: Works with CAT to help neutralize
hydrogen peroxide to water.

See Table 9.3 for a more comprehensive list of antioxidant

defenses both inside and outside cells.

Table 9.3 Internal and

External Cellular
Antioxidant
Defenses Against
ROS
Antioxidant Form Type Location
Enzymatic
Superoxide dismutase (SOD) I A C, E, M
Glutathione peroxidase (GPx) I A C, M
Catalase (CAT) I A C, M
Table 9.3 Internal and
External Cellular
Antioxidant
Defenses Against
ROS
Antioxidant Form Type Location
Nonenzymatic (nutrient) antioxidants
Glutathione (GSH) I A C
Food sources include asparagus,
potatoes, carrots, onion, bell peppers,
broccoli, avocados, tomatoes, grapefruit,
apples, oranges, peaches, bananas, and
melon
Vitamin E D L C, E
Food sources include almonds, spinach,
sweet potato, avocado, sunflower seeds,
butternut squash, and vegetable oils
Vitamin C D A C, E
Food sources include citrus fruits and
other fresh fruits and vegetables
Carotenoids (β-carotene, etc.) D L C, E
Food sources include red, orange, green,
and yellow foods, including tomatoes,
carrots, apricots, spinach, and kale
Uric acid I A C, E
Food sources include sources of purines,
which are converted to uric acid,
including organ meats, meats, fish,
shellfish, and beer
Flavonoids D A, L C, E, M
Food sources include tea, citrus fruit,
berries, red wine, apples, and legumes
Ubiquinones D, I L C, M
Food sources include pork heart and liver,
beef heart and liver, chicken heart and
liver, and red meat
 Table 9.3 Internal and
External Cellular
Antioxidant
Defenses Against
ROS
Antioxidant Form Type Location
`-Lipoic acid I A C, E
Food sources include spinach, broccoli,
yams, potatoes, yeast, tomatoes, Brussels
sprouts, carrots, beets, rice bran, and red
meat

Key: I = Manufactured internally; D = Dietary; A = Aqueous (water based); L = Lipid

(lipid based); C = Cellular (inside the cell); E = Extracellular (outside the cell); M =
Mitochondrial (inside the mitochondria).
Source: Quindry JC, Kavazis AN, Powers SK. Exercise-induced oxidative stress: are
supplemental antioxidants warranted? In: Maughan R, editor Sports Nutrition. Vol. XIX
Encyclopedia of Sports Medicine. London: International Olympic Committee, John Wiley
& Sons Ltd.; 2014. p. 263–76.

Nonenzyme Antioxidants (Nutrients)

There are a number of nutrients that function as antioxidants,
both in the lipid membrane of cells and in the water-based
cytosol of cells. These include GSH, uric acid, vitamin C (ascorbic
acid), vitamin E (α-tocopherol), ubiquinone (coenzyme Q10),
carotenoids (β-carotene), and flavonoids.

Glutathione
GSH is found in the water-based interior of cells with the capacity
to neutralize several ROS. Once used to scavenge ROS, the GSH
is recycled by GSH reductase to renew its capacity to continue
neutralizing ROS. Additional recycling occurs when it comes in
contact with the nutrient antioxidants vitamins C and E. It is this
capacity to scavenge ROS and interact with other antioxidants in
both lipid- and water-based environments to sustain its
scavenging capacity that makes GSH a highly valuable
antioxidant. The anti-inflammatory action of GSH, through its
neutralizing of inflammatory ROS, may also cause it to serve as
an anticarcinogenic substance (46). Fruits and vegetables have
been found to contribute over 50% of the typical dietary GSH
consumption (48). Supplemental consumption of GSH is not
likely to be successful, as it is digested in the small intestine and
fails to become absorbed as an intact molecule. It has been
found, however, that consumption of N-acetylcysteine (NAC),
which also functions as an antioxidant, enables GSH resynthesis
(91). Nonhuman studies found that providing moderate doses of
NAC improved muscle function. However, supplemental NAC
consumption in humans results in severe GI effects that make it
impossible to use as a supplement to derive an ergogenic benefit
(89).

Uric Acid
Uric acid functions as an antioxidant in the blood and in cells
(67). A deficiency of the mineral, molybdenum, which is found
predominantly in grains and nuts, may inhibit uric acid
production and result in higher disease risks (60). Exercise
elevates ROS, which may result in higher uric acid as an
adaptation to greater antioxidant requirements. However, some
attribute the uric acid increase as a result of increased
metabolism of a major uric acid precursor, dietary purines.
Lowering plasma uric acid using pharmacologic agents does not
appear, however, to increase markers of oxidative damage (63).
A chronic elevation of uric acid is associated with gout and
associated joint pain, making uric acid a poor choice for
supplementation with the aim of lowering oxidative stress.
Vitamin C, an antioxidant vitamin, has been found to suppress
excess plasma uric acid, demonstrating once again that
nutrients work together to create a state of cellular/physiologic
balance (115).

Vitamin C (Ascorbic Acid)

Vitamin C, a water-soluble vitamin, is an effective antioxidant
scavenger of ROS. A useful function of vitamin C is to acquire
ROS from both water- and lipid-soluble antioxidants. These ROS
“handoffs” to vitamin C enable the water- and lipid-soluble
antioxidants to retain their function and scavenge more ROS
(119). However, there should be some caution to providing high
supplemental doses of vitamin C because when iron and copper
are present, vitamin C functions as a pro-oxidant rather than as
an antioxidant, resulting in a higher rate of lipid oxidative
damage (84). Once again, more than enough is not better than
enough for producing the desired physiologic outcomes.

Vitamin E (α-Tocopherol)
Vitamin E and related compounds (other tocopherols and
tocotrienols) are found in the lipid membranes of cells. Vitamin E
is an effective antioxidant that can scavenge and neutralize
several ROS forms; it is recycled by transferring the scavenged
ROS to water-borne antioxidants such as vitamin C (76, 104).
Vitamin E is the most abundant lipid-based antioxidant in the
human skin and is present in all underlying layers of skin (102).
Despite its multiple forms (α-, β-, γ-tocopherol, etc.), only α-
tocopherol can reverse a deficiency (105). Although it is a potent
antioxidant, athletes should be cautious about taking
supplemental doses of vitamin E for the purpose of reducing
oxidative damage. A comparison of athletes receiving 800 IU
vitamin E daily for 2 months with athletes receiving a placebo
prior to competing in the Kona triathlon world championship
found that those taking the vitamin E had greater lipid
peroxidation and inflammation, as determined by plasma levels
of IL-6, IL-1ra, and IL-8, during exercise (69).

Ubiquinone (Coenzyme Q10)

Ubiquinone is a fat-soluble compound that is synthesized by the
body but can also be derived from the diet, mainly from soybean
oil, meats, fish, nuts, wheat germ, and some vegetables (25).
Although a limited amount of Q10 appears in the plasma, most
Q10 is found in mitochondria, where it is involved in
mitochondrial ATP synthesis and also functions as an antioxidant.
Because it is mainly found in the mitochondria and therefore is
related to energy metabolism, it is thought that assuring good
Q10 status may reduce the oxidative stress and muscle damage
associated with heavy exercise. However, in a test of
marathoners, it was found that providing excess Q10 reduced
neither oxidative stress nor muscle damage (50). A study
assessing the combined effects of zinc and Q10 on soccer
players found that this antioxidant combination was effective in
enhancing the metabolism of thyroid hormone, which is an
energy metabolic regulating hormone (77).

Carotenoids (β-Carotene)
The carotenoids are found in highest concentration in dark
green, orange, and yellow-colored fruits and vegetables, directly
contributing to their color. They are lipid-soluble compounds,
typically found in the membranes of cells, with antioxidant
properties making them capable of scavenging ROS. Because
they are found in lipids, they limit the formation of peroxides.
The most common of the dietary carotenoids are (47):

α-carotene (provitamin A, with 1/24th the activity of vitamin

A). Dietary sources include pumpkin, carrots, winter squash,
tomatoes, chard, collard greens, green beans, and sweet bell
peppers.
β-carotene (provitamin A, with 1/12th the activity of vitamin
A). Dietary sources include sweet potato, carrots, dark green
leafy vegetables, romaine lettuce, butternut squash,
cantaloupe melon, sweet259 red peppers, dried apricots,
peas, and broccoli.
β-cryptoxanthin (provitamin A, with 1/24th the activity of
vitamin A). Dietary sources include sweet red peppers,
pumpkin, butternut squash, paprika (spice), persimmons,
tangerines, papayas, coriander, and carrots.
Lutein (efficient absorber of blue light that helps protect eyes
from light-induced oxidative damage) (52). Dietary sources
include dark leafy greens, salad greens, summer squash,
broccoli, basil, Brussels sprouts, asparagus, green beans,
leeks, and green peas.
Zeaxanthin (efficient absorber of blue light that helps protect
eyes from light-induced oxidative damage) (52). Dietary
sources are the same as for lutein.
Lycopene (powerful anti-inflammatory/antioxidant agent
found in red-colored fruits and vegetables, particularly
tomatoes, that may reduce prostate and other cancer risk)
 (29). Dietary sources include watermelon, tomato, pink
grapefruit, pink guava, papaya, goji berry, rosehip,
asparagus, and red cabbage.

α- and β-carotene and β-cryptoxanthin are all provitamin A

substances, meaning that they can be converted by tissues to
active vitamin A (retinol). Lutein, zeaxanthin, and lycopene
cannot be converted to active vitamin A.

Flavonoids
Flavonoids are found in fruit, vegetables, chocolate, tea, and
wine and have important antioxidant and ROS scavenging
properties that are health promoting. Although these antioxidant
properties are important, their concentrations are 100–1,000
times lower than other antioxidants including vitamin C, uric
acid, and GSH (57). Importantly, flavonoids have a risk reduction
effect on stroke and cardiovascular disease (109, 111). To a large
degree, the benefits derived from the consumption of a diet rich
in fruits and vegetables are from the high concentration of
flavonoids in these foods. The six subclasses of flavonoids
include:

anthocyanidins (found in red, blue, and purple berries; red

and purple grapes, and red wine)
flavan-3-ols (found in black, green and oolong tea, cocoa,
grapes, berries, red wine, and apples)
flavonols (found in onions, scallions, kale, broccoli, apples,
berries, and teas)
flavanons (found in citrus fruit)
flavones (found in parsley, thyme, celery, and hot peppers)
isoflavones (found in soybeans and other legumes)

Measures of Reactive Oxygen Species and Oxidative

Damage
It is now well established that physical activity results in ROS
production that results in oxidative damage and reduced muscle
function. There is also evidence that ROS may result in
premature fatigue (88). Further, higher intensity activities are
associated with even greater levels of oxidative damage (80).
Taken together, the reduced muscle function and premature
fatigue associated with elevated ROS production may have a
negative impact on athletic performance. Oxidative stress occurs
in specific compartments, including the blood plasma, skeletal
muscle, organs, and other tissues. The measure of oxidative
stress is complicated because the right compartment(s) must be
measured at the right times to detect stress markers. For stress
to occur, the antioxidants resident in the measured tissues must
be depleted for the markers of oxidative stress to appear (15).
The oxidative stress associated with exercise is typically
measured through an analysis of metabolites of the ROS
reaction(s) that are stable relative to the ROS that created them.
(ROS are highly unstable.)

DNA oxidation products are measured via free radical

modifications to guanine, which can be measured in tissue
samples, blood plasma, and urine. Because of the instability
of blood and urine samples, direct measurement of muscle
tissues is usually preferred (39). A common molecule
measured is 8-hydroxydeoxyguanosine.
Protein oxidation is measured through the presence of
carbonyl formation, typically through spectrophotometry or
antibody assessment. These assessments can be made from
muscle tissue samples and also from blood plasma samples
(85).
Lipid oxidation biomarkers are assessed through multiple
techniques. Polyunsaturated fatty acids, when affected by
ROS, form malondialdehydes, which is a common target for
assessment of oxidized lipids (34). Other commonly
measured biomarkers of lipid oxidation include lipid
hydroperoxides (LOOH) and F2-isoprostanes. Both biomarkers
are derived from lipids in cellular membranes, but the F2-
isoprostanes are considered the superior measure of lipid
peroxidation (81).
 Finding a Balance Between Muscular
Performance and Antioxidant Intake

It is well established that ROS and their antioxidant

countermeasures influence skeletal muscle function (89). A
failure to have sufficient antioxidants present in tissues and
plasma (i.e., antioxidant deficiencies) to counteract the
potentially damaging effects of ROS will increase tissue damage
and associated muscle soreness. To a large extent, consumption
of antioxidant supplements is thought to be an easy strategy for
ensuring that tissue defense mechanism is satisfactory.
However, there is little evidence to suggest that athletes
experiencing frequent high-intensity activity actually benefit
from consumption of antioxidant supplements, including
vitamins C and E. Moderately low tissue levels of vitamin C and E
do not appear to negatively affect exercise capacity or increase
muscle weakness (84). Although there are laboratory studies
suggesting that providing antioxidants before and during
exercise may blunt ROS-related fatigue, there are also studies
that antioxidant supplementation may be detrimental (14, 90).
Importantly, although consumption of antioxidants may blunt
exercise-induced ROS, they may also blunt cellular antioxidant
defenses, heat shock protein, and mitochondrial biogenesis (37,
92, 100).

Summary

The ability of an athlete to obtain and use oxygen is a major

factor in athletic performance, regardless of athlete age,
gender, or sport.
Iron is the essential element required in transferring oxygen
from the environment and carrying carbon dioxide so it can
be expelled via the lungs. Despite these critically important
functions, iron deficiency is the most common nutrient
deficiency in the general population and in athletes.
Regardless of the cause of iron deficiency, compromised iron
status may have a negative impact on health, mental
performance, and athletic performance (103). It is important,
therefore, that iron status in athletes be regularly monitored,
perhaps yearly, to ensure assessed iron values are within the
normal range and to enable an intervention before frank iron
deficiency anemia occurs.
Such a screening should include measures of functional and
storage iron, including hemoglobin, hematocrit, and ferritin.
Information from such a test will help athletes and those who
work with them understand if the foods consumed provide
sufficient sources of well-absorbed iron and will help drive
dietary changes to help ensure that oxygen uptake is not a
limiting factor in athletic performance.
Surveys have found that normally menstruating female
athletes of childbearing age and vegans are at highest risk of
developing iron deficiency. However, normal athletic
activities can also increase iron deficiency risk through faster
RBC destruction and loss via urine and sweat.
It has been recommended that athletes with iron deficiency
anemia seek clinical help to improve iron intake, including
from oral iron supplements, and reduce activities that
increase iron loss, including a reduction in weight-bearing
activity to lower hemolysis, and cessation of blood donations
(103).
Other nutrients, including vitamins B12 and folate, are also
important in the formation of RBCs, deficiencies of which
may lead to macrocytic anemia and lower oxygen delivery to
tissues.
Regardless of the cause, athletes with blood tests indicating
iron, folate, or B12 deficiency should seek the advice of a
physician and registered dietitian to determine the best
strategy for corrective action.
It is well established that physical activity, particularly if it is
intense and/or of high duration, will place athletes at higher
oxidative stress than nonathletes, suggesting that it is
important to consume foods containing adequate amounts of
the antioxidant vitamins and minerals.
 Athletes should be cautious, however, of overconsuming
these antioxidant nutrients as excess intakes may inhibit
normal antioxidant processes.
Some athletes may suffer from EIA, a condition that limits
oxygen uptake and, therefore, performance. There are drugs
that are useful in ameliorating EIA, but athletes should be
clinically diagnosed as having the condition prior to
consuming these prescribed medications to avoid being
sanctioned.

Practical Application Activity

Take a survey of friends and family and ask them what

supplements they are taking and how often they are taking
them. Also ask what kinds of foods they tend to eat every day.
From this survey do the following:

1. Estimate the antioxidant intake from the supplements.

2. Estimate the antioxidant intake (vitamin C, vitamin E, β-
carotene) from the consumed foods. Use the strategy for
assessing the nutrient content of foods presented in earlier
chapters by accessing the online USDA Food Composition
Database (https://ndb.nal.usda.gov/ndb/search/list).
3. Calculate the percent of the dietary reference intakes
(recommended dietary allowance) being consumed by
those taking supplements and those not taking
supplements, remembering that excessively high intakes
may create problems.

Chapter Questions

1. Of the following nutrients, which is involved in delivering

oxygen to tissues?
a. Thiamin
b. Pyridoxine
c. Iron
 d. Cobalamin
2. Which of the following nutrients have antioxidant properties
that protect cells from oxidation reactions?
a. Iron, vitamin B12, folic acid, and copper
b. β-Carotene, vitamin E, vitamin C, and selenium
c. Vitamin B1, vitamin B2, vitamin B3, and vitamin B6
d. Protein and pantothenic acid
3. An iron-containing protein (hemoglobin) in RBCs both picks up
oxygen of the lungs and releases carbon dioxide to the lungs.
a. True
b. False
4. The air we breathe is ∼ _____________% oxygen.
a. 80
b. 50
c. 20
d. 5
5. High-intensity exercise may increase the muscle oxygen
requirement by ____ times over a state of rest.
a. 5
b. 10
c. 25
d. 50
6. Athletes with EIA have no problem bringing sufficient oxygen
to cells when exercising.
a. True
b. False
7. Transferrin is
a. Storage iron
b. The molecule that transfers consumed iron to make new
RBCs
c. The blood protein that transports iron to form hemoglobin
d. The liver enzyme that oxidizes fatty acids
8. Ceruloplasmin is a _______-containing protein.
a. Copper
b. Manganese
c. Magnesium
d. Molybdenum
9. Dilutional pseudoanemia occurs because
 a. Iron losses are higher in athletes.
b. Blood volume increases faster than red blood cells in
athletes who initiate an intensive exercise program.
c. Vitamin B12 and folic acid are deficient
d. Vitamin E deficiency results in faster red blood cell
breakdown
10. Foot-strike hemolysis describes a faster breakdown of RBCs
because they are “crushed” in the capillaries at the bottom of
the feet in a hard running athlete.
a. True
b. False

Answers to Chapter Questions

1. c
2. b
3. a
4. c
5. c
6. b
7. c
8. a
9. b
10. a

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CHAPTER OBJECTIVES

Understand the major nutritional issues associated with

athletes of different ages and sex.
Discuss the nutritional demands specific to youth and
how these are increased with regular exercise.
List the multiple factors that must occur simultaneously
for bone mineral density (BMD) to achieve a desired
level.
Athletes should understand that the nutritional strategy
for exercise recovery is an important component of the
exercise itself.
Discuss the reasons why maintaining a normal growth
velocity for young athletes is important and the major
nutritional factors that help ensure this occurs.
Describe the available methods and formulae available
for predicting energy expenditure and the formulas that
are population specific.
Understand the risks and benefits of participation in
"appearance/aesthetic" sports.
Determine macronutrient (carbohydrate, protein, and
fat) requirements for athletes of different ages and
genders who are involved in different sports.
Understand the dehydration risks of children and
adolescence as compared with those of adults.
 Differentiate between the types of eating disorders
observed in, particularly, female athletes.
Know the major physiologic changes experienced by
aging and how meeting nutritional needs can minimize
these changes.

Case Study

All his life he was an athlete — a competitive club

swimmer in elementary and junior high school, a
competitive high school team swimmer, a scholarship
swimmer in college, and a university club water polo
swimmer while in graduate school. Then he graduated
from graduate school to go to work, and the swimming
stopped. John was just too busy with other matters —
work, family, young daughter — to continue spending 2–
3 hours, 3–5 days each week in the pool.
But after several years he started having a bit more
time with his daughter in school, his wife working, and
his work requirements less stressful — and of course the
thought of getting back in the pool to race reentered his
mind. With support from his family, he decided to join a
senior-age group swim club involved in regional, state,
and national competitions, and after nearly 10 years he
found himself back in the pool doing laps. The first
moment he dove in the water he realized how very much
he missed it — and he also realized that his body had
changed, with higher body fat and less muscle. But he
knew he would not get back into competitive shape if he
did not push himself.
To his dismay, after the third day back at swimming
practice he could hardly move. Every muscle in his body
was sore to the point of making normal movement
difficult. The pain was severe, and he did not know what
to do. Should he admit that his swimming days were
over or should he persevere and keep at it, as best he
could? He went to bed thinking about his pain and the
decision to make, and then had a dream. He dreamt he
was back in his collegiate pool and he could visualize the
people, the place, the sports beverages, and the food.
Yes, the food. It struck him like a lightning bolt that when
he was competitive, the team had a recovery strategy
that included an almost immediate consumption of
carbohydrate and protein — sometimes a chicken
sandwich and Greek yogurt with fruit — and the coach
would not let them leave the pool area without seeing
them eat the recovery food. The next morning he made
a plan to prepare some recovery food for his late
afternoon/early evening swim, although dinner would
follow with his family about an hour later. After a few
days, he could not believe how much better he felt, and
a couple of months later he made the age-group cutoff
time to compete at regionals. His swimming life had
returned — with a smile.

CASE STUDY DISCUSSION QUESTIONS

Regular exercise coupled with good nutrition helps to
minimize the effects of sarcopenia.

1. What are the typical body changes that occur with

aging?
2. Are males and females similar? If not, what are the
differences?
3. Take each body change and create a strategy of all
the things you would do, in the best of all worlds,
that could minimize each body change.
4. Put the list together and create a weekly nutrition
plan that incorporates all of your strategies.
5. Now modify the plan to make it realistic. (You now
have a road map for what to do to limit age-related
changes!)
 Introduction

No athlete, regardless of age and sex, can perform at an

optimal level without a good nutrition plan. The basics of all
nutrition plans have similar training and competition
strategies, including:

Eat in a way that encourages long-term health, following

general age- and sex-specific population guidelines.
Satisfy energy needs in a way that dynamically supports
the energy requirements of training and competition.
Ensure that optimal energy stores and hydration status
are achieved prior to the initiation of
training/competition.
Follow a hydration strategy that minimizes dehydration
while supporting maintenance of blood sugar and blood
volume.
Use a training recovery strategy that returns the athlete
to a good state of hydration while supporting efficient
muscle synthesis and diminishing muscle soreness.
Use body composition rather than weight as the marker
of whether the nutrition strategy during a training period
is providing the right level of nutrients and energy
training.
Allow sufficient time to become well adapted to any new
nutrition strategy followed during competition by
practicing the strategy during training.

There are additional nutritional considerations for female

athletes and for younger and older athletes, to ensure that
nutrition supports both optimal health and athletic
performance. Female athletes have unique physiologic
requirements related to normal menstrual function that may
be negatively affected by poor nutrient/energy intake. The
female athlete triad, which includes eating disorders,
menstrual dysfunction, and low bone density, particularly
affects a large number of females involved in aesthetic
sports where appearance is an integral part of the subjective
judging system, including gymnastics, figure skating, and
diving. Understanding these risks can help to minimize the
potential that a female athlete will fail to follow a satisfactory
nutrition plan.
Young athletes also have unique risks, particularly related
to simultaneously satisfying the combined energy/nutrient
needs of growth and physical activity (45). Children have
fewer sweat glands that produce less sweat per gland than
adults, and children are also susceptible to voluntary
dehydration (inadequate fluid consumption even when fluids
are available) (144). This combination of lower cooling
capacity coupled with inadequate fluid consumption places
young athletes at high risk for dehydration-related disorders,
which must be a consideration in any nutrition strategy.
There is also concern that young athletes are prone to obtain
nutrition information from other athletes, health food store
personnel, coaches, gym owners, and sports-related
magazines. Often, these sources of information are
unreliable and may be geared to selling nutritional product(s)
that are neither adequately tested nor needed (41).
Older athletes have a different set of concerns,
particularly as they relate to increased heat-stress risk,
normal changes in body composition, and the rate of
recovery from strenuous athletic endeavors. Individuals
working with older athletes should be sensitive to age-
associated changes in energy expenditure and increased risk
of dehydration. There is also evidence that older athletes
may be at risk of inadequate nutrient intakes, particularly of
riboflavin, vitamin B6, vitamin B12, vitamin D, and folate (32,
65). Athletes of different ages and sexes have different
nutritional risks, associated with energy availability, heat
illness, impaired growth and development, menstrual
dysfunction, eating disorders, low bone density, alterations
in body composition, nutrient inadequacy, and injury risk
(113). Although there are general nutrition principles that
should be followed by all athletes, different groups (males,
females, young, and old) have differing physiologic demands
that require modifications of these principles to lower health
risks and to optimize performance. This chapter reviews the
specific nutrition needs of athletes based on age and sex.

THE YOUNG ATHLETE

Youth is a period of accelerated growth, representing a

period of life with high nutrient and energy needs. Physical
activity further increases the need for nutrients and energy,
making nutrition planning an essential component of a
young athlete’s life to encourage both normal growth and
development and also a desired benefit from sport-
associated training. Optimal nutrition coupled with physical
activity during this period of life has the potential for life-long
benefits. However, a poor match between nutrition and
physical activity may result in poor tissue and bone
development that could increase chronic disease risk later in
life. An insufficient energy supply may result in a failure to
achieve genetically prescribed growth potential, and
inadequate nutrient intake may result in poor development
of organ systems. As an example, insufficient calcium
consumption during the adolescent growth spurt results in
low BMD, with risk of early-onset osteoporosis (a condition of
low BMD that places the individual at fracture risk). It has
been estimated that 25% of total bone mass is acquired
during the adolescent years (143). Although the stimulation
imposed on the skeleton through physical activity is
important for bone development, adequate exposure to
calcium, vitamin D, protein, and energy is also critically
important during this period of growth. Encouraging young
people to be physically active is precisely what is needed for
lowering chronic disease risk, but lower risk can only occur
with adequate nutrition.
Young athletes should be regularly assessed to ensure the
maintenance of a healthy state and normal growth velocity.
The growth spurt in girls begins around the age of 10 or 11
and reaches its peak by age 12, with a cessation of growth at
age 15 or 16. In boys, the adolescent growth spurt begins at
age 12 or 13 and reaches its peak by age 14, with a
cessation of growth by the age of 19. It should be noted that
excess physical activity (i.e., a level of activity that the
individual is not sufficiently accustomed to) that fails to allow
for sufficient rest and nutrient intake may result in overuse
injuries, including tendinitis, Osgood–Schlatter disease, and
stress fractures (8). In adolescent female athletes, secondary
amenorrhea (i.e., the cessation of normal menses in
someone who has experienced menses) may occur during
periods of intense training as a result of insufficient energy
intake. Amenorrhea is associated with low estrogen
production, which is associated with greater risk of stress
fractures (5). A stress fracture can occur at any age with
repeated mechanical loading on a bone with a BMD that is
too low to handle the repeated stress placed on it. Stress
fractures are most likely to be observed in the following
situations (Figure 10.1) (8, 23):

When an athlete increases activity intensity too quickly

to allow bone density to adapt.
When the playing/running surface that the athlete has
become accustomed to changes, causing greater
skeletal stress.
When an athlete wears shoes that fail to properly
cushion and protect the skeleton from the stress of a
specific activity.
FIGURE 10.1: What is a stress fracture? (From Anderson
MW, Greenspan A. Stress fractures. Radiology. 1996;199:1–
12; Bennell KL, Malcolm SA, Wark JD, Brukner PD. Models for
the pathogenesis of stress fractures in athletes. Br J Sports
Med. 1996;30:200–4; Staheli LT. Fundamentals of Pediatric
Orthopedics. 5th ed. Philadelphia (PA): LWW (PE); 2015.)
 As a strategy for avoiding overtraining of specific muscles
or skeletal area, it has been recommended that young
children participate in a variety of sports, with sport
specialization only occurring after puberty (5, 27). This
strategy helps young athletes perform better, lower injury
risk, and maintain participation in the sport for a longer
period of time than those who solely participate in a single
sport too early (5).

Bone Mineral Density

Cross-sectional area of bone (g/cm2) and the commonly

used measure for determining adequacy of bone strength.
Major factors that can affect BMD include race, gender,
diet, size, activity amount, activity type, energy
availability, cortisol, and estrogen.

Energy Needs

Consuming sufficient energy is necessary to satisfy the

combined needs of growth and development and the
demands of training and competition (45). There is difficulty
satisfying the nutritional needs during periods of growth
because there is a high level of nutritional variability in
children of the same age due to sex, size (weight, height),
pubertal maturation, genetic history, and growth velocity
(113, 141). The risk of inadequate energy intake appears to
be particularly high in young athletes involved in sports that
expend high levels of energy, such as the modern
pentathlon, but is also often found to be inadequate in team
sports such as soccer (42, 59). To further complicate our
understanding of the requirement, the methods available for
estimating energy needs in young athletes also have
limitations because of their high variability, made worse by
the fact that young athletes often report energy
consumption patterns that are well below those
recommended by predictive equations (2, 62). Importantly,
the energy needs associated with physical activity induce a
higher energy requirement than the energy requirements
associated with growth (141). For example, it takes only ∼2
kcal/g (or 8.6 kJ/g) of energy for daily weight gain. For a
young male athlete, age 15, who is gaining about 13 lb/year
(or 6 kg/year), this amounts to an additional growth-related
energy requirement of approximately only 33 kcal/day
(or 140 kJ/day) (45). Despite this seemingly low requirement
for growth, the added requirement of physical activity may
place the young athlete in a state of energy intake
inadequacy, resulting in compromised growth and
development.
One method for considering whether a young athlete has
sufficient energy consumption is to use the concept of
energy availability, which involves asking whether there is
sufficient energy available for the activity (87).

Energy Availability

A concept related to having sufficient energy available for

physical activity, plus sufficient energy needed to fulfill
normal physiologic functions related to growth, the
immune system, bone development, muscle development,
and muscle repair.

When addressing how much energy is available for the

tasks that are done, consider the following equation:
[Calculated as: kcal/kg of lean body mass/day]
Failure to supply sufficient energy increases the risk of
compromised growth and health, including delayed
puberty, menstrual dysfunction, low BMD, failure to achieve
predicted height, higher injury risk, and higher risk of
developing an eating disorder (19, 103). Measuring total
daily energy expenditure is complex, involving assessment
of multiple components with a number of possible strategies
for obtaining measures (Figure 10.2).

FIGURE 10.2: Prediction of total daily energy expenditure.

(From Plowman SA, Smith DL. Exercise Physiology for Health,
Fitness, and Performance. 3rd ed. Philadelphia (PA): LWW
(PE); 2010.)

Total Daily Energy Expenditure

Total (daily) energy expenditure (TEE) includes the
following components:

Resting energy expenditure (REE): This represents the

greatest proportion of energy expended and is either
basal metabolic rate (BMR), which is the energy
expended by an individual who is at rest and fasting, or
the more liberal definition called resting metabolic rate,
which produces a slightly higher value as the measure is
taken when the person may not be in a fasting state or in
a complete state of rest. There are common prediction
equations for estimating REE, if it cannot be measured
via doubly labeled water (DLW) or indirect calorimetry
(Box 10.1).

Box 10.1 Equations for Predicting BMR

Harris Benedict Equationsa

BMR calculation for men (metric)

BMR = 66.47 + (13.75 × weight in kg) + (5.003 × height
in cm) − (6.755 × age in yr)
BMR calculation for women (metric)
BMR = 655.1 + (9.563 × weight in kg) + (1.850 × height
in cm) − (4.676 × age in yr)

Schofield Equationsb

Age (yr): 10–17

Males: BMR = 17.686 × (wt kg) + 658.2

SEE = 105
Females: BMR = 13.384 × (wt kg) + 692.6
SEE = 111

Age (yr):18–29
 Males: BMR = 15.057 × (wt kg) + 692.2
SEE = 153
Females: BMR = 14.818 × (wt kg) + 486.6
SEE = 119

Age (years): 30–59

Males: BMR = 11.472 × (wt kg) + 873.1

SEE = 167
Females: BMR = 8.126 × (wt kg) + 845.6
SEE = 111

Age (yr): ≥60

Males: BMR =11.711 × (wt kg) + 587.7

SEE = 164
Females: BMR = 9.082 × (wt kg) + 658.5
SEE: 108
a
Source: Harris JA, Benedict FG. A biometric study of human basal metabolism.
Proc Natl Acad Sci USA. 1918;4(12):370–3.
b
Source: Schofield WN. Predicting basal metabolic rate, new standards and
review of previous work. Hum Nutr Clin Nutr. 1985:39(Suppl 1):5–41.
SEE, Standard error of estimation.

Thermic effect of food (TEF): This represents the

energy required to obtain and metabolize the
energy in consumed food. TEF accounts for 5%–
10% of the total energy consumed, with some
foods having a higher TEF than other foods:
Carbohydrates: 5%–15% of total energy consumed
Proteins: 20%–35% of total energy consumed
Fats: 5%–15% of total energy consumed
Note: The TEF is also referred to as specific dynamic action
and/or thermogenesis.
Activity energy expenditure (AEE): This represents a
combination of exercise and nonexercise energy
expenditure. There are multiple methods available for
predicting AEE (63):
Indirect calorimetry: Equipment measures inspired
and expired air (i.e., oxygen in and carbon dioxide
out), providing an excellent prediction of energy
expended. The ratio of oxygen in and carbon dioxide
out, referred to as the respiratory quotient, also
provides a good prediction of all components of
energy substrate utilization (i.e., of the calories
burned, what proportion are from carbohydrate,
protein, or fat). Indirect calorimetry equipment is
also referred to as a metabolic cart (Figure 10.3).

FIGURE 10.3: Subject having resting energy

expenditure measured using indirect calorimetry. A
commonly used and relatively accurate measure of
energy expenditure at rest and during activity.
Device measures oxygen consumed and carbon
dioxide expended.

DLW: Considered the gold standard, this is capable of

assessing all components of energy expenditure.
This technique uses isotope tracers to label both the
hydrogen and oxygen in water (hence the name
"DLW"). By measuring the oxygen tracer (18O)
expended in carbon dioxide, it is possible to
accurately predict energy expended.
Heart rate monitoring: Heart rate is linearly
associated with energy expenditure, so a measure of
heart rate provides a prediction of calories burned. A
number of wearable activity monitors can predict
energy expenditure using heart rate.
Accelerometry: Accelerometers measure movement
and thus provide a prediction of energy expenditure.
Accelerometry has prediction weaknesses, causing
researchers to recommend caution when using
accelerometers for predicting energy expended (70,
136).
Global positioning system (GPS): The GPSs have the
capacity to monitor movement and speed of
movement to predict energy expenditure. Typically,
newer GPSs are used in conjunction with
accelerometers and heart rate monitors to improve
energy expenditure prediction (131).
Pedometry: Although providing a reasonably
accurate measure of movement, pedometers fail to
provide an accurate means of predicting energy
expended across all activity modes. Therefore, they
should be used with caution when estimating energy
expended (106).
Questionnaires: There are many types of
questionnaires available that attempt to predict
energy expenditure through a description of activity
 intensity that is based on a MET-value scale (i.e.,
multiples of REE). The Ainsworth compendium lists
activity codes and associated energy expenditures
(Box 10.2) (3).

Delayed Puberty

Puberty is the period of time when a body grows and

develops from that of a child to an adult, including
maturation of the sex organ, facial hair in males, and
conversion of some testosterone to estradiol for the
development of the uterus in females. A delay in this
biologic clock, often from insufficient energy intake, may
have lifelong implications for organ, skeleton, and linear
growth development.

Total Energy Expenditure

Represents the combined energy requirements for rest,

activity, TEF, and development (if growing, pregnant, or
lactating).

Activity Energy Expenditure

Represents the energy needed to satisfy the energy needs

for physical activity. This is typically calculated as a
multiple of the energy required at rest. Example: If
someone requires 50 calories/hour at rest, and this person
exercises at an intensity of double that at rest (i.e.,
walking), the hourly requirement for that hour would be
100 calories. If that person was working at an intensity five
times that at rest (i.e., running quickly), the hourly
requirement for that hour would be 200 calories.

Thermic Effect of Food

Represents the energy needed to obtain energy from
consumed foods. Some foods require more energy
investment to derive energy (e.g., protein) than other
foods (e.g., carbohydrate). The average for all foods is
∼10% of the total energy derived from foods.

Box 10.2 Approximate Energy Expenditure for

Various Activities in Relation to Resting Needs for
Males and Females of Average Size

Activity category representative value for activity factor

per unit time of activity

Resting, Sleeping, Reclining: REE × 1.0

Very light: REE × 1.5

Seated and standing activities, painting trades, driving,
laboratory work, typing, sewing, ironing, cooking,
playing cards, and playing a musical instrument.
Light: REE × 2.5
Walking on a level surface at 2.5–3 mph, garage work,
electrical trades, carpentry, restaurant trades, house-
cleaning, child care, golf, sailing, and table tennis.
Moderate: REE × 5.0
Walking at 3.5–4 mph, weeding and hoeing, carrying a
load, cycling, skiing, tennis, and dancing.
Heavy: REE × 7.0
Walking with load uphill, tree felling, heavy manual
digging, basketball, climbing, football, and soccer.
When reported as multiples of basal needs, the expenditures of males and
females are similar.
Source: Institute of Medicine, Food and Nutrition Board. Recommended Dietary
Allowances. 10th ed. Subcommittee on the Tenth Edition of the RDAs, Food and
Nutrition Board, Commission on Life Sciences, National Research Council.
Washington (DC): National Academy Press; 1989. Based on values reported by
Durnin and Passmore (1967) and WHO (1985).
 TEF and REE can be predicted from indirect calorimetry,
whereas TEE can be predicted from DLW (Box 10.3).

Box 10.3 Step-by-Step Strategy for Estimating

24-h Energy Balance in the Young Athlete

Energy Requirement Prediction

Step 1. Predict REE using the age/sex appropriate

Schofield equation.
Step 2. Calculate the hourly value obtained in step 1, by
dividing the REE by 24.
Step 3. Using the obtained REE value, calculate the
number of hours spent at different energy
expenditures using the information in Table 10.1.
Example. Sleeping for 7 h = 1 × REE × 1; exercising at
a light level for 2 h = 2.5 × REE × 2; etc.
Step 4. Sum the values in step 2 for 24-h energy
expenditure
Step 5. Multiply the value in step 3 by 1.10 to calculate
the energy expenditure +10% for the TEF (i.e., the
calories required to obtain the energy from the energy
consumed). This is the value of the total predicted
energy required.

Energy Intake Prediction

Step 1. Write down all the foods/beverages consumed

(amounts, preparation, etc.) during the 24-h period.
Step 2. Using a computerized table of food composition,
find the energy (caloric) content of each food/beverage
consumed.
Step 3. Sum the values obtained in Step 2.
Calculating Energy Balance

Step 1. Divide predicted energy consumed by predicted

energy required to obtain energy balance. Example:

Predicted energy consumed = 2,000 kcal

Predicted energy required = 2,500 kcal
2,000/2,500 = 0.80 (the amount consumed is 80% of the
predicted requirements, indicating that the person is in a
negative energy balance).

Table 10.1 Internal and External

Factors That Can
Influence BMD
Internal Factors External Factors
Table 10.1 Internal and External
Factors That Can
Influence BMD
Internal Factors External Factors
Sex/race: Women typically Diet: Adequate level of
have lower BMD than men. vitamin D, calcium, and
However, multiple factors energy is associated with
can influence within-sex higher BMD, whereas an
BMD. inadequate level of any of
these three is associated
Women with menstrual with lower BMD. Other
irregularity have lower dietary factors may also
BMD than women with influence BMD:
regular menses.
(Estrogen is lower with High dietary fiber (>30
irregular menses, and g/d) may lower calcium
estrogen inhibits the absorption; high caffeine
activity of osteoclasts, intake is associated with
the cells that break down high urinary calcium loss;
bone.) High alcohol
Population studies consumption alters
suggest that African- nutrient absorption and
American and Hispanic metabolism and is
women have higher BMD associated with lower
than White and Asian BMD.
women.
Table 10.1 Internal and External
Factors That Can
Influence BMD
Internal Factors External Factors
Age: After peak BMD is Weight: Higher weight is
reached at around the age of associated with higher BMD
20, BMD is typically stable because of the skeletal
with only moderate adaptation associated with
reductions in BMD until the increased loading.
age of 50.
However, obesity is
After age 50, BMD associated with higher
decreases more rapidly weight but less physical
for both sexes. activity/movement,
Women experience a which can result in a
faster decline on BMD decline in BMD.
following menopause.
Table 10.1 Internal and External
Factors That Can
Influence BMD
Internal Factors External Factors
Size: Lower size results in Activity: Mechanical loading
less stress on bone, with less on bones is important to
adaptive need to increase derive the adaptive increase
BMD. in BMD. (Wolff’s law of
osteology: “Use it or lose it.”)
With the right
nutrient/energy When the loading occurs,
availability, bones there is significant
respond to increased skeletal development
loading stress from (youth), bones can
weight or activity with achieve a significantly
higher BMD. higher BMD that makes
the individual more
resistant to developing
low BMD later in life.
However, physical
activity during youth that
is associated with
energy, calcium, or
vitamin D deficiency fails
to adequately increase
BMD, placing the
individual at higher risk
of osteoporosis later in
life.

BMD, bone mineral density.

Using these methods to predict energy intakes and

expenditures is complex, and given the individual variability
in methods and individual growth rates, excess reliance on
these methods as the sole determinant of whether a young
athlete is receiving sufficient energy/nutrients is not advised.
There are no commonly available energy expenditure
devices/methods/predictive equations that provide
sufficiently accurate results to confidently determine
whether the nutrients/energy consumed are sufficient to
result in desired growth and development. These
methods/devices should be considered guides and estimates
and, because of the potential inaccuracies, normal indicators
of growth and development should be used. In children, the
traditional method for assessing the adequacy of energy
consumption is through a longitudinal assessment of
standard weight-for-age, height-for-age, and weight-for-
height percentile tables (Figure 10.4). After the age of 2,
there is an expectation that growth percentiles are sustained
with increasing age, and a failure to do so may be an
indication of inappropriate energy delivery, malnutrition,
and/or disease. For instance, a child athlete who is at the
50th percentile in height-for-age at age 12, but at a lower
percentile at age 14 would suggest that the athlete has
insufficient energy intake, malnutrition, or disease,
warranting further investigation to determine the cause of
cessation of linear growth that resulted in the drop in
percentile.
FIGURE 10.4: Growth charts for children: (A) girls (B) boys.
(From Centers for Disease Control and Prevention. Nonfatal
sports and recreation heat illness treated in hospital
emergency departments–United States, 2001–2009. MMWR
Morb Mortal Wkly Rep. 2011;60(29):977–80.)

Some young athletes may, of course, be overweight,

which is commonly addressed through a reduction in energy
intake. However, severely restricting energy intake in a
growing child has the potential of negatively affecting long-
term health (103). Using body composition measures in this
population rather than weight may be a useful strategy.
Doing so can help to ensure that lean mass is increased,
indicating normal growth, while there is a concomitant
reduction in fat mass to lower obesity risk. Using weight or
body mass index by itself will not provide the information
necessary to ensure the athlete is sustaining a normal
growth pattern. This is clearly a complicated issue, as
insufficient energy consumption may be associated with
lower weight, but the lower weight may be the result of
reduced lean mass with a higher body fat percent (48).
There is a strong connection between sport involvement
and positive self-esteem in young athletes (53). However,
there is also evidence that appearance sports, which are
subjectively scored (i.e., figure skating, gymnastics), may
increase the risk of eating disorder/disordered eating,
resulting in energy intakes that fail to satisfy the combined
needs of growth and physical activity (100). There is limited
evidence that some athletes with lower than expected
growth patterns during adolescence may experience catch-
up growth after leaving competitive sport (57). This has been
seen in former elite gymnasts, suggesting that there may be
some potential to return to the genetically expected
weight/height percentile once the energy deficiency
associated with sport participation no longer exists (31).
However, there is also evidence that athletes with
inadequate energy intakes during periods of growth fail to
achieve normal developmental expectations (19).
Although not a common occurrence in a physically active
young person, there is an ever-increasing rate of childhood
obesity across all spectrums of society. In sports where a
large mass/size is perceived as providing an advantage, such
as a lineman in football, obesity may be seen as desirable
(36). This is a prime example of where a body composition
assessment, rather than weight measurement, may be
useful in determining if the overweight athlete has a higher
weight because of more muscle or excess fat. The latter
(increased fat mass) is associated with greater lifetime
chronic disease risks and should be addressed by a health
care provider. Helping a young overfat athlete achieve a
desirable body composition will require careful attention to
food/energy consumed, while dynamically matching energy
needs with expenditure (11).

Energy Substrate Distribution

Carbohydrate
Carbohydrate represents a critically important fuel for both
muscular and central nervous system function. The primary
fuel for the brain is carbohydrate (blood glucose), which can
quickly become depleted during physical activity causing
mental fatigue. Carbohydrate depletion is associated with
muscular fatigue and poor performance (44). It was found
that there is a tendency for young athletes to consume
sufficient carbohydrate before and after exercise, but both
male and female athletes fail to consume recommended
levels of carbohydrate (30–60 g carbohydrate/hour) during
practice and/or competition (13). Failure to consume
sufficient carbohydrate during exercise, which was found to
occur in 82% of young male and 71% of young female
athletes, is a contributing factor in failing to satisfy total
energy needs. Therefore, care should be taken to ensure that
athletes have sufficient carbohydrate availability before,
during, and following physical activity. This is particularly
important because, unlike fat, humans have limited
carbohydrate storage. The current recommended
carbohydrate intake strategy for adult athletes with little
reason to modify the requirements for young athletes is
shown in Box 10.4.

Box 10.4 Current Recommended Carbohydrate

Intake Strategy for Adult and Young Athletes

For immediate recovery after exercise:

(0–4 h): 1–1.2 g/kg/h, then resume daily fuel needs

For daily recovery:

Low-intensity or skill-based activity: 3–5 g/kg/d

Moderate exercise program (e.g., training 1 h/d): 5–7
g/kg/d
Endurance program (e.g., training 1–3 h/d): 6–10
g/kg/d
Extreme exercise program (e.g., training 4–5 h/d): 8–12
g/kg/d

During sport:

Short duration exercise (0–75 min): small amounta

Medium/long duration exercise (75 min to 2.5 h): 30–
60 g/h
a
The current Joint Position Statement on Nutrition and Athletic Performance
recommends small amounts of carbohydrate, including mouth rinse for short
duration exercise lasting 45–75 min. However, please note that mouth rinse
does not contribute to energy availability.
Sources: Desbrow B, McCormack J, Burke LM, et al. Sports Dietitians Australia
Position Statement: Sports Nutrition for the Adolescent Athlete. Int J Sport Nutr
Exerc Metab. 2014;24:570–84; Thomas DT, Erdman KA, Burke LM. American
 College of Sports Medicine Joint Position Statement. Nutrition and athletic
performance. Med Sci Sports Exerc. 2016;48(3):543–68.
doi:10.1249/MSS.0000000000000852

Protein
The general recommendation for adult athlete protein intake
is 1.2–2.0 g/kg, or approximately double that of the adult
nonathlete population (0.8 g/kg) (29). For nonathlete
adolescents experiencing peak growth velocity, protein
requirements are higher than for those experiencing steady
growth at a slower pace, ranging from ∼0.8 to 1.0 g/kg.
Studies have found that the protein requirements for
adolescent athletes are nearly double this, or about 1.35–1.6
g/kg (2, 25, 45). Studies have found that adolescent athletes
without disordered eating/eating disorders report protein
intakes that tend to satisfy needs, suggesting that additional
protein intakes, through either foods or supplements, are not
necessary (2). However, there is growing evidence that how
and when the protein is consumed makes a difference in
whether the protein is optimally utilized by tissues. Studies
on adults have found that consumption of relatively small
amounts of protein of ∼20 g that is distributed throughout
the day and also provided immediately after physical activity
improves muscle protein synthesis (61, 114). These findings
suggest that creating appropriate environments for young
athletes that help to encourage protein consumption at
optimal intervals would be a useful strategy.

Fat
As a concentrated source of energy, sufficient fat intake is
necessary to ensure a satisfactory level of energy is
consumed. Fat intake is also needed for fat-soluble vitamin
intake and the intake of essential fatty acids (113). Stored fat
within muscle and fat tissue, even in the leanest athletes, is
the primary source of energy for physical activity, with
adaptations for improved fat metabolism that occurs as a
result of the greater energy needs associated with exercise
(128). However, the high energy density of fat also increases
the risk of obesity with excess consumption. Currently, the
recommended intake of fat as a proportion of total energy
intake is 20%–35%. Although there are studies finding that
children use more fat and less carbohydrate than adults
during endurance activities and more intense activities, the
easy availability of high-fat convenience foods may make it
too easy for young athletes to exceed the desired level of
intake (71, 132).

Nutrients
All nutrients are, of course, needed for optimal tissue
development and lower disease risk. However, it has been
found that three nutrients in particular, including iron,
calcium, and vitamin D, may not be obtained in sufficient
amounts in young athletes and require special attention.
Recent studies have found that many young athletes
between the ages of 11 and 17 years take vitamin and
mineral supplements, with the belief that these supplements
will provide them with the competitive edge they seek, and
that a normal diet is simply not enough to attain a
performance benefit (71, 97, 154). There is evidence from
these studies that parents (not trainers or coaches) play the
major role in young athlete supplement consumption (154).
Coaches often provide young athletes with nutrition
information, but studies suggest that most coaches have
inadequate nutrition knowledge to provide such information
(39, 43, 139). Although many supplements may neither help
nor detract from health and performance, there are known
risks associated with excess consumption of some nutrients
through supplementation that should encourage those who
work with young athletes to be cautious about supplement
intake.
 Ideally, supplement consumption should be used if and
when there is a known nutrient deficiency (e.g., anemia),
and consuming foods to correct the problem is not a possible
strategy. It is notable that, of the young athletes taking
supplements, fewer than 39% had ever met with a dietitian
to discuss safe and effective supplementation practices
(110).

Iron
Insufficient iron intake is the most common nutrient
deficiency worldwide, and iron deficiency anemia has
approximately the same prevalence (3%) in the general
public as in athletes (127). However, low ferritin levels (i.e.,
low iron stores) are often observed when young athletes are
assessed (120, 123). The prevalence of nonanemia iron
deficiency ranges from 7% to 57% in female athletes, and
from 4% to 31% in male athletes, depending on the criteria
used to determine the depletion of iron stores (ferritin) (77).
Poor iron storage, even without anemia, is associated with
suboptimal adaptation to training and poor athletic
performance, both of which appear to be related to poor
oxygen delivery and lowered synthesis of adenosine
triphosphate (45). The risk of iron deficiency in young
athletes is higher than in young nonathletes because of a
combination of issues, including a greater rate of red blood
cell hemolysis, blood loss in the gastrointestinal (GI) tract,
iron losses in sweat, and blood loss through menstruation in
female athletes (77).
Studies examining young athletes suggest that males
tend to exceed the recommended intake of iron, whereas
females have a higher level of variability in iron intake (62).
If it is not possible to consume sufficient iron from food,
there is clearly an elevated risk of iron deficiency, reduced
performance, and impaired immune function. Consumption
of iron-rich foods is the best strategy, as food is the carrier of
both energy and nutrients, both critically important for
ensuring normal growth and development and supporting
physical activity (20). A seemingly easy strategy for ensuring
adequate iron intake, supplemental iron intake is associated
with GI distress and potentially other negative health issues.
Therefore, the assumption that a daily iron supplement is an
effective strategy for lowering iron deficiency risk requires
further investigation. There is evidence, for instance, that a
single weekly iron supplement is as effective as a daily iron
supplement in reducing iron deficiency, but without the
associated negative side effects (129). A good strategy
would be for an athlete to seek the advice of a qualified
medical professional before self-prescribing iron
supplements.

Calcium
Calcium requirements for children and adolescents are
higher than those for adults because of the significant bone
development that occurs during this period of life. Putting
"stress" on the skeleton, which occurs with physical activity,
increases calcium acquisition by bones as a logical
adaptation to increase the skeletal strength needed for the
exercise-associated stress (135, 152). This increased calcium
acquisition by bones requires a higher calcium intake. The
recommended calcium intake is 1,300 mg/day for children
and adolescents, which is 300 mg/day higher than the adult
requirement. Assuming the calcium requirement is satisfied,
the combination of higher calcium intake and physical
activity will result in significantly higher BMD by the end of
adolescence when compared with nonphysically active youth
(12).

Vitamin D
Vitamin D can be obtained from the diet from vitamin D–
fortified foods, including milk and orange juice, and several
other foods, including egg, beef liver, sardines, margarine,
canned tuna, salmon, swordfish, and cod liver oil. With the
exception of eggs, milk, and orange juice, which are not
always fortified with vitamin D, children and adolescents do
not typically consume a significant amount of the other
foods. As a result, vitamin D status is most likely a function
of the vitamin D derived from sunlight exposure. (Ultraviolet
"B" sunlight converts cholesterol under the skin to inactive
vitamin D, which is then converted to the active form by the
kidneys and liver.)
Vitamin D is essential for, among other things, calcium
absorption. So the young athlete who consumes ample
quantities of calcium, but spends the majority of time in
school and training indoors (e.g., basketball, gymnastics,
figure skating) may be at risk for inadequate vitamin D
status and poor bone development. A study of adolescent
female gymnasts found that about 33% had below optimal
serum vitamin D status (88). Poor vitamin D status is also
associated with reduced athletic performance and increased
musculoskeletal injury risk. There is evidence of widespread
vitamin D deficiency in athletes and dancers (mean age 14.7
years), particularly in those who train indoors (40). Improving
vitamin D status with regular sunlight exposure or
supplementation in athletes with suboptimal serum vitamin
D levels helps to correct both the performance and injury risk
problems (84, 150).

Fluids
Children and adolescents have a different physiologic
strategy for dissipating exercise-associated heat than adults
for several reasons (10, 15, 50, 130):

They have a higher body surface area (BSA) (the

measured surface of the body) that acquires more heat
from the environment on a hot day and loses more heat
to the environment on a cold day.
They produce more heat per unit weight during physical
activity.
 They have fewer sweat glands per unit of surface area,
and each sweat gland produces less sweat, resulting in a
reduced potential to dissipate heat.

Body Surface Area

BSA is the calculated or measured surface area of a human

body. The most widely used formula for calculating BSA is
the DuBois formula, where: BSA = 0.007184 × weight0.425
× height0.725. Typical BSA for a 12- to 13-year-old is 1.33
m2, for an adult woman 1.4 m2, and for men 1.9 m2. Larger
BSAs are associated with higher sweat rates (more sweat
glands), resulting in better cooling capacity. The lower BSA
of children may increase heat illness risk.

As a result, children and adolescents are more reliant on

radiative and conductive cooling through greater peripheral
blood flow, rather than through sweating. In addition,
adolescents who exercise regularly appear to adapt to the
increased requirement for heat dissipation through greater
peripheral vasodilation and blood flow (119).
Regardless of whether cooling occurs primarily through
sweating or through greater peripheral blood flow,
consumption of adequate fluid of the right composition is
necessary to avoid heat-illness in young athletes (35). In
addition, despite the lower sweat rate, there is strong
evidence that physically active adolescents can experience
significant fluid loss when training in a hot environment (9).
Water consumption is advised for young athletes involved in
moderate intensity activity in thermoneutral environments,
but prolonged higher intensity activity may require the
additional carbohydrate and electrolytes offered by sports
beverages or, perhaps, milk (149).
 Coaches and parents should become fully aware of the
mental and physical signs of dehydration and heat-related
injuries, with special attention paid to the heat index (see
Chapter 7). The voluntary dehydration (i.e., they consume
insufficient fluids to maintain hydration state even when
fluids are available) seen in young athletes should encourage
those who work with them to observe drinking patterns. It is
also recommended for these young athletes to have readily
available beverages that they are more likely to consume
(14). Both parents and coaches should be encouraged to
attend nutrition education sessions taught by a qualified
sports dietitian, as it has been found that even relatively
brief time in these sessions (two for 90 minutes each)
significantly improves both the number and accuracy of the
nutrition information provided to young athletes (69). There
is also good reason to believe that nutrition education
programs that target young athletes are successful in
helping these athletes understand the nutrition strategies
needed for optimizing growth, development, and athletic
performance (92).

THE FEMALE ATHLETE

A cursory review of the dietary reference intake (DRI)

provides a clear nutritional truth: Males and females have
distinctive nutritional needs, which should be addressed
through appropriate nutritional intakes that address these
differences. Male athletes, for any given sport, have greater
relative musculature than females. However, female athletes
develop their skeletons sooner than males and, therefore,
have nutritional needs specific to this earlier growth pattern.
Females have a slightly greater capacity to "burn" fat as an
energy substrate than males, and the larger muscle mass of
males represents a larger storage capacity for carbohydrate
than females, suggesting that males have a greater potential
for power activities, whereas females may be more
endurance oriented.
Females, typically between the ages of 11 and 13, have
their first menstrual period, which carries with it its own
unique set of nutritional requirements (37). These and other
sex differences create unique nutritional realities that must
be fulfilled to optimally satisfy the health and performance
needs of female athletes. It is important that the
interpretation of general sport nutrition guidelines, which are
often presented as a single set of guidelines that are not sex
specific, be interpreted carefully to address the unique
requirements of both male and female athletes (137). In
particular, there should be some thought to whether the
foods/beverages consumed by the female athlete are
sufficient to fully support the hormone production required to
maintain a normal menstrual cycle; the smaller body size
and musculature of females, compared with that of males,
should also be a consideration in interpreting general
nutrition recommendations. Female athletes in "appearance"
sports may be particularly at risk for eating patterns that
result in poor energy availability, which can increase health
risks and also result in poor training benefits. Nutrition
education should be provided to female athletes, as it has
been found that higher nutrition knowledge in young female
athletes is associated with better dietary quality and intake
(133).

Energy Needs

Energy intakes, regardless of age and sex, are based on total

weight, weight of the metabolic mass, growth phase, and
duration and intensity of exercise. Surveys of female athletes
commonly report an underconsumption of energy, leading
many to conclude that female athletes are at an increased
risk of developing eating disorders regardless of the type of
sport in which they participate (18). In addition, the literature
suggests that intense exercise has an impact on the female
reproductive system, with amenorrhea or oligomenorrhea a
common outcome. An increase in energy intake can offset
the high energy demand and may be sufficient to reverse
the menstrual dysfunction and halt the associated reduction
in bone mass (151). Energy availability (Box 10.5) is an
important factor in determining whether female athletes
meet their energy requirements. By definition, energy
availability represents the available energy for supporting
body functions after energy is used to satisfy the
requirements for exercise training. It is estimated that
female athletes who fall below 30 kcal/kg fat-free mass (FFM)
are at risk for insufficient energy to support vital body
functions. Furthermore, a negative energy balance results in
decreased hormone levels, particularly when self-
selected/unguided, and may be associated with reduced
performance in both anaerobic and aerobic athletic
endeavors (29, 54).

Box 10.5 Energy Availability Calculation

1. Step 1: Estimate the energy obtained from the diet.

2. Step 2: Estimate the energy used during exercise
training.
3. Step 3: Subtract the energy used during exercise
training from the total energy obtained from the diet to
obtain remaining energy (kcal).
4. Step 4: Estimate the proportion of the body that is
FFM (i.e., total mass − fat mass) to obtain kg FFM.
5. Step 5: Calculate energy availability = remaining
energy (kcal)/kg FFM/d.
Note: See www.femaleathletetriad.org for calculators that predict energy
availability.
 Female athletes who participate in vigorous exercise
training are at risk for low energy availability, which results
in irregular menses or a cessation of menses and is
associated with poor skeletal development (i.e., low BMD,
Table 10.1) (58, 117).
Recent evidence suggests that virtually all menstrual
disturbances in female athletes are the result of inadequate
energy consumption, either from restrictive intakes or from
failure to adequately satisfy increased exercise-associated
energy requirements (67, 86). A significant proportion (39%)
of female athletes were found to have low energy
availability, with 54% of these presenting with menstrual
function abnormalities (64). Female athletes with
components of the female athlete triad are at increased risk
of developing other endocrine, GI, renal, neuropsychiatric,
musculoskeletal, and cardiovascular problems (46).
This is paradoxical in athletes, as with sufficient energy,
vitamin D, and calcium availability, weight-bearing physical
activity (i.e., running, jumping, weight lifting) should increase
BMD. However, in chronically low energy availability, young
female athletes may develop osteopenia (i.e., low bone
density) and/or osteoporosis (i.e., bone density sufficiently
low that has reached the fracture threshold) (103). The
American College of Sports Medicine (ACSM) recommends
that energy availability should be restored through an
increase in energy consumption, a reduction in energy
expenditure, or a combination of the two to improve
reproductive function and skeletal health in female athletes
(Figure 10.5) (103).
FIGURE 10.5: Normal and low bone mineral density (BMD).
A. The current standard for assessing BMD is dual-energy x-
ray absorptiometry. B. Normal BMD. C. Low BMD
characteristic of osteopenia, osteoporosis, and osteomalacia.
(From Anatomical Chart Company. Understanding
Osteoporosis Anatomical Chart. Philadelphia (PA): LWW (PE);
2003.)

There is also evidence that wide fluctuations in within-day

energy balance may also have an impact on menstrual
function and bone health in young female athletes. A case
study of an elite junior female triathlete suggested that
nearly half of the energy consumed was after 6:00 PM, which
was associated with low energy balance earlier in the day
while the athlete was physically active. This, coupled with a
low energy availability, was associated with low
triiodothyronine (T3, a thyroid hormone), where low T3 is a
sign that the body is trying to conserve energy by lowering
the rate of energy metabolism, poor menstrual function, and
poor bone health (146).

Body Image and Eating Disorders

Female athletes are more likely than male athletes to
engage in unhealthy weight loss methods, including
inappropriate use of laxatives, diet pills, vomiting, and
fasting (66). Many of these strategies are aimed at achieving
a desired appearance and improved athletic performance,
despite the fact that these methods are likely to be
counterproductive and may increase health risks (79). It now
seems clear that disordered eating behaviors, if they
continue, are precursors to subclinical eating disorders that
can be life-threatening because of severe energy restriction
and pathologic weight loss methods. Eating disorders are
associated with a distorted perception of body shape (Table
10.2) (6, 140).
Table 10.2 General Characteristics for
Subclinical Eating Disorders
Observed in Female Athletes:
Anorexia Nervosa, Bulimia
Nervosa, and Binge Eating
Disorder
Anorexia Nervosa Bulimia Nervosa Binge Eating
Disorder

Severe Recurrent Similar to

restriction of episodes of bulimia
energy intake binge eating nervosa.
relative to characterized Eating rapidly
requirements, by extremely and until
resulting in low large amount uncomfortably
body weight for of food full.
age, sex, consumed Eating large
developmental within a 2-h amounts even
period, and period. when not
physical health. Loss of hungry, and
Fear of gaining control eating alone
weight or of during binge out of
becoming fat, eating embarrassment
despite being episode. over how much
underweight. Recurrent is being
Misperception inappropriate consumed.
of body purging Sense of
weight/shape, behaviors, disgust and
with denial of such as embarrassment
severity of vomiting and over how much
actual low body laxative is being
weight. abuse, aimed consumed.
at preventing
weight gain.
 Table 10.2 General Characteristics for
Subclinical Eating Disorders
Observed in Female Athletes:
Anorexia Nervosa, Bulimia
Nervosa, and Binge Eating
Disorder
Anorexia Nervosa Bulimia Nervosa Binge Eating
Disorder
Average
binge eating
occurs a
minimum of
once per
week for 3
mo.
Excessive
focus on
body shape
and weight.

Source: American Psychiatric Association. Diagnostic and Statistical Manual of

Mental Disorders: DSM-V. Arlington (VA): American Psychiatric Association; 2013.

Health practitioners should use some caution when

weighing female athletes or when focusing on athlete weight
as a measure of athletic proficiency. It may be
counterproductive to have a positive goal (i.e., increased
muscle mass) than a negative one (lower weight or lower
body fat), as the latter may predispose an athlete to
disordered eating behaviors (33).

Female Athlete Triad

The female athlete triad (the triad) is a condition
characterized by low energy availability, menstrual cycle
disturbances, and low BMD. The condition was officially
recognized by the ACSM in 1992, after an increase in the
number of stress fractures, findings of low BMD, and
increased menstrual dysfunction in significant proportions of
female athletes (46). The triad commonly begins with
inadequate energy consumption, which results in an
amenorrhea-associated reduction in estrogen levels and
leads to decreased bone development (Box 10.6) (95).

Box 10.6 The Female Athlete Triad

The female athlete triad is a medical condition seen often

in physically active girls and women, involving three
interrelated factors:

Low energy availability that may or may not be

associated with disordered eating or an eating
disorder.
Menstrual dysfunction (typically amenorrhea or
oligomenorrhea).
Low BMD.

Failure to address this triad with early intervention may

result in a progression to a more serious eating disorder
and may predispose the athlete to early-onset
osteoporosis.

A survey of 191 Australian exercising women between the

ages of 18 and 40 years assessed their knowledge, attitude,
and behavior related to the triad. Despite the high
prevalence of the triad among female athletes, only 10% of
those surveyed could name the three components of the
triad; 45% did not understand that amenorrhea negatively
affects bone health; and 25% indicated they would not take
corrective action if experiencing amenorrhea (99). A group of
those same lean-build sports participants were also
associated with having a history of menstrual dysfunction
and stress fractures, despite knowing that both could be
related to energy deficiency. In addition, over 33% of the
subjects believed that irregular menstrual periods are a
"normal" part of being an athlete. Interestingly, a number of
the respondents in this study had suffered both amenorrhea
and stress fractures, yet did not realize that these are both
associated with inadequate energy intake. This study
demonstrates the need for educating active females and
female athletes about the health risks associated with a
failure to consume sufficient energy to support both physical
activity and normal physiologic function (99).
Prevalence of the triad may be difficult to estimate
because of its multifactorial components and because of
poor standardization for determining the presence of each of
the triad factors. It is estimated that ∼4% of all female
athletes meet the criteria for all three components of the
triad, with certain sports having a higher prevalence (104).
Higher prevalence sports often have an aesthetic component
to the competition, including subjectively scored sports
(dance, gymnastics, figure skating) and sports where
contoured and revealing clothing is required (swimming,
diving). Higher prevalence of the triad is also seen in
endurance sports (distance, running, and cycling) and weight
category sports (martial arts and wrestling) (103). As an
illustration of this higher prevalence, the general female
population has a rate of eating disorders in the range of 5%–
9%, although studies have found the prevalence of eating
disorders in selected female athlete groups to range from
28% to 62%, with menstrual dysfunction as high as 78% in
certain sports (103). In a study of high school female
athletes, it was found that low energy availability was
present in 54% of participants, with a greater prevalence of
low BMD in these athletes (64). There is increasing evidence
that an effective strategy for reducing the prevalence of the
triad is to educate parents, coaches, and athletes on how
and why this problem is so pervasive and on nutritional
strategies for reducing the risk of relative energy deficiency
(126).
The general medical recommendations to decrease the
risk of the triad are as follows (111):

Screen all adolescent female athletes for components of

the triad as part of the preparticipation examination.
Perform a BMD scan using dual-energy x-ray
absorptiometry (DEXA) on all athletes who present with a
stress fracture, regardless of whether or not they have
reported menstrual dysfunction or disordered eating.

Inadequate Energy Consumption

Energy availability represents the amount of dietary energy
required to satisfy all physiologic functions plus the
increased energy requirement associated with physical
activity. In healthy individuals, it is estimated that an
average of 45 kcal/kg FFM/day is sufficient to satisfy needs,
whereas intake of <30 kcal/kg FFM/day may result in altered
reproductive function and low bone development or
decreased BMD as compensation for the inadequate energy
availability. Low energy availability is often seen in
endurance sports, where the energy expended exceeds the
energy consumed. Female athletes in sports that emphasize
aesthetics and leanness, including diving, gymnastics,
synchronized swimming, and figure skating, are at high risk
of having low energy availability (95). A study of eating
attitudes, risk for eating disorders, and food intakes of elite
figure skaters found that, despite being within a normal
weight range for height, 38% thought of themselves as
overweight and 22% were told by others that they were
overweight. This resulted in an average daily energy intake
that was far below the predicted requirement, increasing
risks of menstrual dysfunction and poor bone health (52).
Menstrual Dysfunction
Menstrual dysfunction in female athletes includes a wide
array of disorders, including amenorrhea, oligomenorrhea,
and anovulation (Box 10.7).

Box 10.7 Menstrual Function Terms

Menstrual Cycle: A recurring cycle in women of

childbearing age that begins at menarche and ends at
menopause. During this cycle, the lining of the uterus
prepares for pregnancy, but without pregnancy the uterus
lining is shed (menstruation). The average menstrual cycle
is 28 d, with a typical range of between 21 and 35 d.
Eumenorrhea: Normal and regular menstrual cycle.
(e.g., A eumenorrheic female has a normal and regular
menstrual cycle.)
Amenorrhea: Absence of at least three sequential
menstrual periods.

A 15-year-old female who has never had a menstrual

period has primary amenorrhea.
A female who has experienced a previous menstrual
period, but has missed at least three sequential
menstrual periods has secondary amenorrhea.

Oligomenorrhea: Infrequent menstrual periods in

women of childbearing age. A female who goes longer
than 35 d without menstruating and/or only 4–9 menstrual
periods per year may be diagnosed as having
oligomenorrhea.
Anovulation: Failure of the ovaries to release an egg
(ova) for over a 3-mo period. Typically, ovaries release 1
egg every 25–28 d.
 Menstrual Dysfunction

As it relates to female athletes, typically refers to

amenorrhea (cessation of the menstrual period) or
oligomenorrhea (irregular menstrual period). Both are
closely linked to inadequate energy intake. The lower
estrogen with either amenorrhea or oligomenorrhea is
associated with lower bone density.

Menstrual cycle problems originate from the suppression

of the release of gonadotropin-releasing hormone from the
hypothalamus. This results in a lowered luteinizing hormone
and follicle-stimulating hormone secretion, both of which are
necessary for normal ovarian function. The outcome is
decreased estrogen and progesterone production by the
ovaries, resulting in multiple health risks that include a
reduced ability to increase BMD (103). Bones are constantly
being remodeled through the action of two primary cells,
including osteoblasts, which build up bone, and osteoclasts,
which break down bone. Estrogen inhibits the activity of
osteoclasts, enabling relatively greater osteoblastic activity
and, ultimately, higher BMD.
It was initially thought that menstrual dysfunction was the
result of an excessively low body fat in female athletes, but
this theory has been found to be inaccurate. Energy
availability has been found to be the primary regulator of
normal ovarian function, and women falling below 30 kcal/kg
LBM (Lean Body Mass)/day are at risk of abnormal ovarian
function (86). It appears that cortisol, a stress hormone that
is produced with low energy availability, is an inhibitor of
estrogen production, while it also is highly catabolic to bone
tissue and soft (muscle/fat) tissue (95). Athletes, and the
health care providers who work with them, should know that
returning an athlete to a state of good energy availability
does not immediately result in a return to normal ovarian
function, and it may take several months to return to a
normally functioning state (83).

Bone Health
Physically active females require good bone health to absorb
the additional gravitational and muscular stresses associated
with sport. However, bone health is compromised in the
triad, predisposing the affected athlete to stress fractures,
fractures from increased skeletal fragility, and early-onset
osteoporosis (16). On the other hand, female athletes with
adequate energy availability experience positive changes in
bone development, with higher BMD than nonathletes and
lower risk of developing osteoporosis (95).
The reduction in bone mass associated with menstrual
dysfunction is clinically relevant for female athletes because
it places them at an increased risk for stress fractures and
later an increased risk for osteoporosis. In one study of 46
female athletes (31 with multiple stress fractures and 15
without stress fractures), nearly half of all athletes with
stress fractures had menstrual irregularities, with a
particularly high prevalence observed in endurance runners
with high weekly training mileage (80). Although consuming
sufficient calories and calcium will not correct the
biomechanical factors associated with stress fractures,
including a high longitudinal foot arch and leg-length
inequality will substantially reduce risk if this strategy helps
females return to normal menstrual function (102).
The prevalence of bone-related problems associated with
menstrual dysfunction is high. In runners, it was found that
34.2% were osteopenic (i.e., low BMD) at the lumbar spine
and 33% were osteoporotic in the forearm. Of this
population, 38% were oligomenorrheic and 25% were
amenorrheic, with a significant proportion having low energy
availability as a result of disordered eating (116). Low bone
density may be used as a primary diagnostic factor
associated with low energy availability and/or the triad (82).
It has also been found that high dietary fiber intakes and
vegetable protein consumption, which are associated with
vegetarian diets that often supply insufficient total energy,
are associated with low BMD in young female athletes with
oligomenorrhea (17). High-fiber diets are associated with
high consumption of phytic acid and oxalic acid, both of
which have a high binding affinity for bivalent minerals (e.g.,
calcium, zinc, iron, and magnesium), creating poor
absorption for the calcium in food (90, 108).

Total Daily Energy Expenditure

Energy Substrates, Vitamins, and Minerals

Carbohydrate
Carbohydrate is a critically important part of the female
athlete diet for multiple reasons: 1) it is the primary source
of fuel for the central nervous system/brain; 2) it is the
primary substrate necessary for glycogen storage in the liver
and muscles; 3) it can be metabolized both anaerobically
and aerobically, so is important for both endurance and high-
intensity activities; and 4) storage of carbohydrate can be
easily altered through physical activity (29). Female athletes
may put themselves on reduced carbohydrate intakes as an
ill-founded strategy for lowering body fat and weight, despite
current recommendations that carbohydrate should be 50%–
60% of total calories consumed (Table 10.3).

Table Recommended Carbohydrate Intake for

10.3 Different Intensities of Activity
Light Low-intensity or skill-based activity 3–5 g/kg
activity body
mass/d
Moderate Moderate exercise program of ∼1 5–7 g/kg
 activity h/d body
mass/d
High Endurance program of 1–3 h/d of 6–10 g/kg
activity moderate- to high-intensity body
exercise mass/d
Very high Extreme exercise program of 4–5 8–12 g/kg
activity h/d of moderate to high-intensity body
exercise mass/d

Source: Burke LM. Nutritional guidelines for female athletes. In: Mountjoy ML,
editor. The Female Athlete. 1st ed. London: John Wiley & Sons, Inc.; 2015.

A series of studies assessing the carbohydrate

consumption pattern of female athletes involved in different
sports have indicated a wide range of intakes. Few of the
assessed female athlete groups meet the recommended
carbohydrate intake of 5–7 g/kg/day for general training and
7–10 g/kg/day for endurance athletes (30). In one study, only
29% of female athletes consumed the recommended
carbohydrate during practice and/or competition (13).

Protein
The general (nonathlete) recommendation for protein
consumption in adults is 8 g/kg/day. The athlete
recommendation is approximately double this and ranges
between 1.2 and 2.0 g/kg/day, depending on the degree to
which the athlete is involved in endurance activity (29, 85).
It should be noted that no specific protein requirement data
are available for female athletes, so these values are derived
from mixed-athlete or male studies. Until female-specific
protein requirement data are determined, female athletes
should aim to consume a protein level within the currently
established range. How the protein is consumed is also
important, with current recommendations to optimize tissue
utilization in the range of 20–25 g protein/meal (26, 29, 109).
As an example, a young female athlete weighing 50 kg (110
lb) would require 50 × 1.5 or 75 g of protein per day.
Consumed in 20 g doses, this athlete would require about
four meals with 20 g of protein in each meal to satisfy her
requirement.

Fat
Fat is a concentrated source of energy, ideally contributing
20%–35% of total energy consumed, and is also needed for
providing the essential fatty acids and the fat-soluble
vitamins A, D, E, and K (29, 121). Although fat restriction is
often a component of low-calorie diets aimed at improving
appearance, athletes should be discouraged from consuming
less than 20% of total energy from dietary fat (29). There has
been recent interest in consumption of high-fat/low-
carbohydrate diets for the purpose of enhancing fat
metabolism, but the results of studies investigating this
strategy fail to show that fat metabolism is enhanced, while
there is consistent evidence that low-carbohydrate diets may
diminish exercise performance (29, 60, 148).

Nutrients
As food is the carrier of energy and micronutrients,
inadequate energy consumption increases the likelihood that
micronutrients will also be inadequately consumed. The
information on vitamins and minerals that follows
emphasizes the micronutrients that are of highest concern in
female athletes, including calcium, vitamin D, iron, and
certain antioxidants.

Iron
It is hard to imagine any athlete performing up to their
conditioned capacity with poor iron status. Despite this,
young female athletes are at particularly high risk for both
iron deficiency and iron deficiency anemia (see Chapter 6).
Poor iron status can result in a compromised immune
system, extreme fatigue, poor endurance, poor
concentration ability, weakness, shortness of breath, and
dizziness. A study assessing the prevalence of iron deficiency
in young female rhythmic gymnasts found that nearly half
(48.3%) had blood values consistent with iron deficiency
(78). Similar findings of poor iron status have been found in
other female groups, including young ballet dancers, who
were found to be at high risk for iron deficiency (21). It was
found that the female athletes with iron deficiency had
significantly lower energy, protein, and fat intakes than those
with normal iron status. Protein intake, in particular, was
found to be significantly different among the iron-deficient
(protein intake was lower) and normal iron (protein intake
was higher) groups. Surveys have found low storage iron
(ferritin) in female runners, and other studies have found
that female athletes with anemia can improve aerobic
performance through a program of iron supplementation (4,
96). However, taking iron supplements in the absence of iron
deficiency may cause GI tract and other difficulties, including
lower absorption rates of calcium, zinc, and magnesium.
Given the very real health and performance risks associated
with poor iron status, female athletes should have iron status
assessed on a yearly basis, with the inclusion of ferritin in
the assessment protocol.

Calcium
Adequate calcium consumption is necessary to develop and
maintain high-density bones that are resistant to fracture.
For athletes concerned about dairy product consumption
because of allergies or lactose intolerance, calcium-fortified
orange juice is an excellent alternative and, per equal
volume, has the same calcium concentration as fluid milk. It
should be understood, however, that calcium intake alone
does not guarantee healthy bones, as vitamin D, estrogen,
adequate energy, and physical stress are all needed for bone
development.
Despite the difficulties associated with estimating and
interpreting dietary adequacy from food intake data in
athletes (62), it is especially concerning that the calcium
consumption of adolescent athletes may be as low as 50% of
the recommended intake level (59, 72), with inadequate
intakes being much more common in female athletes than in
male athletes (93). As amenorrheic adolescent athletes have
significantly impaired bone microarchitecture compared with
eumenorrheic athletes (those with normal menstrual cycles)
and nonathletic controls, it is especially important that all
adolescent female athletes, regardless of menstrual function,
achieve adequate calcium intakes (Box 10.8) (1).

Box 10.8 Good Sources of Calcium in Food

Milk, 1 cup, 300 mg

Kale (cooked), 1 cup, 245 mg
Sardines (with bones), 2 oz, 217 mg
Canned salmon (with bones), 2 oz, 232 mg
Cheese, 1 oz, 224 mg
Almonds, 1 oz, 76 mg
Broccoli (cooked), 1 cup, 62 mg

Vitamin D
There is concern that young female athletes, particularly in
sports that involve indoor training and competition, are at
risk for low vitamin D status. It has been estimated that in
some parts of the world 32.8% of adolescent females were
vitamin D deficient when using plasma concentrations of
25.0 nmol/L; 68.4% were vitamin D deficient when using
37.5 nmol/L; and 89.2% were vitamin D deficient when using
50 nmol/L (56). Poor vitamin D status can negatively affect
skeletal development, but may also negatively affect muscle
function and athletic performance (see Chapter 5: Vitamin
D). This concern is particularly acute in young females
involved in indoor activities because maximal BMD is
achieved by the age of 20. Failure to reach a sufficiently high
bone density creates a predisposition to early-onset
osteoporosis. Seasonal variation also makes a difference in
vitamin D status, with winter associated with the lowest
serum vitamin D concentrations. Serum vitamin D
concentrations are reportedly highest in September,
following a period of higher direct sun exposure, and lowest
in March, following a period of lower direct sun exposure,
with indoor athletes having significantly lower serum vitamin
D levels than outdoor athletes regardless of the season (94).
Given the relatively high prevalence of vitamin D
deficiency in all populations, including young female
athletes, there is good reason to periodically assess athletes
for vitamin D status. If it is found to be low, a trained medical
professional should recommend appropriate sun exposure for
different skin pigmentations (e.g., two times per week
between 10 AM and 3 PM with arms and legs exposed for 5–
30 minutes), foods, and, if necessary, supplements (155).

THE OLDER ATHLETE

There are far too many examples of older athletes

performing well to suggest that there is a maximum age to
put away the athletic shoes. The World Masters Athletics
Association lists many athletes who are still competing
above age 60 in virtually every track and field discipline
including steeplechase, pole vault, marathon, and the
10,000-m run. The world record holder for the men’s outdoor
100 m in the 100-year-old group is Russian Philip Rabinowitz
with a time of 30.86 seconds, and British Ron Taylor holds
the record for 60-year-olds, an impressive 11.70 seconds!
Older female athletes also excel. In 1994 Russian Yekaterina
Podkopayeva won the world indoor 1,500 m at the age of 42
with a time of 3:59:78. At the age of 80, Johanna Luther from
Germany ran the 10,000 m in an impressive time of
58:40:03. Clearly, being older does not mean a mandatory
cessation of sport participation. Nevertheless, the aging
process does bring with it certain undeniable changes that
should be addressed to be certain that exercise remains a
healthful activity. Of particular concern are the following
health-related issues (32, 98, 153):

Age-related changes in body composition and the impact

this has on REE;
Lowered capacity to quickly recover from intensive or
long bouts of exercise;
Gradually diminishing bone mass;
Subtle changes in GI tract function that could influence
nutrient absorption;
Progressively lower heat tolerance;
Progressive decreases in the glomerular filtration rate
and renal blood flow;
Reduced capacity to concentrating urine, increasing
urinary frequency, and, potentially, lowering fluid
consumption.

These age-related changes may result in specific

performance-related reductions in:

Aerobic and anaerobic capacity (105, 147) (Figure 10.6)

Exercise efficiency (156)
Strength (112)
Power (81)

See Figure 10.6 for age-related reductions in triathlon

completion rates.
FIGURE 10.6: Age-related drop in triathlon completion rates
at world championships. (From Bernard T, Sultana F, Lepers
R, Hausswirth C, Brisswalter J. Age-related decline in Olympic
triathlon performance: effect of locomotion mode. Exp Aging
Res. 2010:36(1);64–78.)

Despite these changes, appropriate training combined

with optimally satisfying nutritional needs can significantly
diminish the reduction in performance capabilities (28). It
appears that an appropriate nutrition strategy for exercise
recovery is an important factor in reducing injuries and in
benefiting from the exercise bout (22). Included in the
postexercise recovery strategy is consumption of
carbohydrate and protein to recover glycogen and to
stimulate muscle protein synthesis for improved muscle
recovery. Postexercise carbohydrate ingestion has been well
established as the most important determinant of muscle
glycogen resynthesis. In addition, consumption of ∼20 g of
dietary protein five to six times daily appears to aid muscle
protein synthesis rates during the day (38, 49). A review of
studies investigating protein supplementation providing high
levels of protein in conjunction with resistance training,
however, found that these high levels fail to increase either
muscle mass or strength (55).

Energy Needs

Adulthood is characterized by a decrease in lean body mass

that is associated with a lower metabolic rate and is referred
to as sarcopenia. Unless accounted for, this lower
metabolic rate can be associated with gradually higher body
fat levels that predispose adults to type II diabetes, high
blood pressure, heart disease, and cancer. The change in
body composition is associated with a reduction in energy
expenditure, which decreases ∼10 calories each year for
men and 7 calories each year for women after the age of 20
(32). Active individuals who maintain their lean body
(muscle) mass can avoid the conditions associated with
sarcopenia. The typical reduction in energy metabolism,
therefore, varies greatly with the relative fitness of the older
athlete. Interestingly, older male athletes working at near
maximal rates of energy expenditure during a 14-day cycling
expedition were unable to consume sufficient energy to fully
satisfy tissue needs (122). This inability or unwillingness to
consume sufficient energy may be at least partially
responsible for the reduction in lean mass commonly seen in
aging. It is also recommended that older athletes avoid diets
that are high (>35% of total calories) or low (<20% of total
calories) in fat, as both extremes are associated with a
failure to achieve an appropriate energy intake (29).
 Sarcopenia

Age-related degenerative loss of skeletal muscle mass loss

of between ½ and 1% for each year after reaching the age
of 50. This is also associated with an increase in body fat
percent. The loss of muscle and increase in fat are
associated with a progressive increase in weakness, as less
muscle is being asked to move relatively more mass. This
weakness is associated with less movement, which also
results in lower BMD and risk of osteopenia and
osteoporosis. Regular exercise coupled with good nutrition
practices is a good strategy for limiting the risk of
sarcopenia.

Fluids and Heat Stress

Older athletes are more susceptible to dehydration and the
problems dehydration creates because of a number of age-
associated changes. These include a blunted sensation of
thirst, altered kidney function, and slower/lower sweat
responses to heat that appear to reduce the older athlete’s
capacity to drink sufficient fluid to sustain a euhydrated
state, resulting in a difficulty to cope with the heat-related
stresses of exercise (118). Increased risk of heat stress in
older athletes should be seriously considered because the
result of heat exhaustion and heatstroke is often death.
During periods of high heat and humidity, those most likely
to become seriously ill or die are older adults. Although the
older adult population should not be confused with the
masters athlete population, even if they are in the same age
group, there may be an age-related drop in the capacity to
dissipate heat regardless of fitness level. An important factor
in sweat production and cooling capacity is the ability to
increase blood flow to the skin. Blood flow to the skin in
older, fit athletes is lower than in younger athletes (75, 76).
In addition, the lower blood flow associated with increasing
age appears to be independent of hydration state. It also
appears that, although sweat gland recruitment is similar to
that of younger athletes, older athletes produce less sweat
per gland (74). There is a wide genetically based variability
in sweat production, but these studies suggest that older
athletes should be vigilant in their capacity to produce
sweat. Older athletes and their exercise partners should be
cognizant of the symptoms of heat exhaustion and
heatstroke. They should also be aware that most heat
exhaustion occurs due to poor acclimatization to a hot and
humid environment. Therefore, normal exercise intensities
and durations should be reduced for the first few days in a
new environment until the athlete has adapted.

Bone Mineral Density

Bone density becomes progressively lower with age, and
females experience a faster drop in bone density after
menopause due to the decrease in the bone-protective
action of estrogen. Other factors associated with low bone
density include inadequate calcium intakes, lower absorption
of calcium, poor vitamin D status, and loss of calcium
through sweat. This explains why it is so important to
achieve a high bone density by young adulthood so that,
even with a progressive loss of density later on, there will be
sufficient density to avoid reaching the fracture threshold in
older age (101). The rate of change in bone density can be
altered through an adequate intake of calcium, periodic and
regular exposure to the sun for vitamin D, and regular stress
on the skeleton through weight-bearing exercise. In addition,
women may choose to take, through the advice of their
physicians, estrogen/hormone replacement therapy (HRT).
HRT may be particularly useful when there is a family history
of osteoporosis or a woman has been diagnosed with low
bone density (142). Certain cortisone-based drugs taken for
the control of pain or osteoarthritis appear to be catabolic to
bone; therefore, the regular use of these drugs may place
the older athlete at increased risk of low bone density. The
fact that older athletes continually stress the skeleton
through regular physical activity is a major protective factor
in keeping bone density elevated.

Organ Function
It would be expected that older athletes experience some
degree of progressive GI dysfunction and changes in nutrient
requirements, although no athlete-specific studies confirm
that this, indeed, occurs. The typical effects of age on the GI
tract include reduced motility; decreased absorption of
dietary calcium, vitamin B6, and vitamin B12; and greater
requirement for fluid and fiber to counteract reduced GI
motility (32, 91). The absorption of iron and zinc may also be
a concern, but older individuals appear to have higher iron
stores, diminishing the daily requirement for iron (34). Aging
is often associated with reduced kidney function, resulting in
a loss of nutrients and fluid that may otherwise be retained
(118).

Immune Function
Changes in immune function should also be considered, but
regular long-term exercise appears to attenuate the changes
in the immune system that are typically associated with
aging (107). Vitamin D is important for the immune system,
but the capability of the older person to synthesize vitamin D
from sunlight exposure is reduced, suggesting that vitamin D
status may be a concern (89, 125). Vitamin and mineral
supplementation is common among older athletes, often in
an attempt to boost the immune system. However, there is
little evidence that this is a useful strategy, but if the
supplements target nutrients that are not well absorbed,
they may be warranted. It is recommended that older
athletes consult with their doctors to determine the best
strategy for delivering needed nutrients. In some cases, as in
the case of vitamin B12, a periodic injection may be the only
strategy that reduces the risk of pernicious anemia (32).
Good protein status is an important component of a stable
immune function, but there is no evidence that protein
intake should in any way be increased beyond the normal
values established for athletes (∼1.5 g/kg/day). Ideally,
protein should be consumed as part of a balanced intake of
carbohydrate, protein, and fat to satisfy total energy needs.
Aging often brings with it a reduction in kidney function, so
increasing protein intake to a level above 2.0 g/kg/day is
likely to increase the need to excrete nitrogenous waste, so
is not warranted. The current recommendation for protein
intake in older adults is at least 1.0–1.2 g protein/kg/day,
with a recommendation that daily physical activity or
exercise should be undertaken by all older people for as long
as possible (47). There is also evidence that calculating the
total daily protein requirement and distributing it evenly
throughout the day’s meals (e.g., 30 g/meal) is a useful
strategy for lowering the risk of sarcopenia (109).

Summary

Young Athletes

Young athletes typically consume sufficient protein, but

fail to consume sufficient carbohydrates. As a result,
total energy consumption is insufficient to support
normal growth and development plus the added energy
requirement of physical activity. As a general guide,
young athletes should regularly be tracked on growth
charts that measure height for age, weight for age, and
weight for height (often used by pediatricians). A
lowering of the established growth percentile may be a
sign of inadequate energy intake, a disease state, or
both.
It is difficult to accurately estimate the energy
requirement of physical active young athletes. When
making energy requirement predictions it should be
considered that all children, but particularly those in a
growth spurt, use more energy per unit of body weight
than adults performing the same activity. Typically, the
added energy need is 20%–25% higher than the adult
energy requirement per kg. When estimating energy
needs, it is recommended to use prediction equations
that have been validated for children (i.e., the Schofield
equation). Even when using these equations, it is
important to consider that appropriate growth and
development is often the best guide that the young
athlete is optimally satisfying energy needs.
The distribution of energy substrates is important, but
parents and coaches should understand that total energy
intake adequacy is likely to be more important than the
distribution of protein, carbohydrate, or fat in the diet.
Fat intake is often a concern because it is easy to access
high-fat foods and, as a highly concentrated source of
energy, it is easy to consume an excess intake of energy.
However, young athletes should be cautious of
excessively lowering fat intake, as this can make it far
more difficult for them to obtain the energy they require.
A good goal is to make sure carbohydrate and protein
needs are met, and satisfy the remaining energy
requirement with up to 35% of total calories from fat.
"Backloading" intake (i.e., consuming most protein and
energy at the end of the day) is a common problem in
young athletes that detracts both from optimal growth
and development and performance.
Young athletes tend to underconsume fluids,
predisposing them to dehydration and increasing the risk
of heat illness. Athletes should be encouraged to drink
fluids regularly by supervising adults. Voluntary
dehydration, or the failure to consume sufficient fluids
even when fluids are readily available, is a common
problem among young athletes. Resolving a voluntary
failure to consume sufficient fluids may require fixed
time-schedule drinking opportunities by the "team" that
are organized by supervising adults. Young athletes who
are in training or competition should have regular
opportunities to consume fluids every 10–20 minutes
(depending on the heat index), even if that requires
periodic stoppage of play. Depending on the duration
and intensity of exercise, consumed fluids may require
inclusion of electrolytes and carbohydrate.
Energy-restrictive diets should not be followed by young
athletes, as the resulting negative energy balance
produced by these diets may likely be counterproductive
for the achievement of a desirable weight and body
composition while negatively affecting growth and
development. Contrary to common beliefs, energy-
restrictive diets result in a greater loss of lean (i.e.,
muscle) mass than fat mass, inhibit skeletal
development/growth, and increase long-term chronic
disease risk. Strategies for correcting the obesity (i.e.,
lowering the relative fat mass) should be under the
direct supervision of trained medical professionals.
It is difficult for young athletes, and in particular young
female athletes, to obtain sufficient iron, and surveys
suggest that calcium intake is also marginal. Therefore,
the parents of young athletes should consult with the
family doctor and a registered dietitian to determine if an
altered dietary strategy and/or iron or calcium
supplements are warranted. Ideally, a test for iron status
that measures hemoglobin, hematocrit, and ferritin
performed on a regular yearly basis will help to ensure if
the current diet is satisfying iron requirements.
Female Athletes

Female athletes should be made fully aware of the

negative consequences associated with menstrual
dysfunction and the role energy inadequacy plays in its
development (51). It is important to ensure that female
athletes consume sufficient energy to eliminate the risk
that menstrual dysfunction results from inadequate
energy consumption.
A preparticipation physical examination should be a
standard feature for all athletes involved in all sports. For
the female athlete, the screening should include an
assessment for the presence of the triad and any of its
sequelae, including low BMD and amenorrhea (145).
Calcium status should be regularly assessed and, if
inadequate, corrected through a program of altered food
intake (preferred) or through a physician-supervised
supplementation program. A reasonable means of
assessing calcium status is to periodically assess bone
density via DEXA scan. In addition, a dietary intake
analysis will determine if consumed foods are providing
sufficient calcium.
Iron status should be assessed yearly, including
measures of hemoglobin, hematocrit, and ferritin. In the
event of iron deficiency, a dietary modification to
increase iron intake and/or a physician-supervised
program of iron supplementation with follow-up blood
tests should be immediately implemented.
Female athletes are at higher risk than male athletes for
eating disorders, inadequate bone density attainment,
and inadequate iron consumption. They also have the
unique risk of dysmenorrhea. Most of these difficulties
can be controlled through the consumption of a
nutritionally balanced diet that delivers an adequate
caloric load. To achieve this, female athletes should
understand that an underconsumption of calories, while
 lowering weight, is likely to have a greater catabolic
impact on lean mass than on fat mass. This altered body
composition, by forcing the athlete to consume a still
lower food intake to achieve a desired body profile, will
place the athlete at greater future risk of malnutrition
and associated diseases.
Female athletes may view dieting as a strategy for
improving sport performance. However, while they
perceive to have a high level of control over their food-
eating environment, family, teammates, coaches, and
friends all have significant influence over how the athlete
actually eats (73). Therefore, nutrition education efforts
should target all potential individuals who may have an
impact on the female athlete’s eating behavior.

Older Athletes

Older athletes should take steps to reduce the risk of

dehydration and should develop strategies for fluid
consumption that they can tolerate. Being aware of the
signs of heat stress are important because older athletes
are likely to have lower sweat rates than younger
athletes involved in the same activity.
GI function may require additional vitamin and mineral
intake, perhaps through supplements. Older athletes
should regularly consult with doctors to determine the
biologic need for specific supplements and take them
only in reasonable, prescribed doses. Vitamins and
minerals of particular concern are calcium, iron, zinc,
vitamin B6, and vitamin B12.
Reduced gut motility requires a slight increase in fiber
consumption, but this should always take place in
conjunction with additional fluid intake. Focusing on fresh
fruits and vegetables as well as whole grain products is
an excellent means of obtaining additional fiber, plus
these foods provide needed carbohydrate energy.
 Frequent illness may be a sign that immune function is
depressed. There is no perfect weapon for combating a
reduction in immune function, but exercising reasonably,
eating well, and resting well are useful strategies. Older
athletes with frequent eating patterns should consult
with their physicians.
It takes longer for older athletes to adapt to new
environments, so reducing exercise intensity and
frequency for several days after travel is a logical and
useful step to avoid overheating and illness.
Older athletes can expect some slowing of the metabolic
rate, which makes it more difficult to sustain a desirable
body composition and weight without making the
appropriate reduction in energy consumption. At the
same time, nutrient requirement mandates the
consumption of a diet with a high nutrient density (i.e., a
higher nutrient-to-calorie ratio). Avoidance of
overtraining is important for injury reduction and
sustaining immune function. This is particularly
important because healing time for both injury and
disease is longer with increasing age. Finally, adequate
fluid intake is critically important to avoid dehydration
and to sustain gut motility because the frequency of
urination associated with advanced age may inhibit fluid
consumption.

Practical Application Activity

As a means of assessing the different nutrient

requirements of young athletes, female athletes, and older
athletes, ask yourself some questions regarding the
different issues that are faced by different groups:

1. To adult male and female athletes face the same

nutritional risks? If not, what would you focus on
 differently if you were working with an adult male and
an adult female athlete?
2. How are the DRI/recommended dietary allowances
different for different groups:
a. Do adolescents have the same requirements for
calcium as adults? How would you help ensure that
the greater adolescent calcium requirement is met
without compromising the intake of other
nutrients?
b. Do adult females have the same requirements for
protein as adult males? What strategy would you
follow for advising adult females and adult males
how to optimally satisfy protein intake without
providing excess fat or insufficient carbohydrate?
c. A female of childbearing age has a significantly
higher iron requirement than an equivalently aged
male. How would you ensure that the female
satisfy iron requirement without also providing a
level of energy intake that would be considered
excessive. Can you think of an appropriate dietary
(nonsupplement) strategy for consuming adequate
iron in male and female vegan athletes?
3. The focus on weight, particularly in sports that have a
subjective scoring scheme, such as figure skating and
gymnastics, may predispose the athlete to developing
eating disorders. What nutritional strategies could be
followed that would diminish the risk of developing an
eating disorder?

Chapter Questions

1. In female athletes, amenorrhea is likely to be a sign of:

a. Poor fluid intake
b. Inadequate energy consumption
 c. Low calcium intake
d. Protein being used to satisfy energy needs
2. Heat stress is most likely to be of high concern in:
a. Younger and older athletes
b. Male athletes
c. Female athletes
d. Power athletes
3. Because children and adolescents have such high
appetites, it is easy to satisfy the energy needs of young
athletes.
a. True
b. False
4. Satisfying calcium needs in young athletes is important
because _____% of bone mass is acquired during
adolescence.
a. 10
b. 25
c. 50
d. 75
5. Girls commonly end their adolescent growth spurt by
age______, while boys typically end their growth spurt by
age _______.
a. 16, 19
b. 13, 20
c. 18, 18
d. 15, 21
6. Secondary amenorrhea in female athletes refers to a
condition where:
a. Menses has never been experienced.
b. The first menses occurred late, but by no later than age
16.
c. Menses occurs irregularly.
d. The athlete has experienced a menstrual period, but has
not had a period 3 months or more.
7. Eumenorrhea refers to a female of childbearing age who:
a. Has never had a period.
 b. Has irregular periods.
c. Has regular periods.
d. Has missed only 3 or 4 periods in the last year.
8. Young athletes who practice and compete indoors are at
risk for poor status for which of the following nutrients?
a. Calcium
b. Vitamin A
c. Vitamin D
d. β-Carotene
9. Protein consumption exceeding 30 g at a single meal may
result in an increase in blood urea nitrogen, which is
associated with both dehydration and lower BMD.
a. True
b. False
10. Which of the following young athletes is at increased risk
for having low BMD?
a. Long-distance runners
b. Football players
c. Swimmers
d. Tennis players

Answers to Chapter Questions

1. b
2. a
3. b
4. b
5. a
6. d
7. c
8. a
9. d
10. c
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CHAPTER OBJECTIVES
Identify the differences in energy metabolic processes
between power, team, and endurance athletes.
Explain the best dietary strategies for fueling power
athletes before, during, and after training/competition.
Explain the best dietary strategies for fueling endurance
athletes before, during, and after training/competition.
Explain the best dietary strategies for fueling team sport
athletes before, during, and after training/competition.
Discuss the common dietary problems observed in power
athletes, endurance athletes, and team sport athletes.
Identify appropriate foods and beverages that can be
consumed during competitions for specific power sports,
endurance sports, and team sports.
Know the different muscle types and their energy
utilization characteristics.
Analyze the different potential outcomes well-nourished
and poorly nourished athletes may obtain from
consumption of creatine monohydrate supplements.
Identify the relative energy availability from stored
glycogen, fat, and protein.
Know the primary reason for gluconeogenesis, and the
amino acid and nonamino acid substances that can be
 used to create glucose from noncarbohydrate
substances.

Lots of Protein — All the

Time

Jonathan, a recent college graduate, was deeply

saddened by the recent death of his father at age 72
from cardiovascular disease with kidney failure
complications. He thought seriously about what he could
do to honor his father, a successful businessman and a
former competitive weightlifter with a family room full of
trophies. He decided that his dad would be greatly
pleased to know that his son had taken up weightlifting
with an eye toward being competitive. Jonathan’s father
always wanted his son to take up weightlifting to help
build both his muscles and his self-esteem, but Jonathan
was a bookworm with only minimal interest in sport.
Jonathan joined a weightlifting club, got all the necessary
gear and clothes, and met his coach, who instructed him
on the weightlifting schedule and the nutritional protocol
to follow. Jonathan was seriously committed to doing this
in honor of his dad’s memory, so after his first session he
immediately went to the neighborhood health food store
and picked up large jars of whey protein concentrate,
whey protein isolate, and boxes of high-protein bars —
his new dietary focus to help his muscles and to develop
the weightlifting. He also went to the grocery store and
stocked up on meats — steak, chicken, fish. He was told
to eat lots of protein all the time, as that was the key to
his development as a weightlifter, and that is precisely
what he was going to do. Carbohydrates, he was told,
were not good for him, so he decided to limit his intake
to an occasional baked potato.
 After following the weightlifting and high-protein
intake protocol for several weeks, Jonathan started
noticing some changes. His body was definitely growing
muscle, and some of the muscles were starting to peek
through this body fat. Despite these changes, he was not
feeling as good as he had hoped. The first few weeks
were terrible, but he understood that to be a common
problem associated with the increased physical activity.
But he had hoped that, by now, he could feel better and
more vigorous. Instead, he smelled terrible, he was
urinating with greater frequency than ever before, and
his urine was dark yellow. To make matters worse, he felt
tired all the time, as if his brain needed to be purposely
jolted to focus. His bookworm days were over, as reading
just one page made him lose his concentration.
After a few more weeks of this he decided something
was just not right, so he forced himself to look into some
recommended nutrition protocols for getting fit. What he
found surprised him. All that protein was not the best
way to fuel his muscle, plus the volume of protein he was
eating was forcing him to excrete a great deal of
nitrogenous waste that increased dehydration risk (thus
the deep-yellow urine). To make matters worse, the low-
carbohydrate intake made it difficult for him to maintain
normal central nervous system (i.e., brain) function,
which is reliant on blood sugar (carbohydrate) as a
primary fuel. Then he learned that much of the protein
he was eating was really high in saturated animal fat
that, in the long term, would cause the same problems
responsible for his dad’s death.
He decided to do it right by eating good foods with
good-quality protein distributed well throughout the day.
The way he felt changed almost immediately, and his
time at the gym while weightlifting became an act of
pleasure rather than an act of suffering.
 CASE STUDY DISCUSSION QUESTIONS
High protein consumption is common among power
athletes, as it is commonly believed that only protein will
help to increase muscle mass, which is a necessary part
of power sports such as weightlifting.

1. What is the maximum protein consumption that an

athlete, including a power athlete, should consume
on a daily basis (in g/kg)?
2. What are the components of eating protein and other
nutrients correctly to help ensure that the consumed
protein can be used anabolically to help build and
maintain muscle tissue?
3. What are the common health problems that can be
experienced from a high-protein/low-carbohydrate
intake?
4. If you were standing in front of a group of power
athletes, what are the three key nutrition messages
you would give them to help them achieve their
goals?

Introduction

Following an appropriate nutritional strategy that is well

integrated into the athlete’s lifestyle and the demands of the
sport is a critical component of success in the competitive
athlete. Interestingly, many of the general nutrition
recommendations for athletes deviate little from the general
recommendations for the general public to lower chronic
disease risk. Regardless of the sport, poor nutrient exposure
through consumption of foods that have low nutrient density,
poor hydration, and poor energy balance during the day has
a negative impact on athlete health, increases injury risk,
and diminishes performance. However, the type of physical
activity related to the demands of sport-specific training and
competition requires that nutrition recommendations are
fine-tuned to ensure that the athlete can perform at her or
his conditioned capacity.
Ensuring that these specific nutritional requirements are
met requires an understanding of the energy metabolic
pathways, the desired body composition of the athlete, and
the opportunities during competition (i.e., breaks between
quarters, half-time) that provide natural opportunities for
supplying needed nutrients and fluids. Importantly, studies
of competitive athletes suggest that many have suboptimal
dietary intakes that fail to provide the nutrients and fluids
that could enable better performance (18). Athletes often
consume the same few foods that fail to optimally expose
tissues to the needed array of nutrients, they often attempt
to “make weight” using strategies that result in poor energy
availability, and the hydration behaviors suggest insufficient
consumption of less-than-optimal beverages. Poor energy
delivery that results in low blood sugar will result in
gluconeogenesis, which diminishes the muscular benefit
an athlete may achieve from exercise. Any of these factors
alone can diminish performance, but athletes often fail to
satisfy all of these nutritional factors (i.e., energy, nutrients,
and fluids). This may be due to not only inadequate planning
but also nutrition-related myths and the confusion associated
with the availability of a wide array of different products,
each with different content, that are marketed to athletes. As
an example, the carbohydrate energy products commercially
available to athletes all appear to target the same nutritional
needs, but they have an enormous variability in energy
delivered, carbohydrate content, composition of
carbohydrate and free sugar content, and osmolality (133)
(Table 11.1).
Table Descriptions of CHO Gels for Parameters
11.1 Related to Service Size, Energy Density,
Energy Content, CHO Content, Free Sugar
Content, Fructose Content, and Osmolality
Mean é Median Range Comments
SD
Serving 50 ± 22 45 29– 20 out of 31
size (g) 120 products are
offered in
packages below
45 g. Only two
product ranges are
packaged over
100 g.
Energy 2.34 ± 2.60 0.83– Only one product
density 0.70 3.40 has an energy
(kcal/g) density <1 kcal/g.
The most popular
range of energy
densities is 2–3
kcal/g, although a
significant number
of products (7 out
of 31) do offer
energy densities
>3 kcal/g.
Energy/gel 105 ± 100 78– The most popular
(kcal) 24 204 energy range is
between 100 and
120 kcal/gel.
25/31 products fall
within this range,
the majority falling
within 100–110
kcal/gel.
Table Descriptions of CHO Gels for Parameters
11.1 Related to Service Size, Energy Density,
Energy Content, CHO Content, Free Sugar
Content, Fructose Content, and Osmolality
Mean é Median Range Comments
SD
Total CHO 25.9 ± 24.6 18–51 The most popular
(g) 6.2 carbohydrate
range is 20–30
g/gel. 25/31
products fall into
this range, with
the majority of
those (14
products)
containing less
than 25 g. Only
three products
offer less than 20
g, and only three
offer more than 30
g.
Free 9.3 ± 7.9 0.6– Only one product
sugars/gel 7.0 26.8 has free sugars <1
(g) g/gel. Of the
remainder, the
majority (15
products) provide
5–15 g free
sugar/gel. Four
products provide
>20 g free
sugars/gel.
 Table Descriptions of CHO Gels for Parameters
11.1 Related to Service Size, Energy Density,
Energy Content, CHO Content, Free Sugar
Content, Fructose Content, and Osmolality
Mean é Median Range Comments
SD
Free 35 ± 25 33 3–95
Only two products
sugars/gel have free sugars
(% of total <10% total CHO.
CHO) 20/31 products
have free sugars
>20% of total
CHO, and of these
nearly half (nine
products) have
free sugars >50%
of total CHO.
Fructose Unknown Unknown 0– Out of 31
content >20% products, only 3
CHO do not contain
fructose in some
form. Exact
amounts present
cannot be
quantified from
the ingredient
labels.
Osmolality 4,424 ± 4,722 303– Only one product
(mmol/kg) 2,883 10,135 range is isotonic.
27 out of 31
products have
osmolality >1,000
mmol/kg.

CHO, cholesterol.
Source: Zhang X, O’Kennedy N, Morton JP. Extreme variation of nutritional
composition and osmolality of commercially available carbohydrate energy gels
Int J Sport Nutr Exerc Metab. 2015;25:504–9.

Gluconeogenesis

Refers to the metabolic process for producing glucose from

noncarbohydrate substances, including lactate, glycerol,
and glucogenic amino acids. The primary stimulus for
gluconeogenesis is to maintain blood glucose, which is the
primary fuel for the brain. As there is no storage depot for
proteins, the glucogenic amino acids are obtained from the
undesired catabolism of lean mass (muscle and organ
mass).

Some sports require quick bursts of activity, some require

steady continuous movement with occasional periods of fast
activity, and others require that muscles work slowly and
continuously for hours. Each type of activity places unique
demands on the muscles and on the fuels that muscles
demand. There are clear metabolic differences in activities
that require endurance and power. This chapter reviews the
special nutrition requirements for athletes involved in power
sports, endurance sports, and team sports.
The type of physical activity being performed influences
the demands on how cells will derive the energy they
require. Different sports place different demands on the
energy system, but it is important to consider that all energy
metabolic systems are functioning during power activities,
including anaerobic metabolism, which includes energy
derived from phosphagen breakdown and from anaerobic
glycolysis (carbohydrate), and from aerobic metabolism from
energy derived from carbohydrates and fats. Power activities
mandate that the athlete have the ability to explode off a
starting block, jump high distances, throw a heavy weight, or
push someone of equal size backward. The better the power
athlete can do some of these things, the more successful the
athlete is. Getting power athletes to train muscles for these
activities is critical for competitive success, and this training
regimen must be supported by proper nutrition, or all that
hard work will be fruitless.
Individual amino acids have been widely used by athletes
and amino acid mixtures represent a large category of
supplements targeting bodybuilders (43, 47). There are no
convincing studies to show that self-directed consumption of
supplements is an effective strategy for performance
enhancement. In addition, there are potential health risks
associated with taking high-dose supplements (23).
However, there are a number of studies on athletes that
demonstrate that consumption of milk-based protein
following resistance activity effectively increases muscle
strength and enables favorable changes in body
composition (57, 119). Good food sources of protein, such as
meat, fish, poultry, dairy products, and legumes, in
combination with cereals all provide good-quality protein
with a desirable distribution of essential amino acids.
Because of the scant evidence that consumption of
supplementary protein is superior to eating these foods,
which also expose athletes to other needed nutrients that
include iron and zinc, athletes should take a food-first
nutritional approach to improving performance (66, 81, 116).

Energy Demands

Power Activities

The term applied to sports that require the athlete to

generate a high level of muscular force to produce fast and
powerful movement speeds that are highly reliant on
anaerobic metabolic processes. Examples of these
anaerobic sports include sprinting, boxing, baseball, and
hockey.

Anaerobic Sports

Includes sports that rely heavily, but not exclusively, on

anaerobic metabolic processes and are typically sports
that involve short duration/short distances with relatively
high intensity. Examples include sprinting, boxing,
wrestling, weightlifting, and bodybuilding.

Strength

Often used synonymously with power, strength is a

measure of the mass that can be moved (i.e., lifted,
pushed) by an athlete and is highly dependent on
muscular mass or the muscle-to-weight ratio. For instance,
an athlete with a high muscle-to-weight ratio should be
able to move more mass for his/her weight than an athlete
with a lower muscle-to-weight ratio.

Important Factors to Consider

Different sports place different demands on energy

metabolic systems, but all energy metabolic systems
are being used nearly all the time. The difference is the
proportion of demand. For instance, long-distance
runners may be 10% reliant on anaerobic metabolic
systems and 90% reliant on aerobic metabolic
systems, whereas a 100-m sprinter may have
proportions reversed (after all, the sprinter is still
breathing and bringing oxygen into the system).
 Different energy systems draw on different sources of
energy, which helps explain why primarily anaerobic
activities can only proceed for a relatively short period
of time. We have high levels of fat storage, which can
be accessed aerobically for energy and allow the
aerobic athlete to perform for long periods of time.
However, anaerobic fuels, phosphocreatine (PCr) and
glycogen, have limited storage that will become
depleted quickly with continuous high-intensity
activity.

Power athletes utilize multiple energy-producing

pathways that provide energy from phosphagen,
carbohydrate, and/or fat. Understanding the different energy
systems and the fuels needed for the production of
adenosine triphosphate (ATP) is necessary when making
nutritional recommendations (111). Power activities rely on
appropriate conditioning of fast-twitch muscle fibers. Fast-
twitch (type IIb) fibers can produce a tremendous amount of
power and also have a high capacity to store carbohydrate
as glycogen. However, they have a limited capacity to store
fats as triglycerides. The different energy fuel storage
potential helps to clarify the fuel dependence of each unique
muscle fiber type (Table 11.2). At their genetic baseline, the
intermediate fast-twitch muscle fibers (type IIa) also produce
a high level of power, but these muscle fibers can be trained
to behave more like the type I slow-twitch fibers in athletes
who spend long hours in endurance activities (134). The type
of training that is done is an important factor, therefore, in
determining muscle fiber behavior. Power athletes require
that the muscle fibers are capable of producing a high level
of power. If a significant proportion of the training involves
aerobic (i.e., endurance) conditioning, the type IIa fibers may
lose some power capacity because they have been
conditioned to have more endurance potential. Interestingly,
there is evidence that the intermediate fast-twitch fibers will
revert to their genetic baseline (more power and less aerobic
potential) rather quickly if the aerobic training ceases (120).

Table 11.2 Muscle Fiber Types and Their Energy

Utilization Characteristics
Muscle Fiber Type I Type IIa (Red)- Type IIb
(Red)-Slow Intermediate (White)-
Twitch Fast Twitch Fast Twitch
(High (Moderate (Low
Fatigue Fatigue Fatigue
Resistance) Resistance) Resistance)
Ability to store Low Moderate High
and use
glycogen
Ability to store High Moderate Low
and use fat
Ability to store Moderate High High
and use
phosphocreatine
Ability to use High Moderate Low
oxygen in
energy
reactions
(oxidative
capacity)
Ability to Low High Very High
produce power
(contraction
speed)
Blood (capillary) High Moderate Low
supply to
muscle fibers
Sources: Gleeson M. Chapter 3: Biochemistry of Exercise. In: Maughan RJ. (Ed)
Sports Nutrition: Volume XIX of the Encyclopaedia of Sports Medicine – An IOC
Medical Commission Publication Wiley/Blackwell: London © 2014. pp 36–38.
Kenney LW, Wilmore J, and Costill D. Physiology of Sport and Exercise 6th Edition.
Human Kinetics/Champaign. © 2015. pp 40–41.

High-speed activity of short duration (such as the 100-m

sprint) demands fuel that is already in the muscles in a near
ready-to-go state. The amount of this ready-to-go fuel, PCr,
that muscles can hold is limited, creating limits to the
maximum duration of maximal speed/power activity. For a
well-nourished athlete, the phosphagen system may provide
sufficient fuel for the first 5–8 seconds. This is not sufficient
for most events, requiring muscles to have the ability to
quickly convert stored glycogen into useable fuel that can be
metabolized anaerobically.
More ATP is produced per unit of time from the
phosphagen system (i.e., PCr) than from anaerobic
glycolysis. As a result, the reduction in energy availability to
muscles results in slower contraction and reduced speed. As
a result, the speed of a sprinter slows when PCr can no
longer provide the necessary ATP (Figure 11.1). Total fatigue
occurs when PCr is depleted and blood and muscle lactate
are at the maximum level. Most scientists believe that the
anaerobic maximum (i.e., the amount of time an athlete can
exercise at a maximal level) is ∼1.5 minutes, but with wide
variability depending on conditioned state (51, 52). The
combination of both anaerobic systems (phosphagen and
anaerobic glycolysis), which are used when an athlete is
going as hard and fast as possible, will be depleted in ∼1.5
minutes with a concomitant increase in lactate, resulting in
athlete fatigue and cessation of high-intensity work. This
stoppage of high-intensity work varies widely between
athletes, often a function of anaerobic conditioning, occurs in
∼1.5 minutes, and is commonly referred to as the
anaerobic threshold.
FIGURE 11.1: The predominant energy systems for different
activities, ranging from sudden high intensity to endurance.
Short-term maximal high-intensity activity is highly reliant on
PCr to obtain sufficient ATP. When the limited stores of PCr
are exhausted, more energy must be derived from anaerobic
glycolysis, which cannot produce ATP at the same high rate
as that of PCr. In practical terms, exhausting PCr stores
necessarily results in having to “slow down” because of
lower ATP production. Complete fatigue occurs when PCr is
depleted and blood and muscle lactate are at the maximal
level. ATP, adenosine triphosphate; PCr, phosphocreatine.
(Illustration from Premkumar K. The Massage Connection,
Anatomy and Physiology. 2nd ed. Baltimore (MD): Lippincott
Williams & Wilkins; 2004. Data from Hirvonen J, Nummela A,
Rusko H, Rehunen S, Härkönen M. Fatigue and changes of
ATP, creatine phosphate, and lactate during the 400 m
sprint. Can J Sport Sci. 1992;17(2):141–4 and Hirvonen J,
Rehunen S, Rusko H, Härkönen. Breakdown of high-energy
phosphate compounds and lactate accumulation during
short supramaximal exercise. Eur J Appl Physiol Occup
Physiol. 1987;56(3):253–9.)

As exercise time increases, power production decreases

and a higher proportion of energy is derived from aerobic
metabolic processes. Aerobic metabolism enables the
metabolism of fat as an energy substrate, thereby reducing
the reliance on glycogen and PCr, both of which have a
limited storage capacity. Faster/harder physical activity
results in greater fuel utilization per unit of time, with greater
oxygen requirements needed to oxidatively burn the fuel.
Muscular work that is sufficiently hard and fast to exceed the
capacity to supply sufficient oxygen results in the anaerobic
metabolism of PCr and glycogen to provide the needed fuel.
However, although fat storage is virtually unlimited for even
lean athletes, both PCr and glycogen have limited storage.
Well-conditioned athletes have better oxygen delivery to
cells, enabling relatively greater reliance on
aerobic/oxidative metabolic processes and lower reliance on
anaerobic metabolic processes (99). This allows them to go
faster longer without achieving the fatigue associated with a
buildup of lactate and depletion of PCr and glycogen.
However, for fats to burn cleanly, carbohydrates are also
necessary. Running out of available carbohydrate fuel
diminishes the capacity to burn fats effectively and muscular
fatigue sets in.
 Adenosine Triphosphate

Abbreviated as ATP, a molecule made of high-energy

bonds that can rapidly release energy for all body
processes that include muscle contraction.

Phosphocreatine

Abbreviated as PCr, a high-energy phosphate found in

body cells that are part of the anaerobic PCr energy
system. PCr can be used to rapidly replenish ATP.

Anaerobic Threshold

Refers to the intensity of exercise during which lactic acid

buildup exceeds the tissue capacity to remove it from
working muscles. It is at this point that muscle function
quickly degrades and the activity must stop, which is
typically about 1.5 minutes after the initiation of the high-
intensity activity. It is also referred to as the lactate
threshold, the lactate turning point, and the lactate
inflection point. In practical terms, the anaerobic threshold
is often expressed as 75% of maximal oxygen consumption
(i.e., 75% VO2max) or 85% of the maximal predicted heart
rate.

Aerobic Metabolism

Refers to energy processes that occur with the

incorporation of oxygen. These processes include aerobic
glycolysis, which is used for high-intensity activities that
require a large volume of ATP, but that are within the
athlete’s capacity to bring sufficient oxygen into the
system; and also the metabolism of fats, which is used for
low-intensity activities of long duration that can produce a
 substantial volume of ATP, but without the production of
system-limiting by-products such as lactic acid (lactate).

To summarize, energy can be obtained anaerobically

(without oxygen) and also aerobically (with oxygen).
Proportionately greater anaerobic energy pathways are used
with high-intensity activities of shorter duration, whereas
proportionately greater aerobic energy pathways are
typically used with activities of lower intensity but longer
duration (Table 11.3).

Phosphagen System (Creatine Phosphate)

Energy can be released anaerobically from the phosphates in
ATP and creatine phosphate (PCr) to support high-intensity
exercise for up to ∼8 seconds. This system, referred to as
the phosphagen system because of the immediate
availability of high-energy phosphate, is dependent on PCr to
quickly provide a high-energy phosphate molecule to form
ATP, which is the ultimate source of energy for all body
functions. There are a number of sports that rely heavily (if
not exclusively) on this phosphagen system. These sports
include shot put, long jump, triple jump, discus, gymnastics
vault, and short sprints. In addition, other sports that have
quick bursts of activity intermingled in the activity (such as
football, volleyball, and hockey) are also reliant on this
energy pathway. In some of these sports, the ability to do
repeat high-intensity moves often determines the winner. For
instance, the high jumper, long jumper, and pole-vaulter all
need two or three stellar efforts with the hope that one of
them will be good enough to win. These repeated bouts of
high-intensity work place a tremendous reliance on the
phosphagen system. The athlete who has the ability to store
more creatine may be at an advantage in these activities.
With improved creatine storage, it is possible that the athlete
would retain, because of the capacity to adequately reform
PCr, much of the power produced on the first attempt than in
the second and third attempts.
Assuming that total energy and protein intake is
adequate, athletes can manufacture the creatine needed for
multiple quick bursts of high-intensity activity. To improve
the storage of ATP-PCr in the muscles, athletes must practice
activities that focus on this system (i.e., activities that last
no more than 8 seconds, that are high intensity, and that are
repeated multiple times during an exercise session). This
type of training, by itself, is not sufficient to improve short-
duration, high-intensity performance. At the same time,
consuming sufficient energy and protein, by itself, is also not
sufficient to improve short-duration, high-intensity
performance. However, when both proper training and
proper nutrition are combined, the athlete can experience
very real gains in short-duration, high-intensity performance.
Even with higher creatine storage, the maximum preformed
PCr is sufficient to last up to only 8 seconds of hard physical
work. (If humans stored more than 8 seconds worth, we
could probably combust for the high heat created with so
much energy produced so quickly.) Athletes performing
maximal exercise for up to 8 seconds (sprint, vault, jumps)
must take a break of 2–4 minutes with ample oxygen
availability to allow for the regeneration of PCr before
undertaking another maximal bout of exercise (39, 49).
Imagine a 100-m sprinter accelerating over the first 8
seconds of the race, but then PCr runs out and anaerobic
glycolysis takes over. Because anaerobic glycolysis cannot
produce as much ATP per unit of time as PCr, the person who
wins the 100-m dash is typically the person who slows down
the least during the last 2 seconds of the race.
In theory, having a higher level of stored creatine in the
tissues enables improved PCr availability to form ATP and,
therefore, greater capacity to do more extremely high-
intensity work. It is for this reason that creatine monohydrate
supplementation is popular with athletes who want to find a
way to increase power and reduce the onset of fatigue.
Although supplementation may increase creatine storage,
the upper limit for preformed PCr remains about 8 seconds
worth of fuel. In athletes who fail to consume sufficient
energy and protein, supplementing with creatine may be
useful in maximizing PCr potential (30). However, there is
evidence that sufficient energy intake may be the key to
ensuring that sufficient PCr is stored and remanufactured
when required (61). As displayed in Table 11.4, different fuels
have different capacities to supply energy. As indicated, we
have an enormous capacity to supply fat for energy, whereas
the storage of carbohydrate fuels is limited. Although the
protein mass has the potential of being broken down as a
source of energy, this typically only occurs when
carbohydrate fuel becomes depleted.

Table Energy Metabolic Systems

11.3
System Characteristics Duration
PCr system Anaerobic Used for maximal intensity
production of ATP activities lasting no more
from stored PCr. than 8 s.
Anaerobic Anaerobic Used for extremely-high-
glycolysis production of ATP intensity activities that
(lactic acid from the exceed the athlete’s
system) breakdown of capacity to bring in
glycogen. By- sufficient oxygen. Can
product of this continue producing ATP
system is the with this system no more
production of than 2 min.
lactic acid.
Table Energy Metabolic Systems
11.3
System Characteristics
Duration
Aerobic Aerobic Used for high-intensity
glycolysis production of
activities that require a
large amounts of
large volume of ATP, but
ATP from thethat are within the
breakdown ofathlete’s capacity to bring
glycogen. sufficient oxygen into the
system.
Oxygen Aerobic Used for lower-intensity
system production of ATP activities on long duration
(aerobic from the that can produce a
metabolism) breakdown of substantial volume of ATP,
carbohydrates but without the production
and fats. of system-limiting by-
products.

ATP, adenosine triphosphate; PCr, phosphocreatine.

The glucogenic amino acids can be converted to

carbohydrate (glucose) (Box 11.1), but fat cannot be
converted to carbohydrate (86). It is important, therefore, for
athletes to sustain carbohydrate availability during physical
activity to help ensure that the protein mass (i.e., muscles) is
not broken down as a source of needed fuel. The protein
mass indicated in Table 11.4 is provided as a source of
potential energy, but by no means should this protein mass
be considered as a desired source of energy for the athlete.

Box 11.1 Glucogenic Amino Acids

Amino acids derived from protein tissues, including

muscles and organs, that can be converted to glucose are:
 alanine
threonine
serine
glycine
α-aminobutyrate
methionine
tyrosine
lysine

Anaerobic Metabolism (Glycolysis)

Anaerobic metabolism (glycolysis) is used to provide
energy during high-intensity exercise that exceeds the
athlete’s ability to provide sufficient oxygen to tissues for the
work being performed. Intense physical activity is, to a large
degree, dependent on the availability of muscle glycogen
(the storage form of glucose). Depletion of glycogen during
high-intensity activity results, therefore, in rapid fatigue and
the cessation of exercise. In normal daily nonintense activity,
glycolysis provides only a small proportion of the total
energy required by working muscles. A sudden increase in
muscle movement and/or continuous high-intensity activity
is reliant on glycolysis because it is capable of providing
tissue energy quickly and fills the energy gap between the
onset of sudden movement and/or intense activity and the
time required for aerobic energy metabolism to satisfy
energy needs. If someone tries to maintain a high-intensity
(i.e., anaerobic) activity, the fuel for this will run out after
∼1.5 minutes, and the athlete will become quickly fatigued.
Even predominantly aerobic sports may rely on the
anaerobic energy pathway to make the difference between
winning and losing. The long-distance runner who has run
most of the race aerobically and has preserved some muscle
glycogen is likely to require the added ATP energy from
glycolysis to finish the race with a strong (anaerobic) “kick”
(19, 75). The athlete who has this energy preserved at the
end of the race may be the only difference between first
place and those who follow. For runners running short-
distance races, for swimmers in short races, and for hockey
players skating at full bore at the end of a game to go for a
winning score, this anaerobic pathway is an important key to
success. Carbohydrate storage is the key to making this
happen, and storage occurs best with the consumption of
carbohydrate foods/beverages (91).

Table Energy Stores in an Average Man Weighing

11.4 70 kg (154 lb) With 15% Body Fat
Energy Mass (kg) Energy (kcal) Exercise (min)a
Source
Liver 0.08 307 16
glycogen
Muscle 0.40 1,530 80
glycogen
Blood 0.01 38 2
glucoseb
Fat 10.5 92,800 4,856
Protein 12.0 48,725 2,550

Values assume sole energy substrate availability during marathon pace activity
or about 20 kcal/min.
a
Minutes refer to the hypothetic time of exercise if the person were solely reliant
on the energy source indicated. The value is provided for comparison purposes,
to display relative availability of different fuels.
b
Value for blood glucose includes the glucose content of extracellular fluid. Not
all of this and not more than a very small part of the total protein is available for
use during exercise.
Source: Gleeson M. Biochemistry of exercise. In: Maughan R. editor. IOC
Encyclopedia of Sports Medicine: Sports Nutrition. London: Wiley Blackwell; 2000.
p. 48.

Anaerobic Metabolism
Refers to energy processes that occur without the need for
oxygen. Includes anaerobic glycolysis, which involves
cellular metabolic processes that produce energy from
glycogen (stored carbohydrate) without the need for
oxygen; also includes the phosphagen system, which
produces energy from PCr metabolism.

Aerobic Sports

Includes sports that rely heavily, but not exclusively, on

aerobic metabolic processes and typically involve long
duration/long distances with relatively low intensity.
Examples include long-distance running, distance
swimming, distance cycling, and speed walking.

Important Factors to Consider

Sprinting is used to define brief maximum effort in running,

cycling, swimming, canoeing, rowing, field hockey, soccer,
and rugby. In general, a sprint is considered brief maximal
effort of less than 60 seconds duration, with an exercise
intensity of effort well beyond VO2max.

Elite male sprinters can maintain maximal speed for

20–30 m
Elite female sprinters can maintain maximal speed for
15–20 m
Gender differences due to
Mechanical factors (foot strike, neuromuscular
coordination, air resistance) and
Metabolic factors (PCr availability)
 Nutrition Strategies for Improving Power
and Speed

Depending on the speed and VO2max percent of the activity,

the proportion of the energy derived from these different
energy metabolic systems varies (111). As indicated in Table
11.5, quicker activities are proportionately more reliant on
anaerobic energy metabolism, whereas longer duration
activities are proportionately more reliant on aerobic energy
metabolism. However, all metabolic systems are contributors
to satisfying the athlete’s energy needs.
Power athletes perform power and speed activities that
utilize primarily the PCr and glycolytic anaerobic metabolic
systems. Glycogen and lipid stores are present in all muscle
fiber types, but fast-twitch muscle fibers have a 16%–31%
greater level of glycogen storage than slow-twitch fibers
(100). During exercise, the glycogen concentration
decreases first in slow-twitch fibers, but decreases quickly in
fast-twitch fibers thereafter (45). The lower fat storage in
type IIa and IIb muscle fibers is a result of having limited
oxidative capacity because of relatively poor blood supply.
This makes it difficult to supply these fibers with energy
substrates and to remove metabolic by-products (i.e.,
lactate) out of the fibers during physical activity. This also
helps to explain why high-intensity/power activities rarely go
beyond 1.5–2.0 minutes and why athletes require a recovery
break of 2–5 minutes to enable muscle recovery of PCr (58).

Table 11.5 Proportionate Usage of Energy

Metabolic Systems to Satisfy Energy
Needs in Power Sports
Event Time % Anaerobic Anaerobic Aerobic
Range VO2max Phosphocreatine Glycolysis
Table 11.5 Proportionate Usage of Energy
Metabolic Systems to Satisfy Energy
Needs in Power Sports
Event Time % Anaerobic Anaerobic Aerobic
Range VO2max Phosphocreatine Glycolysis
0.5–1 min, ∼150 ∼10 ∼47–60 ∼30–
such as 400 43
m run; 100 m
swim
1.5–2.0 min, 113– ∼5 ∼29–45 ∼50–
such as 800 130 66
m run; 200 m
swim; 500 m
kayak
3.0–5.0 min, 103– ∼2 ∼14–18 ∼70–
such as 1,500 115 84
m run; 400 m
swim; 1,000
m kayak
5.0–8.0 min, 98– <1 ∼10–12 ∼88–
such as 3,000 102 90
m run; 2,000
m rowing

Sources: Spencer MR, Gastin PB. Energy system contribution during 200- to 1500-
m running in highly trained athletes. Med Sci Sports Exerc. 2001;33:157–62;
Stellingwerff T, Maughan RJ, Burke LM. Nutrition for power sports: middle-
distance running, track cycling, rowing, canoeing/kayaking, and swimming. J
Sports Sci. 2011;29(S1):S79–89.

The high dependence on fast-twitch muscle fibers needed

for high-intensity anaerobic work makes it relatively more
difficult for power athletes to metabolize fat as an energy
substrate when compared with athletes that perform aerobic
activities and are more reliant on oxidative metabolism
(105). Power athletes continue to burn limited amounts of
fat, but high-intensity anaerobic activity dramatically favors
carbohydrate (glycogen) over fat as a fuel because of the
kind of muscle fibers that are being used. When power
athletes stop their intensive in-season training but maintain
their high-calorie, relatively high-fat diets, a sufficient
difference in energy balance occurs that causes inevitable
increases in body fat. This may be at least in part due to fat
intakes that often exceed recommended intake levels,
perhaps from an emphasis on meat-derived high-protein
diets that are naturally high in fat (132). Besides the poor
competitive body composition this excessively high-fat
intake results in, there is evidence that the weight cycling
many power athletes often experience may predispose them
to obesity following retirement from the sport, which
increases risk of greater illness frequency and earlier
mortality (55, 112).

Important Factors to Consider

Air resistance can influence speed and energy utilization in

sprint performance:

Elite 100-m sprinters running 10 m/s would run 0.25–

0.5 s faster if they did not have to overcome air
resistance (28).
Air resistance accounts for 16% of total energy
expended to run 100 m in 10 s (88).
Mexico City altitude (less air resistance) provides a
0.07 s advantage over 100 m (63).

Carbohydrate Recommendations for

Power/Strength/Speed Athletes
Glycogen is a key source of energy in anaerobic metabolism,
and high-carbohydrate diets enhance glycogen stores,
resulting in longer time to fatigue when compared with high-
protein, low-carbohydrate diets (17). Studies have
consistently found that low-carbohydrate diets providing
∼3%–15% of total calories from carbohydrate weaken high-
intensity performance (21, 68). Carbohydrate metabolism
provides the majority of ATP during exercise exceeding 75%
VO2max. These high intensities mandate consumption of
high-carbohydrate diets to avoid glycogen depletion. Even a
single bout of high-intensity training can lower glycogen
stores by 24%–40%, depending on exercise duration and
intensity (62, 117).
Current carbohydrate intake guidelines recommend
consumption of ∼8–12 g/kg/day for power/strength athletes
who spend a significant proportion of the day (>4–5
hours/day) involved in moderate- to high-intensity exercise.
For athletes involved in 1–3 hours/day of moderate- to high-
intensity activity, the recommended carbohydrate intake is
6–10 g/kg/day (118). Surveys of strength athletes vary
widely in the typical consumption of carbohydrate, often
suggesting that intakes are far below the recommended
level. Lifters and throwers typically report carbohydrate
intakes of 3–5 g/kg/day, and body bodybuilders report
intakes of 4–7 g/kg/day, regardless of gender (105).

Protein Recommendations
For power/speed athletes, a protein intake of 1.5–1.7
g/kg/day is recommended, or approximately double the
requirement for an average healthy nonathlete (0.8
g/kg/day) (84). The recommendation of the American College
of Sports Medicine (ACSM) for all athletes is a protein intake
that typically ranges from 1.2 to 2.0 g/kg/day (118). The
ACSM now also recommends that the protein be consumed
in modest amounts (∼0.3 g/kg per meal) of high-quality
protein with regular spacing throughout the day to optimize
muscle protein synthesis and muscle recovery (see Example
11.1). Optimal utilization of protein only occurs with
sufficient energy availability, so ensuring an adequate caloric
intake that is dynamically spaced during the day to satisfy
energy requirements is an important dietary strategy (113).
Taking these factors together strongly implies that athletes
should consume good-quality protein in meals and snacks
that are distributed throughout the day, with special focus on
protein consumption immediately following exercise to
encourage muscle protein synthesis (85).

Example: Calculating Protein Distribution During the

Day for Athletes Weighing 110 kg
Calculate total protein requirement:

Calculate amount per meal:

Calculate number of meals with recommended protein:

Interpretation: This athlete requires 33 g of protein

∼6×/day to satisfy the protein requirement of 187
g/day

Surveys of athletes consuming >3,000 kcal/day suggest

that they consume at or above the currently recommended
level of protein, but often fail to appropriately distribute the
protein consumption in amounts that will result in optimal
muscle protein synthesis (105). There is also reason to
believe that consumption of greater than the recommended
amount of protein, often at the expense of carbohydrate,
fails to enhance muscle protein synthesis and muscle
recovery and results in catabolizing more protein as a source
of energy with no anabolic benefit (69).

Fat Recommendations
Carbohydrate should serve as the primary fuel for power
athletes, but fat is also an important fuel that is available for
moderate- to high-intensity activity of up to 85% VO2max
(110). The generally recommended level of fat intake has
been estimated at 2 g/kg/day, as intakes greater than this
level may interfere with muscle glycogen recovery and
muscle tissue repair through displacement of needed
carbohydrate and protein (31). This level of intake should
suffice for delivery of fat-soluble vitamins, essential fatty
acids, and synthesis of hormones (111). Surveys of
power/strength athletes suggest that fat consumption
exceeds currently recommended levels, and the fat is often
high in saturated fatty acids (132). It has been suggested
that the excessively high intake of fat may be the result of a
high consumption of meat, as these athletes try to consume
high levels of protein (105). It is important to consider that
excess consumption of one energy substrate necessarily
results in an inadequate consumption of another energy
substrate in athletes who are satisfying total energy
requirements.

Building Lean (Muscle) Mass

Building muscle mass has been the tradition for centuries
with power athletes, including for the 6th century Greek
Olympic wrestling champion, Milo of Croton, who was famous
for carrying a growing calf the length of the stadium each
day (progressive resistance exercise), and after 4 years of
carrying it, he ate the calf (excessively high protein intake)
(60, 94). Modern power athletes also investigate strategies
for enhancing muscle mass to improve both strength and
power. There are many techniques employed for increasing
muscle mass, including resistance training, consumption of
more energy (calories), and consuming products (often
illegal) that claim to improve muscle acquisition. Some
strategies work, whereas others do not, so power/strength
athletes should be careful about the strategies that follow. It
may appear that consumption of a substance works to
improve musculature, but often this may be because it
merely fulfills a dietary weakness that could more easily and
less expensively be resolved by following some relatively
simple dietary strategies. Excess protein consumption is
commonly believed to enhance muscle development, but
this strategy may be counterproductive because of the
excess nitrogenous excretion and associated dehydration
that develops. Excess protein consumption has been
reported in a number of surveys, ranging from 1.9 to 4.3
g/kg for men and 0.8 to 2.8 g/kg for women (50, 107).
Assuming the protein is distributed well throughout the day,
there is some evidence that protein intake levels of up to 2.2
g/kg/day may be useful in bodybuilding (79). It is well
established that resistance training stimulates muscle
development and that the level of muscle development may
be influenced by the circulating level of human growth
hormone, insulin, testosterone, and other anabolic hormones
(10, 33, 46, 131). Inasmuch as nutrition may have an impact
on the availability of these substances, it seems reasonable
to believe that specific nutrients may play a role in muscle
development. However, it is also reasonable to believe that
nutrient intake would not influence the body’s production of
these substances if their levels are already normal. In other
words, in the absence of a specific nutrient deficiency it is
difficult to believe that taking more of a nutrient would alter
the production of muscle-building hormones. Again, more
than enough is not better than enough.
 Nutrition Strategies for Improving
Endurance

Endurance athletes are involved in events with continuous

movement for longer than 20 minutes. Typically, endurance
sports require continuous movement over long distances or
time periods (marathon, cross-country skiing, triathlon, etc.).
Premature fatigue most likely occurs from either dehydration
or depletion of carbohydrate stores (98). Other problems
experienced by endurance athletes, including
gastrointestinal (GI) distress and hyponatremia, may also
result in performance failure (56). GI distress is most likely to
occur in long-distance races, often the result of poor
adaptation to the consumption of drinks that contain
excessively concentrated electrolytes, energy substrates, or
other substances. Hyponatremia is typically seen in events
lasting longer than 4 hours in athletes who overconsume
fluids with insufficient electrolyte concentrations and, should
the associated edema occur in the brain, could be life-
threatening (77). The endurance athlete’s goal is to establish
a strategy, practiced in training, for supplying sufficient
fluids and energy of the right types and concentrations to
sustain muscular work for a long duration.
As defined earlier in this chapter, aerobic metabolism is
the energy system of greatest importance for endurance
athletes, with both fat and glycogen serving as critically
important fuels. In this energy pathway, oxygen is used to
help transfer phosphorus into new ATP molecules. Unlike
anaerobic metabolism, this energy pathway can use protein,
fat, and carbohydrate for fuel by converting pieces of these
energy substrates into a compound called acetyl coenzyme
A (acetyl CoA). Glucose is converted to pyruvic acid (an
anaerobic, energy-releasing process), and this pyruvic acid
can be converted either to acetyl CoA with the help of
oxygen or to an energy storage product called lactic acid. Of
course, if too much lactic acid builds up, the muscle will
fatigue and activity will stop (the problem with doing
exclusively anaerobic work). However, the lactic acid can
easily be reconverted to pyruvic acid to be used as a fuel
aerobically. Aerobic metabolism occurs in the mitochondria
of cells, where the vast majority of all ATP is produced from
the entering acetyl CoA. Fats can be converted to acetyl CoA
through a process called the β-oxidative metabolic pathway.
This pathway is very oxygen dependent, which means that
fats can only be burned aerobically.
The majority of endurance activity takes place at an
intensity that allows fats to contribute a high proportion of
the fuel for muscular work (Figure 11.2). Because there is an
almost inexhaustible supply of fat in even the leanest
athlete, supplying fats before and during physical activity is
not a concern and would not be a goal. However,
carbohydrate is involved in the complete combustion of fats,
and because the storage capacity for carbohydrates is
relatively low and easily depleted, the goal for endurance
athletes is to find a way to supply enough carbohydrates to
last for the duration of the activity. In prolonged exercise,
approximately half the energy is initially derived from
carbohydrate and half from fat. However, as muscle
glycogen concentration becomes reduced, blood glucose
becomes a more important source of muscle energy. After 2
hours of exercise, or sooner depending on conditioning and
exercise intensity, carbohydrate intake is required to
maintain blood glucose and carbohydrate metabolism (27).
Failure to maintain blood glucose results in mental fatigue,
which results in muscular fatigue even if there is remaining
energy availability in muscles.
FIGURE 11.2: Energy utilization changes with duration of
exercise. During 20 minutes of exercise with increasing
intensity, the utilization of carbohydrate and fat changes,
with an increasing proportion of muscle glycogen satisfying
total energy requirements of higher intensities. FFA, free
fatty acids. (Reprinted with permission from Van Loon LJC,
Greenhaff PL, Constantin-Teodosiu D, Saris WH,
Wagenmakers AJ. The effects of increasing exercise intensity
on muscle fuel utilization in humans. J Physiol.
2001;536:301.)

An athlete’s ability to achieve a steady state of oxygen

uptake into the cells is a function of how well an athlete is
aerobically conditioned. An athlete that frequently trains
aerobically is likely to reach a steady state faster than one
who does not train aerobically (108). Well-conditioned
athletes may require 5 minutes before sufficient oxygen is
available to cells for aerobic metabolism to continue at a
steady state. As indicated in Figure 11.3, the first 5 minutes
of activity is supported by a combination of anaerobic and
aerobic metabolism. The ability to quickly achieve a fast
steady state is important because it diminishes the duration
of time spent in acquiring energy anaerobically, which places
a heavy burden on carbohydrate (muscle and liver
glycogen), for which humans have limited storage.

FIGURE 11.3: Relative change in energy metabolism during

the initiation of exercise. At the onset of exercise, three
energy systems are used continuously, but the contribution
of each system to satisfying total energy needs changes as
the exercise continues. At the initiation of exercise, the
anaerobic PCr system provides the most ATP, following by
anaerobic glycolysis, and then followed by aerobic
metabolism. ATP, adenosine triphosphate; PCr,
phosphocreatine. (From Bandy WD. Therapeutic Exercise for
Physical Therapy Assistants. 3rd ed. Philadelphia (PA): LWW
(PE); 2013.)

Athletes in aerobic sports are better able to use oxygen

metabolically than power athletes (Table 11.6). However,
because carbohydrate is needed for the complete
combustion of fat, carbohydrate remains the limiting energy
source for endurance work because, relative to fat storage,
the storage of carbohydrate is low. This is clearly
demonstrated by findings that athletes consuming a high-fat
diet have a maximal endurance time of 57 minutes; on a
normal mixed diet their endurance rises to 114 minutes; and
on a high-carbohydrate diet, their maximal endurance rises
to 167 minutes (82).
Athletes with different levels of conditioning achieve
steady state at different levels of exercise intensity. A well-
conditioned athlete may be capable of maintaining a steady
state at a sufficiently high level of exercise intensity to win a
race. For instance, this athlete can perform at a very high
pace but is still able to provide enough oxygen to cells to
satisfy aerobic requirements. At the London Olympic Games
in the summer of 2012, the winner of the marathon ran 26.2
miles at a pace of about 4 minutes 50 seconds per mile! This
is an extremely fast pace, but the athlete maintained
primarily aerobic metabolism during the race or would not
have been able to complete it if a higher proportion of
energy was derived anaerobically from carbohydrate.
Whatever the athlete’s oxidative capacity, exceeding that
level causes a greater proportion of the muscular work to
rely on anaerobic metabolism, with an associated increase in
the reliance on carbohydrate fuel. Because there is a limited
storage of carbohydrate fuel, the carbohydrate fuel tank runs
out more quickly, and the person becomes exhausted faster.

Important Factors to Consider: Carbohydrate Depletion

Causes Activity Cessation in Both Anaerobic and Aerobic
Activities

The primary fuel for anaerobic metabolism is

carbohydrate. Power athletes are involved in short-
duration, high-intensity activity that is characterized
by a high proportion of anaerobic activity that is
carbohydrate dependent. Therefore, carbohydrate
 depletion is an inhibition to the continuation of
anaerobic activity.
The primary fuels for aerobic metabolism are fat and,
to a lesser extent, carbohydrate. Endurance athletes
are involved in long-duration aerobic activity that is
both fat and carbohydrate dependent. Although a
smaller proportion of carbohydrate is used in
endurance activity, the activity is longer than in
anaerobic activity. Therefore, carbohydrate depletion is
an inhibition to the continuation of aerobic activity.

Table 11.6 Typical Maximal Oxygen Uptake

(mL/kg/min) of Trained Athletes in
Selected Sports1
Sport/Activity Males Females
VO2Max VO2Max
Cross- 73.4 ± 6.7 68 ± 4.2
country
skiing
Endurance 69.8 ± 6.3 (No Data)
running
5 Km running 64.0 ± 4.0 53.2 ± 5.5
Cyclists 64.0 ± 5.5 53.5 ± 3.6
Triathlon 61.9 ± 9.6 (No Data)
Soccer 58.3 ± 4.2 (No Data)
Sedentary 51.5 ± 4.40 34.8 ± 5.6
1
Data for sport specific female athletes provided where available.
Sources: Crisp AH, Verlengia R, Gonsalves Sindorf MA, Germano MD, de Castro
Cesar M, and Lopes CR. Time to exhaustion at VO2max velocity in basketball and
soccer athletes. Journal of Exercise Physiology 2013; 16(2): 82–85.
Marsland F, Mackintosh C, Holmberg H-C, Anson J, Waddington G, Lyons K, and
Chapman D. Full course macro-kinematic analysis of a 10km classical cross-
country skiing competition. PLoS ONE 2017; 12(8): e0182262.
https://doi.org/10.1371/journal.pone.0182262
Sandbakk Ø, and Holmberg H-C. A reappraisal of success factors for Olympic
Cross-Country Skiing. International Journal of Sports Physiology and Performance
2014; 9: 117–121.
Nummela AT, Paavolainen LM, Sharwood KA, Lambert MI, Noakes TD, and Rusko
HK. Neuromuscular factors determining 5 km running performance and running
economy in well-trained athletes. European Journal of Applied Physiology 2006;
97: 1–8.
Galbraith A, Hopker J, Cardinale M, Cunniffe B, and Passfield L. A 1-year study of
endurance runners: training, laboratory tests, and field tests. International
Journal of Sports Physiology and Performance 2014; 9: 1019–1025.
Ramsbottom R, Nute MGL, and Williams C. Determinants of five kilometer running
performance in active men and women. British Journal of Sports Medicine 1987;
21(2): 9–13.
Costa VP, de Matos DG, Pertence LC, Martins JAN, and de Lima JRP. Reproducibility
of cycling time to exhaustion at VO2max in competitive cyclists. Journal of
Exercise Physiology. 2011; 14(1): 28–34.
Vikmoen O. Ellefsen S, Tr⊘en Ø, Hollan I, Hanestadhaugen M, Raastad T, and
R⊘nnestad BR. Scandinavian Journal of Medicine & Science in Sports 2016; 26:
384–396.
Karlsen A, Racinais S, Jensen MV, N⊘rgaard SJ, Bonne T, and Nybo L. Heat
acclimatization does not improve VO2max or cycling performance in a cool climate
in trained cyclists. Scandinavian Journal of Medicine & Science in Sports 2015;
25(suppl 1): 269–276.
Brisswalter J, Wu SSX, Sultana F, Bernard T, and Abbiss CR. Age difference in
efficiency of locomotion and maximal power output in well-trained triathletes.
European Journal of Applied Physiology 2014; 114: 2579–2586.
Unal M, Unal DO, Baltaci AK, Mogulkoc R, and Kayserilioglu A. Investigation of
serup leptin levels in professional male football players and healthy sedentary
males. Neuroendocrinology Letters 2005; 26(2): 148–151.
Woorons X, Mollard P, Lamberto C, Letournel M, and Richalet J-P. Effect of acute
hypoxia on maximal exercise in trained and sedentary women. Medicine &
Science in Sports & Exercise 2005; 37(1): 147–154.

Practicing nutrition strategies for the provision of fuel and

fluids makes it easier for the athlete to tolerate the
strategies during competition. Human systems require time
and repetition to adapt to whatever you do, and this
adaptation also affects nutritional strategies.

Energy Demands
It has been estimated that cross-country skiers use ∼4,000
calories during a 50-km race and may use even more energy
(up to 8,000 calories per day) when in intensive training
(36). The energy consumption in ultramarathon runners is
reported to average 5,530 kcal/day, with average hourly
energy expenditures that exceed 333 kcal/day (108). It has
been estimated that a 25-year-old female marathoner
weighing 125 lb and running 10 miles at a 6-minute-per-mile
pace in the morning and 8 miles of interval training in the
afternoon would require 3,000 calories for the activity, plus
1,331 calories to cover the needs of “resting energy
expenditure,” for a total daily energy requirement of more
than 4,300 kcal (73). (Resting energy expenditure represents
the energy needed to maintain the lean mass and to carry
on normal body functions when the body is at rest.) A
consistent failure to supply sufficient energy to satisfy both
the needs of exercise and resting energy expenditure results
in the loss of weight and muscle (80).

Fluid Recommendations
As athletes exercise, there is an inevitable loss of body water
through sweat. This cooling system, plus the normal urinary
water loss, may amount to over 10 L (about 11 quarts) of
daily water loss when exercising in a warm environment (2).
In a hot and humid environment, water losses may exceed 3
L/hour but may be less than 0.5 L/hour in cool and dry
environments (97). Despite the high rates of sweat losses
experienced by athletes, most athletes replace only 50% of
the water that is lost, a behavior that inevitably leads to
progressive dehydration and a decline in performance (48,
89). Research has clearly demonstrated that even a slight
dehydration (2% of body weight) causes a measurable
decrease in athletic performance (3, 127). Therefore, when
athletes take steps to satisfy fluid requirements, they are
helping to guarantee optimal athletic performance (see
Chapter 7, “Hydration Issues in Athletic Performance”).

Carbohydrate Recommendations
Because carbohydrate storage is relatively low when
compared with fat stores, athletes must make a conscious
effort to replace carbohydrate at every opportunity. Having
high levels of stored carbohydrate (glycogen) and consuming
carbohydrate during activities that last 1 hour or more are
well-established techniques for optimizing athletic
endurance. It is well documented that consuming
carbohydrate during activity helps to maintain blood sugar
(glucose) and insulin, which encourages sugar uptake by
working muscles (67). An example can be seen in the 100
km ultramarathon world champion winner, who ran for ∼6.5
hours. It was necessary for him to consume ∼58 g of
carbohydrate/hour during the race to avoid glycogen
depletion (108). It was found that endurance cyclists who
consumed a carbohydrate-containing beverage during the
exercise were able to exercise an additional hour when
compared with cyclists who consumed only water (27).
Athletes are encouraged to consume ∼9–10 g (35–40
calories) of carbohydrate per kilogram of body weight each
day. For a 150 lb athlete, this level of intake amounts to 600
g (2,400 calories) of daily carbohydrate consumption.
Expressed as a percent of total calories, this
recommendation suggests that ∼60% of total calories should
be derived from carbohydrate (24).
During competition, the concentration of carbohydrate is
an important consideration to avoid GI distress. It has been
found that a 5.5% (13 g of carbohydrate per 8 oz of fluid)
carbohydrate solution produced almost no GI distress, which
was similar to the lack of gastric distress with the
consumption of plain water. However, a concentration
slightly greater than this level (6.9% carbohydrate, or 16 g of
carbohydrate per 8 oz of fluid) appeared to double the
incidence of GI distress when athletes were asked to perform
the same exercise (129). This finding suggests that
endurance athletes should consume appropriate amounts of
carbohydrate early in the event with continued regular
consumption to obtain the needed amount without inducing
GI distress. There were similar results in a study of marathon
running performance, which found on three separate tests
that consumption of a 5.5% carbohydrate solution produced
superior performance results than a 6.9% carbohydrate
solution (122). Therefore, the classic nutritional paradigm of
more than enough is not better than enough appears to be
true. Although athletes have a high requirement for
carbohydrate, providing excessive amounts too quickly
creates difficulties that may detract from performance.
The composition of the carbohydrate provided may also
influence endurance performance and GI distress. A study
comparing 6% carbohydrate solutions containing a
combination of glucose, fructose, and sucrose or fructose
alone during 105 minutes of cycling exercise found that the
fructose-only beverage resulted in a greater frequency of GI
distress, a more significant drop in blood volume, a higher
increase in cortisol, angiotensin-I, and adrenocorticotropic
hormone (all of which are considered stress hormones), and
reduced exercise performance (29). It is generally
recommended that for events lasting longer than 2.5 hours,
relatively large amounts (up to 90 g/hour) of mixed source
carbohydrates (i.e., combinations of glucose, sucrose,
maltodextrin) should be consumed during physical activity to
avoid glycogen depletion (56, 118). For endurance events of
between 1 and 2.5 hours, the recommended carbohydrate
intake is between 30 and 60 g/hour (118).
Resynthesis of glycogen following activity is also
important, because glycogen reserves are severely depleted
following activity lasting 1 hour or longer. The efficiency of
glycogen resynthesis is dependent on several factors (25):

the timing of the carbohydrate intake,

the amount of carbohydrate consumed,
the type of carbohydrate consumed, and
 the degree to which muscle has been damaged during
the exercise (damaged muscle is slower to resynthesize
glycogen than healthy muscle).

Foods containing carbohydrates that enter the blood

quickly (i.e., high glycemic index foods) are better able to
resynthesize liver and muscle glycogen than foods low on
the glycemic index scale, especially when consumed
immediately following exercise. The general
recommendation is to consume ∼200 calories of
carbohydrate every 2 hours following exercise, with the first
200 calories being provided as soon after exercise as
possible (26).

Protein Recommendations
Although power/speed athletes, on average, consume more
protein, it appears that endurance athletes actually require
slightly more protein than power athletes (20, 93). The
estimated requirement for endurance athletes is
approximately double the level recommended for
nonathletes (1.5 vs. 0.8 g/kg) (26). With the exception of
vegetarians, most endurance athletes appear to consume
this level of protein from food alone (94, 114). A summary of
protein intakes suggests an average intake of 1.8 g/kg for
both male and female endurance runners (109). High levels
of protein consumption are common for athletes, but there is
concern that chronic excess protein consumption may result
in progressive renal damage (1). There is also concern that
excess protein intakes may compromise bone mineral
density, placing the athlete at higher risk of fracture (37). In
addition, excess protein may also increase dehydration risk
(35). Regardless of the athletic endeavor, therefore, athletes
should be cautious about getting sufficient protein to satisfy
needs and to consume the protein in a pattern that optimizes
utilization, but should also be careful that they do not
consume levels of protein that far exceed requirements.
Fat Recommendations
High-fat diets are periodically recycled in the literature as
being performance enhancing, but there are clear data to
suggest that improving fat metabolism occurs best with
high-carbohydrate diets in endurance athletes. Therefore,
endurance athletes should consume fats at levels that
enable satisfaction of total energy requirements when
consuming relatively high-carbohydrate and moderate
protein diets (118, 126).

Vitamin Recommendations
The B-vitamins (thiamin, riboflavin, and niacin) are
particularly important for endurance activities, but
endurance athletes with carbohydrate intakes that satisfy
needs (∼60% of total calories) are virtually ensured of
satisfying the need for B-vitamins from the foods they
consume (92). Despite this, many endurance athletes take
vitamin supplements, but these supplements fail to provide
any performance benefit. In addition, the excess niacin
consumption resulted in the inhibition of fat metabolism with
greater reliance on glycogen, resulting in premature fatigue
(74). Endurance athletes should consider performing a cost–
benefit analysis to determine if the money spent on
supplements might be better spent on good-quality foods
(118).

Minerals
Ensuring optimal iron status is critically important for
endurance performance, which relies heavily on aerobic
metabolism (32). Given the importance of iron status in
endurance activity, and because iron deficiency is the most
common nutrient deficiency in both athletes and
nonathletes, endurance athletes should give serious
consideration to having iron status (hemoglobin, serum
ferritin, hematocrit) assessed at regular yearly intervals.
Vegetarian athletes are at higher risk of iron, zinc, and
calcium deficiencies, all of which are important for aerobic
metabolism and/or athlete health (118). As such, it may be
even more important for vegetarian athletes to have regular,
objective measures of these nutrients. Should an
examination of the blood and/or bone density suggest a
nutritional weakness, a medical professional can then
prescribe an appropriate strategy, which may include
supplementation, to the athlete.
Endurance athletes should be cautious about excess
nutrient consumption. It was found that men who
supplemented with an oral dose of 1 g (1,000 mg) of vitamin
C per day experienced a significant reduction in endurance
capacity, perhaps by preventing key cellular adaptations to
exercise that would allow for training improvements (42). On
the other hand, getting enough of each nutrient and enough
energy is critical to both performance and health. It is clear
that restrained eating patterns in elite female endurance
runners is the single biggest factor in low bone mass, and
that the longer the caloric restriction, the greater the
problems associated with recovery of muscle mass and
glucose tolerance (6, 7, 38). So, although more than enough
is not better than enough, it is still important to get enough.
Many endurance athletes fail to consume sufficient nutrients
and/or energy to get the most out of their training and
reduce injury risk. Studies of athletes participating in the
Ironman¯ triathlon, simulated adventure races, and other
ultraendurance cycling events all have found significant
nutritional weaknesses in participating athletes (6, 135).
Ideally, these athletes should obtain all of the needed
nutrients through the appropriate consumption of food.
Failing that, however, taking low-dose supplements of
targeted nutrients that are known to be inadequate through
medical tests is a reasonable option. The clear message is
food first.
Building Energy and Fluid Reserves to Support
Endurance Activities
In virtually every study that has examined athletes with high
glycogen reserves versus those with lower reserves, those
with higher reserves consistently perform better. Endurance
athletes who begin competition with more stored
carbohydrate (glycogen) have more glycogen available at
the end of the competition. This difference alone may be
enough to determine the winner (108). In addition,
endurance athletes who initiate exercise in a better hydrated
state perform better than those who are less well hydrated
(98, 118). Achieving an optimal carbohydrate and fluid
intake does not happen, however, without careful planning
for what to consume before, during, and after practice and/or
competition.

Before Training and/or Competition

Consumption of between 800 and 1,200 kcal of carbohydrate
for the 24 hours prior to exercise results in improved
performance (22, 101). Current recommendations encourage
additional carbohydrate intake (1–4 g/kg) in the period
immediately prior to exercise to ensure sustained glycogen
availability (118). Ideally, the foods consumed prior to
training or competition should be familiar foods that are
known to be well tolerated. New foods, gels, or sports
beverages consumed prior to a competition have the
potential to create unexpected GI distress that inhibits
performance at a high level. Ideally, the athlete should
practice what they intend to do during competition during
training to ensure the body is well adapted to both the type
of food/beverage and the amounts that are likely to be
consumed. Competition is not the best time for athletes to
experiment with any nutrition strategy.

Hydration
Ensuring that the endurance athlete achieves a well-
hydrated state prior to exercise is important, as any level of
underhydration may have a negative impact on performance
(103). The current recommendation is consumption of 5–10
mL/kg during the 2–4 hours before exercise initiation (98).
Ideally, the athlete should strive to achieve urine that is
light, pale yellow in color, as darker urine color is a sign of
underhydration (44). In the past, endurance athletes tried
consuming high-sodium foods and beverages to enhance
fluid retention, and some consumed glycerol (glycerine) as a
means of enlarging the blood volume. Although glycerine
consumption has been found to be successful, the use of
glycerol and other substances that can be used to
superhydrate is specifically banned by the World Anti-Doping
Agency, making this strategy one that should not be
followed (70).
Fluid loss during physical activity exceeds the rate that
fluids can be consumed and absorbed. Therefore, it is
impossible to achieve a well-hydrated state during exercise if
the athlete initiates exercise already poorly hydrated.
Consumption of sports beverages prior to exercise is useful
because they provide several things that athletes most
require: carbohydrates, fluids, and electrolytes:

the fluid consumed should be flavored and sweetened to

encourage fluid intake,
to help maintain training intensity, the fluid should
contain carbohydrate, and
to stimulate rapid and complete rehydration, the
beverage should contain sodium chloride (salt).

Glycogen Stores
Optimizing glycogen stores can typically occur within 24
hours of training, with consumption of high levels of
carbohydrate and cessation of any activity that may be
glycogen depleting (15). For ultraendurance events, athletes
can maximize glycogen storage through consumption of high
levels of carbohydrate for 4–5 days, during which glycogen-
depleting exercise is diminished (14). During the period
immediately preceding training or competition, athletes can
continue to ensure that liver and muscle glycogen remain
high through consumption of well-tolerated carbohydrates
and beverages at a level of 1–4 g/kg. Ideally, these foods
should be relatively low in fiber and fats, and moderate in
protein to enable gastric emptying (15, 90). (Athletes do best
if they initiate exercise with no solids in the stomach.)
Carbohydrate-containing liquids consumed prior to exercise
may also be useful for athletes who are predisposed to GI
distress prior to competition (118). Consuming a small
amount of protein, coupled with carbohydrate and fluids,
prior to exercise may be useful for synthesizing glycogen and
for stimulating muscle protein synthesis (119). However,
current studies are mixed regarding whether protein
consumed prior to exercise improves endurance
performance (123). Consumption of fat is important to
ensure adequate energy consumption, typically with a
recommended range of 20%–35% of total energy consumed.
However, consumption of fat prior to physical activity may
delay gastric emptying, thereby limiting the consumption of
adequate levels of carbohydrates and fluids, and increasing
the risk of GI distress. There are relatively new claims that
restricting carbohydrate and replacing carbohydrate with fat
is performance enhancing. However, there is no evidence
that this high-fat dietary strategy is supported by scientific
studies (118).

During Training and/or Competition

In events such as 10-km races and marathons, where fluids
are available at regular intervals, the athlete should take full
advantage of each fluid station and consume fluids. Because
water is constantly being lost, frequent and regular
consumption of fluids helps to maintain the body’s water
level. Because most athletes consume less water than they
need, techniques for ensuring hydration during activity have
been studied. The following recommendations have been
suggested (12):

Make certain that fluid is always nearby, because

accessibility helps to ensure better fluid intake.
All athletes should have their own bottle from which to
drink, and this bottle should be with them whenever they
exercise or are at a competition.
Coaches should design practices that enable athletes to
drink frequently.
The coaching staff should be aware of those athletes
with high sweat rates to make certain they consume
more fluids than those with lower sweat rates.
Help athletes learn to drink frequently by considering
this to be part of the training regimen.

To understand how much fluid an athlete needs to

consume during practice and competition, a log should be
maintained with the amount of fluid consumed and the
beginning and ending weight of the athletes. If an athlete
consumes 32 oz during practice and weighs 2 lb less at the
end of practice than at the beginning, this athlete should
learn to consume an additional 32 oz of fluid during the
practice (1 lb = 16 oz of fluid). Consumption of fluids that
contain carbohydrates is important during exercise, and
properly designed sports beverages can aid in providing both
fluids and carbohydrates quickly. The ideal sports beverage
should have the following characteristics:

Cool beverages are tolerated best.

A carbohydrate solution of between 6% and 7% delivers
both the carbohydrate and the fluid quickly. A higher
carbohydrate concentration slows delivery to the
 muscles by delaying gastric emptying and may increase
the risk of gut upset.
A small amount of sodium helps drive the desire to drink,
and in so doing helps to ensure that the athlete stays
better hydrated. Sodium may also aid in getting the
water and carbohydrate absorbed more quickly and help
to maintain blood volume. Maintenance of blood volume
is an important predictor of athletic performance. There
is some evidence that hyponatremia (low blood sodium),
which results from large losses of sodium in sweat that
goes unreplaced, occurs in endurance and
ultraendurance events (34). This is a rare but serious
condition that may result in seizures, coma, or death.
The beverage should taste good to the athlete. The taste
sensation may be altered during exercise, so there is no
guarantee that a fluid you enjoy drinking at dinner will
taste good to you while exercising. Make sure an athlete
tries different flavors during exercise to determine what
is best liked.
The carbohydrate should be from a combination of
glucose and sucrose. Beverages containing
predominantly fructose increase the risk of creating gut
upset.
Noncarbonated sports drinks are preferred over
carbonated drinks during endurance exercise.

Consumption of carbohydrates in both solid and liquid

forms results in the same performance outcomes, so athletes
in some sports may choose to consume carbohydrate foods
rather than carbohydrate beverages (65). Cyclists who go
long distances, for instance, often consume bananas and
carbohydrate gels to support their carbohydrate
requirement. It appears as if the consumption of 45–75 g of
carbohydrate per hour (180–300 calories from carbohydrate
per hour) helps to improve athletic performance (102). This
amount of carbohydrate can be found in approximately one
quart of sports beverage with a 6% carbohydrate
concentration.

After Training and/or Competition

Although you may think you have done everything you need
to do once your exercise is over — except shower — it is
clear that drinking more fluids and consuming more
carbohydrates after the exercise or competition is important.
Doing this will help you replenish your glycogen stores and
get you ready for the next day of exercise. The best glycogen
replenishment occurs if you consume high glycemic index
carbohydrates immediately following exercise and continue
consuming carbohydrates (via snacks) until the next meal
(26). Dietary protein plays a role. There is increasing
evidence strongly suggesting that skeletal muscle
breakdown increases with endurance training and/or with a
single endurance exercise bout. Athletes who consume foods
immediately following endurance activity have a favorable
synthesis of skeletal muscle protein (92). The postendurance
activity period is critically important for athletes, making it a
time for serious planning. Carbohydrate should be consumed
during this postexercise period at a rate of 1.2 g of
carbohydrate per kilogram of body weight per hour (1.2
g/kg/hour) over several hours, and mixing this with some
high-quality protein appears to be useful from an exercise
recovery standpoint (115). There is also a good deal of
beginning evidence to suggest that the amount and timing
of protein is important from a tissue utilization standpoint.

General Daily Considerations

The before-, during-, and after-exercise periods are meant to
provide carbohydrates and fluids to support the activity, but
what you do the rest of the time helps to ensure that the
before-, during-, and after-exercise strategies actually work.
Obviously, the consumption of carbohydrates and fluids
during these periods does not provide all the nutrients and
minerals an athlete needs to support health and activity. For
this reason, it is imperative that what you eat the rest of the
time provides a balance of nutrients that can keep you
healthy. It is very true that healthy athletes are better
athletes. A good basic strategy to follow is to encourage the
consumption of a wide variety of foods that are high in
complex carbohydrates, moderate in protein, and low in fats
and sugars. This type of food distribution is perfect for
athletes and will help to ensure that all necessary nutrients
are consumed.
There is nothing an athlete can do just before competition
to correct a nutrient deficiency and help performance. If your
intake of iron is consistently low, and you develop iron
deficiency anemia, it could take 6 months on a good diet and
iron supplements to bring your iron level up to a point where
performance will not be negatively affected. If you have a
nutrient deficiency, doing everything right before, during,
and after exercise still will not have you performing up to
your conditioned ability. So eat well and eat wisely when you
have the chance and, of course, drink plenty of fluids.

Other Nutritional Recommendations

There are several rules of nutrition that apply here. Among
them is the idea of the need to consume a wide variety of
foods to ensure that the body is exposed to all of the
essential nutrients. On the backside of this rule, there is
another benefit. By consuming a wide variety of foods,
athletes can avoid being exposed to any potentially toxic
substances that are more prevalent in some foods.
Therefore, eating a wide variety of foods is a good nutritional
rule to live by. Another rule is the idea that it is possible to
eat too much of something, even if it is believed to be a
“good” food. Learning to balance your diet through variety
will help ensure your body of both proper maintenance and
adequate nutrient intake.
 Nutrition Strategies for Combined
Power/Endurance Sports

Most team sports (basketball, volleyball, soccer, etc.) have

combinations of higher- and lower-intensity activities
(combination aerobic/anaerobic sports), making them
different from purely power activities, such as gymnastics, or
purely endurance activities, such as the marathon.
Therefore, team athletes must possess both power and
endurance characteristics that were described earlier in this
chapter. Different team sports have different metabolic
requirements. For instance, American football has a greater
emphasis on power than soccer (54). Despite these
differences, the major characteristic of team sports is that
there are periods of relatively low-intensity activity that are
interrupted with bursts of high-intensity activity, and this
intermittent activity influences nutritional requirements (40,
53). The high-intensity bursts of activity, which are
dependent on the phosphagen and anaerobic glycolysis
systems, place high importance on carbohydrate availability,
and the lower-intensity aerobic activity places high
importance of carbohydrate and fat availability (16). It
makes perfect sense, therefore, that studies have found
clear performance benefits from consumption of
carbohydrate in intermittent sprint activities, such as those
seen in football or basketball (11, 64).
Despite the importance of carbohydrate consumption in
intermittent-intensity activities, surveys of team sport
athletes suggest carbohydrate intake that, on average, are
below the recommended level for carbohydrate of 6–10
g/day, with average intakes of both male and female team
sport athletes consuming less than 6 g/day (54). Of concern
is that the expenditure of energy and carbohydrate on
competition days is higher than on training days, yet team
sport athletes consume less on these competition days than
on training days (16).

Combination Aerobic/Anaerobic Sports

Include sports that have a heavy reliance on both aerobic

and anaerobic metabolic processes and are typically sports
that involve intermittent activity that varies from slower
movement to sprinting. Examples include basketball,
hockey, field-hockey, and soccer.

Before Training and/or Competition

It is generally recommended that the preexercise or
precompetition meal be constituted heavily of starchy, easy-
to-digest, high-carbohydrate foods, and consumed ∼3 hours
before exercise. Consumption of ample fluids with meals and
during the period between the meal and the exercise session
or competition is also important (13). It has been reported
that teams prefer to add low-fat protein sources to provide
more satiety, but high-fiber foods should not be consumed
prior to an event to avoid GI distress. It is also recommended
that high-fat foods also be limited to avoid delays in gastric
emptying (128). Food consumption patterns in team sport
players typically occur 2–4 hours prior to training and/or
competition (128).

During Training and/or Competition

Consumption of carbohydrate is also important in team
sports. Compared with the results of a trial when a placebo
(water) was consumed, subjects performed seven additional
1-minute cycling sprints at 120%–130% of VO2max when they
consumed a 6% carbohydrate-electrolyte beverage. This is
equivalent to making a dramatic improvement in sprint
capability during the last 5–10 minutes of a basketball game
(104). A similar study found that sports drinks (i.e.,
carbohydrate-electrolyte beverages) can help maintain high-
intensity efforts that consist of intermittent sprinting,
running, and jogging (76). The general recommendation is to
consume carbohydrate-electrolyte sports beverages at every
opportunity the game permits and to take particular
advantage of half-time to consume carbohydrate and fluids
(54).

After Training and/or Competition

Postexercise or postcompetition is a time to support muscle
recovery through appropriate nutritional strategies. Ideally,
athletes should immediately consume high-carbohydrate
foods/drinks that also contain protein. This strategy enables
better glycogen and protein synthesis (8, 95). Fluid
consumption for rehydration and replenishment of depleted
glycogen stores should provide ∼24 oz/lb of body weight (1.5
L/kg of body weight) that was lost during the activity (118).
Because the enzyme involved in synthesizing glycogen
(glycogen synthetase) reaches its peak immediately
following physical activity, muscle glycogen stores are
efficiently replaced if the athlete consumes carbohydrate
immediately following the activity. For the 2 hours
immediately following activity, consume high glycemic index
foods (i.e., foods high in natural sugars or foods that are
quickly and easily digested into sugars) (92). The goal is to
consume at least 50 g (200 calories) of carbohydrate every
hour until the next meal time. In general, strive to consume
∼4 g of carbohydrate per pound of body weight during the
24 hours following exercise or competition.
The two keys to these guidelines are fluids and
carbohydrates in the context of a generally varied diet.
Athletes should find ways to consume both fluids and
carbohydrates at, literally, every opportunity. Recent findings
tend to contradict the traditional and commonly followed
belief that carbohydrate-containing beverages are useful
only for endurance (aerobic) activities that last longer than
60 minutes. The best predictors of athletic performance are
maintenance of blood volume and maintenance of
glycogen/glucose.

Summary

Strategies that might be useful for achieving both enhanced

hydration and improved maintenance of system
carbohydrate in different sports are as follows:

Power/Speed Sports

Power and speed sports require a high muscle-to-weight

ratio. A critically important strategy for achieving greater
muscle mass is to stop doing things that decrease
muscle mass.
A dietary factor that is associated with a reduced muscle
synthesis and loss of muscle is achievement of frequent
relative energy deficiency, making avoidance of relative
energy deficiency a key component of success in power
and speed sports. In addition, relative energy deficiency
is also associated with lower glycogen stores (71).
Energy availability of ∼45 kcal/kg fat-free mass
(FFM)/day is associated with energy balance, whereas
levels below 30 kcal/kg FFM/day are associated with
impaired body functions.
It is also important for the athlete to consume an
appropriate level of protein to support lean body mass
(typically ∼1.7 g/kg/day) and to consume this protein in
an evenly distributed pattern during the day (118).
Ideally, this protein should be consumed when the
athlete is not in a severe relative energy deficiency to
help ensure the protein is utilized anabolically to
 build/repair tissue, rather than used to satisfy the energy
requirement. (Humans have energy-first systems.)
Following practice/activity, power and speed athletes
should consume ∼10 g of high-quality protein with
carbohydrate and fluids in the early recovery phase (0–2
hours postexercise) to stimulate muscle protein
synthesis and help recover used glycogen (83). Because
anaerobic glycolysis is an important metabolic pçathway
for power/speed athletes, they should plan on consuming
plenty of carbohydrate (typically ∼10 g/kg/day) that is
evenly distributed throughout the day (118).

Endurance Sports

In general, endurance athletes should focus on the

consumption of diets that are relatively high in
carbohydrate before, during, and after exercise, as the
limiting energy substrate in endurance events is
glycogen (56).
They should also develop strategies that sustain blood
volume to ensure maintenance of sweat rates, delivery
of nutrients to working muscles, and removal of
metabolic by-products from working muscle.
Fats, blood, and tissues are the source of most energy for
endurance (aerobic) activities, and the storage capacity
for fat is relatively high for even lean athletes. The
storage capacity for carbohydrates, however, is limited.
Because fats require some carbohydrate to be
completely burned, the limited storage capacity for
carbohydrate can limit the body’s ability to burn fat
during exercise. To overcome this limitation, athletes
should be constantly vigilant to keep body stores of
carbohydrate at maximal levels before activity begins
and should replace carbohydrate during activity through
whatever means are available (125).
 Ideally, athletes should attempt to replace carbohydrate
at a rate that is dynamically linked to the proportion of
time spent in more intense exercise, as higher intensity
will more quickly deplete glycogen stores.
The best carbohydrates are composed of more than a
single carbohydrate molecular type to optimize
carbohydrate receptors. As an example, a carbohydrate
beverage containing sucrose and free glucose is superior
to one containing only glucose (121).
Failure to supply sufficient carbohydrate before and
during endurance activity will significantly reduce
athletic performance. Recovery of depleted glycogen
requires a relatively high consumption of carbohydrate.
Ideally, endurance athletes should consume a mix of
protein, carbohydrate, and fluids immediately
postexercise, followed by relatively high carbohydrate
and moderate protein consumption at other times (9).

Team Sports

Studies assessing sports that require a combination of

power and endurance have found that carbohydrate
consumption is useful in enhancing performance even if
the activity lasts less than 1 hour (5, 130). This is an
important finding, because the traditional thought has
been that water is an appropriate hydration beverage for
activities lasting less than 1 hour, but that carbohydrate-
containing sports beverages are important to consume
for activities lasting longer than 1 hour. It appears that
even in these shorter intermittent-intensity activities,
carbohydrate consumption as part of a sports beverage
is performance enhancing.
Because many of these sports (basketball, soccer,
tennis) place an enormous caloric drain on the system,
athletes should develop eating strategies (i.e., eating
enough) that encourage maintenance of muscle mass
 during long and arduous seasons (78). Team sports often
have natural breaks in the event, including half-time.
These are opportunities for athletes to replenish
carbohydrate and fluids that should be taken advantage
of (72).

Practical Application Activity

Using the procedure provided in Chapter 8 for predicting

the energy cost of activity, do the following:

1. Ask an endurance athlete what a nontraining day looks

like in terms of foods consumed and activity and
analyze the energy cost of this day.
2. Then ask an endurance athlete what his or her typical
training schedule is, including the number of hours and
the typical intensity during each hour that the athlete
is training, and analyze the energy cost of this day.
3. Determine if the food consumed satisfies energy needs
for both the training and nontraining day. If not, try
adding or subtracting foods and beverages to/from
each day to see what it would take to satisfy energy
needs.
4. Repeat steps 1 through 3, but now for a power athlete.
It should become quickly clear that even though a
power athlete may spend less time in training, the
higher intensity of training quickly increases energy
needs.

Chapter Questions

1. Commercially available athlete performance gels are

different in the following ways:
 a. Serving size, energy density (kcal/g), total energy (kcal),
total carbohydrate, free sugars, and osmolality
(mmol/kg)
b. Service size, energy density (kcal/g), and osmolality
(mmol/kg)
c. Serving size and osmolality (mmol/kg)
d. Flavor
2. Although all energy systems are functioning during power
activities, the predominant energy systems are anaerobic
a. True
b. False
3. There is convincing evidence that high consumption of
amino acid supplements in addition to a well-balanced diet
improves power activities and bodybuilding by:
a. Enhancing fast enlargement of skeletal muscle mass
b. Improving reaction time
c. Improving creatine synthesis
d. All the above
e. None of the above
4. The nutritional needs of power athletes are so high that it
is nearly impossible to obtain all of the needed nutrients
from food alone.
a. True
b. False
5. The fastest 100-m sprinters use the greatest amount of
______ during the first 80 m of the sprint.
a. Glycogen
b. Blood glucose
c. PCr
d. Triglyceride
6. Air resistance accounts for ∼_____% of total energy
expended to run 100 m in ∼10 seconds:
a. 5
b. 12
c. 16
d. 21
7. The typical male endurance athlete eating patterns
suggest:
a. Overconsumption of carbohydrate and
underconsumption of protein
b. Underconsumption of carbohydrate and
overconsumption of fat
c. Overconsumption of both carbohydrate and protein
d. Underconsumption of both protein and carbohydrate
8. The optimal tissue temperature range for muscular
enzymes to metabolize energy is _______°F.
a. ∼98.6
b. ∼102.2
c. ∼100.5
d. ∼104.0
9. The recommended hourly intake of carbohydrate during
prolonged endurance activity is:
a. 10–20 g/hour
b. 30–60 g/hour
c. 60–90 g/hour
d. 90–111 g/hour
10. The recommended hourly intake of carbohydrate during
“stop and go” activity (e.g., soccer, basketball) is:
a. 10–20 g/hour
b. 30–60 g/hour
c. 60–90 g/hour
d. 90–111 g/hour

Answers to Chapter Questions

1. a
2. a
3. e
4. b
5. c
6. c
7. b
8. b
9. b
10. b

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CHAPTER OBJECTIVES
Recognize the nutritional problems that may occur with travel
associated with crossing multiple time zones.
Identify how circadian rhythm changes can influence dietary
requirements and how, unless adjusted, it can influence athletic
performance.
Recall the logical planning strategies that athletes should follow
when traveling to unfamiliar locations.
Know the nutritional strategies associated with minimizing the
effects of jet lag.
List the items that athletes should bring along when traveling to
countries that have different cultures than their own.
Identify the food safety concerns that could create health
problems unless appropriate preventative actions are followed.
Analyze the nutritional issues associated with performance-
related athletic endeavors in high altitudes and cold
environments.
List the health and nutrition-associated health conditions (high-
altitude sickness) that may occur when exercising in a high-
altitude and cold-weather environment.
Create strategies that athletes can follow to help satisfy fluid,
energy, and nutrient needs when exercising in a high-altitude
and cold-weather environment.
Recognize the nutritional issues associated with exercise in a
high heat and humid environment, and how to best ameliorate
these issues.
 Traveling to His First
International Marathon

John, after several years of trying, finally made the qualifying

time to run the Athens (Greece) Marathon, allowing him to run
with the best runners in the world at the front of the pack. He
could not wait to get on the plane to travel from his home in San
Diego, California, to a city he had never before visited: Athens,
the original home of the modern Olympic Games. He was even
more excited to begin the race from Marathonas, the city for
which the marathon is named, to finish in the famous
Panathenaic Stadium in Athens, which was originally built as a
racecourse in the 6th century BC and reconstructed in 1896 as
the primary stadium for the first modern Olympic Games. When
he arrived in Athens at 5 PM, 2 days before the marathon, he
was more than excited and happy to be there for two reasons:
because of what he had accomplished and also because of the
immense history of the city.
He went for dinner to the hotel dining room, only to find a
menu filled with unfamiliar dishes. Excellent! he thought and
was excited to try the new cuisine. He ordered barbounia (small
red mullet) sautéed in olive oil, with roasted quartered potatoes
covered in delicious spices, and more green vegetables than he
had ever eaten in a single meal. Delicious! After dinner he took a
brief tour around the city, and at about 10 PM decided it was
time to sleep. He was not certain if the rumblings in his stomach
were keeping him up, or if it was due to the difference in time
zones (after all, it was only noon in San Diego). After a sleepless
night, he got out of bed exhausted and decided to go for his
usual 6-mile prebreakfast run at 7 AM. Difficult run, he thought,
because he was so exhausted, but then breakfast of some fried
eggs with toast, fruit, and feta cheese went down nicely — but
he was totally exhausted. He went back to bed and, to his
surprise, he slept soundly from 10 AM to 4 PM.
When he awoke, he prepared all of his running gear for the
marathon, scheduled to begin at 8 AM the next morning. He was
feeling great after that long nap and was excited to go to dinner
with a friend from home who was leading a historical tour of the
city for his university. His friend knew some great restaurants in
the Plaka historical district of Athens, and John was excited to go
and see the city with someone familiar with it. It was agreed
between them that it would be an early evening so John could
get some rest before the marathon. They left the hotel at 7 PM
and went to the Plaka, only a 10-minute taxi ride away. Beautiful
place, with a full view of the Parthenon, and restaurants and
music everywhere. Pure fun. They ate at a traditional Greek
restaurant that specialized in lamb dishes, and the restaurant
owner made his own retsina (a pine resin–laced wine). The
owner insisted that John try a small glass, and John agreed that a
small glass of wine could not hurt. At 9 PM they headed back to
the hotel, where John went to bed excited for the next day’s
marathon. He set the alarm for 5 AM to have plenty of time to
prepare and take the bus to the city of Marathonas for the start
of the race.
John did not sleep much (from the excitement, he thought)
and dragged himself to the bus. The race started (it is an uphill
run for the first 20 km of the race), and by the time it finished
John had his slowest marathon time in 2 years with terrible
gastrointestinal (GI) problems during the last half of the race.
This was not what he expected or wanted. John came to the first-
hand realization that so many of his fellow runners had warned
him about: Travel is exhausting and potentially performance
reducing no matter how experienced the athlete, and it is
particularly exhausting for athletes traveling across multiple
time zones to unfamiliar countries with unfamiliar food and
drink.

CASE STUDY DISCUSSION QUESTIONS

Imagine that you were flying from your current ___location to an
unfamiliar ___location/country that is at least six time zones away.
Consider the following:
1. What would you bring with you that could help you sustain a
performance-sustaining and illness-reducing nutritional
status in your new ___location?
2. What would you do on the flight to reduce the chance that
the flight would negatively influence how you feel and your
readiness to perform while reducing possible feelings of ill
health?
3. Once you get to your ___location, how would you time your
eating behavior and your sleep behavior to help you adjust
 to your new ___location?
4. What foods and beverages would you avoid to minimize any
potential negative performance and health risks?
5. What foods would you focus on to help ensure maintenance
of performance readiness and good health?
6. What nutrition planning would you do prior to your trip to
help ensure that you can perform up to your conditioned
capacity?

Introduction

Athletes often find themselves having to travel to competitions or to

train at a new ___location with a new coach. Without good planning and
a logical strategy, travel itself may be the cause of several problems
that have nutritional implications. If the travel ___location is in an
environment that is hotter, colder, or at higher altitude than the
athlete is accustomed to, then the athlete should make plans to
arrive at the ___location sufficiently early to allow time to acclimate to
the new environment. If the travel is in a ___location with an unfamiliar
cuisine, there should be planning to see what foods in this new
environment are likely to be well tolerated. Athletes with existing
food allergies, intolerances, or sensitivities should take no chances
when traveling by printing out cards in the native language that
clearly spell out what they cannot eat, with the goal of giving these
cards to chefs and servers to limit the chance of eating a poorly
tolerated food or food ingredient. In some cases, it is possible that
the only logical solution is to bring snacks and other foods to ensure
sufficient energy consumption. This chapter reviews the planning
steps that should be taken by traveling athletes, and the special
considerations to account for when traveling long distances and to
environments that are warmer, colder, or at different altitudes than
those to which the athlete is accustomed.

Travel

Athletes often find themselves traveling to competitions far from

home, where the foods are unfamiliar. To overcome both the
exhaustion of travel and the unfamiliar cuisine, planning ahead to be
prepared for any contingency is important for the athlete to compete
at his/her conditioned capacity. It is a mistake to believe that a
healthy athlete can quickly adapt to a new time zone and new foods,
and the biggest mistake they can make is to assume that they can
sleep and eat in a pattern they have adapted to at home. Although it
takes time to adapt to a new ___location, it also takes time to adjust to
different temperatures and altitudes. For instance, in high-heat
environments it may take 1 to 2 weeks to develop the physiologic
adjustments necessary to perform at an optimal level (57). Whether
it is concerning food or time for adaptation, carefully planning the
trip will greatly enhance the probability of athletic success (Figure
12.1).

FIGURE 12.1: Planning for the trip is important for an athlete’s

success. GI, gastrointestinal.

Travel is associated with unfamiliar stress that affects body

function with a potential detrimental effect on performance. Having
an appropriate nutrition strategy can help to moderate the effect of
travel-associated changes in circadian rhythms that can
negatively affect sleep and the GI tract, including alterations in food
absorption that can result in sleep disruption and bloating (1, 43, 73,
75, 82, 107). There is evidence that how the meals are timed, the
content of the foods consumed, and the size of the meals consumed
before, during, and after flights can have an impact on how the
athlete feels. In general, lower fat and smaller meals are better
tolerated before, during, and after travel (3, 4, 74). There are also a
number of hormones affected by circadian rhythms that show
diurnal (during the day) variation and can affect the cardiovascular
and other systems. These include arginine vasopressin,
corticotropin, endogenous opioids, insulin, melatonin, somatotropin,
serotonin, thyrotropin-releasing hormone, and vasoactive intestinal
peptide (16, 19, 37, 44, 45, 49, 71) (Table 12.1).

Table 12.1 Major Hormones Affected by Circadian

Rhythms That Affect the Cardiovascular
and Other Systems
Hormone Action
Arginine Also referred to as antidiruetic hormone, AVP
vasopressin (AVP) mainly acts on the kidney to increase the
reabsorption of water to help sustain body
water and blood volume. The result is the
production of a concentrated urine with a
deep-yellow color that is suggestive of
dehydration.
Corticotropin Produced by the anterior pituitary gland, its
principal effect is the increased production and
release of cortisol (stress hormone) by the
adrenal gland.
Endogenous A group of peptides referred to as “endorphins”
opioids that are involved in “built-in” pain relief that
are produced by the pituitary gland and the
central nervous system. Besides the analgesic
(pain relief) effect, endorphins may also result
in a state of feeling good.
Insulin A peptide hormone produced by the β-cells of
the pancreas and involved in the regulation
and metabolism of energy substrates
(particularly blood glucose) through enabling
fat, liver, and muscle cells to take up glucose.
 Table 12.1 Major Hormones Affected by Circadian
Rhythms That Affect the Cardiovascular
and Other Systems
Hormone Action
Melatonin A hormone produced by the pineal gland of the
brain that is involved in the regulation of sleep
and wakefulness and also as a defense against
oxidative stress. It is involved in regulation of
circadian rhythms, including sleep–wake timing
and regulation of blood pressure.
Serotonin (5- Also referred to as 5-HT, this neurotransmitter,
hydroxytryptamine made from the amino acid L-tryptophan, is
[HT]) found in the gastrointestinal tract, red blood
cells, and the central nervous system. It is
involved in creating a sense of well-being, a
state of relaxation, and memory.
Somatotropin Also referred to as growth hormone or human
growth hormone, it is produced by the anterior
pituitary gland and is involved in stimulating
growth, cell reproduction, and cell
regeneration. It is also involved in the
production of insulin-like growth factor 1 (IGF-
1), which is necessary for muscle development
and repair.
Thyrotropin- Produced by the hypothalamus, it stimulates
releasing hormone the release of thyroid-stimulating hormone,
which is involved in the control of energy
metabolism.
Vasoactive A peptide hormone found in the intestine and
intestinal peptide stimulates heart contractility, results in
vasodilation, increases the breakdown of
glycogen (glycogenolysis), lowers blood
pressure, and helps to regulate circadian
rhythm.

Sources: From Refs. (1), (4), (16), (19), (37), (43), (44), (45), (49), (71), (73), (75), (97), and
(107).

Jet lag has implications for performance, with Olympic and sport-
governing bodies creating training camps near competition sites to
enable precompetition adjustments in circadian rhythms and to
allow for jet lag recovery (74). Specific diets have been suggested to
help reset the athlete’s circadian rhythm. For instance, lower protein
and higher carbohydrate diets may improve cellular tryptophan
levels, thereby enhancing serotonin to improve a sense of relaxation
and well-being, and improve sleep (46). It has also been suggested
that athletes consume diets higher in protein and lower in
carbohydrate to enhance epinephrine production and alertness
through a greater cellular uptake of the amino acid tyrosine (54).
Consumption of excess energy, particularly through higher fat diets,
may cause an athlete to take longer to adapt to the new
environment, whereas carefully controlling energy intake to sustain
energy availability may improve adaptation to the new environment
(2). There is evidence that switching from a high-carbohydrate, low-
fat diet to a high-fat, low-carbohydrate diet while keeping total
energy intake the same alters the circadian clock in humans, as
measured by salivary cortisol and human blood monocytes (69).
These findings suggest that adaptation to a new environment may
be made more complicated if the composition of the typical diet is
also changed.

Circadian Rhythms

Circadian (circa = approximately; dian = day) rhythms are

physical, mental, and behavioral changes that follow a roughly 24-
hour cycle, responding primarily to light and darkness in a
person’s environment. Circadian rhythms affect biologic processes,
including sleep, appetite, bowel movements, and optimal alertness
that are associated with specific times of the day. Alterations in
circadian rhythm may be the result of alterations in sun exposure,
weather, and other common stimuli. Travel, as it may result in
changes in all of these, may be associated with alterations in
circadian rhythm that can influence these timed biologic processes
and negatively impact athletic performance.

General Rules for Travel

Satisfying fueling and hydration needs is critically important for
athletic success, and these are the primary concerns for the
traveling athlete. Thought should be given to ensuring that the
traveling athlete will have familiar foods and beverages to consume
prior to the competition and that the athlete will adapt well to the
available beverages to be consumed during the competition.
(Competitions are no time to try out new foods/beverages.) Having a
checklist well in advance of the trip is a good strategy to make sure
the items required by the athlete are readily available. Athletes
should make plans to ensure that, while traveling, thirst and/or
hunger will never occur because of poor food/beverage availability.
Ideally, the athlete should begin planning for the trip long before
the trip begins. This planning involves studying the cuisine, culture,
and eating behaviors in the destination (67). It also involves knowing
the daily schedule while at the destination to plan for meals, snacks,
and drinks. The athlete should know the typical times that meals are
consumed and how many meals they can rely on. In some countries,
it is typical to have three meals per day (breakfast, lunch, and
dinner), whereas in others it is common to have six meals per day
(early breakfast, mid-morning meal, lunch, mid-afternoon meal,
dinner, and evening meal). It helps for athletes to visit local
traditional restaurants serving the cuisine of the country they will be
visiting prior to the trip so the athlete knows what he or she likes
and tolerates. If visiting a country where the population generally
adheres to Ramadan, it is customary to fast between sunrise and
sunset. If unaccustomed to this pattern of eating, athletes should
make more advanced planning and preparation to find culturally
acceptable eating locations and to develop strategies that will
enable eating in an accustomed pattern with foods known to be well
tolerated, while maintaining sensitivity to those around who are
adhering to Ramadan.
Athletes should consider following these tips for travel (67, 88,
93):

Bring snacks that are liked and tolerated. Fresh fruits, fruit
juices, crackers, low-fat rice, and low-fat energy bars are
nutritious, easy to carry, and carry few food safety risks.
Beware of hidden fats. Creamy soups, bread-type flaky/crispy
pastries, mayonnaise-based salad dressings, and sauces in
sandwiches add unnecessary fat to the food. Good alternatives
to these include clear, broth-based soups instead of creamy
soups; lemon juice–based salad dressing rather than
mayonnaise-type dressing.
Grilled, baked, boiled, and broiled foods are better than fried,
deep-fried, or sautéed foods. Athletes must learn to be specific
about how they would prefer the food to be prepared and should
make no assumptions about how it will be prepared by the
description on the menu. There is nothing wrong with requesting
low-fat dairy products and low-fat salad dressings.
Athletes should order à la carte to have the food exactly as they
want it. Full dinners may have some desired foods, but may also
provide foods that are unwanted. As an example, the grilled fish
may be precisely what is wanted, but the grilled fish full dinner
also comes with gravy-soaked mashed potatoes, broccoli
covered with cheese sauce, and apple pie with ice cream. The à
la carte order might better request broiled fish, a plain baked
potato, broccoli with lemon juice, and fresh fruit for dessert.
If traveling by air, athletes should give the airlines fair warning
of special dietary requirements at least 24 hours in advance of
the flight. Vegetarian offerings are often lower in fat and higher
in needed carbohydrate than the standard fare.
Air travel is one of the most dehydrating experiences a person
can have. Because of this, passengers often contract sore
throats and other upper respiratory illnesses. As a preventative
measure, keep sipping on fluids during the flight to keep your
mouth and throat moist because there may be a significant
delay between the time you take off and when you receive your
first drink. Drink bottled water or sports beverages.
To avoid any delay in available beverages and if traveling by air,
athletes should bring something to drink on the plane. Note,
however, that liquids and gels brought from home or purchased
before going through the security checkpoint in amounts larger
than 100 mL (note: 1 cup = 240 mL) are only allowed in checked
luggage. Beverages that are purchased after security screening
may be brought onto the plane.
Athletes changing time zones should make every attempt to get
on the local schedule as soon as possible. As an example, they
should have dinner when the local population is eating rather
than at the time dinner would be eaten while at home. This is
tiring and disorienting if changing time zones, but making this
change as quickly as possible makes it easier for the athlete to
perform at their conditioned best. Ideally, the athlete should try
 to arrive at the competition site early. The general rule is 1 day
early for every time zone change.
Because safety/hygiene standards are not the same worldwide,
athletes traveling to other countries increase the risk of
developing diarrhea, which can result in dehydration. To lower
risk of developing diarrhea and the inevitable dehydration that is
associated with it, traveling athletes should take great care to
avoid consumption of raw or minimally cooked foods. For
instance, it is better to consume fully cooked scrambled eggs
than eggs with runny yolks and albumin. When the safety of the
water is in doubt, consumption of bottled water is strongly
recommended for use with personal hygiene (i.e., brushing
teeth). When showering/bathing in water of unknown safety,
care should be taken to avoid ingesting the water (46).
Athletes with food sensitivities, allergies, or intolerances should
create 3 × 5 cards in advance of the travel in the native
language of the country of destination. These cards should list in
clear terms the foods/ingredients that create GI
difficulties/allergic responses, and when giving the order at a
restaurant, the card should be handed to the waiter. See Box
12.1 for an example for someone with a gluten intolerance.
There are a number of excellent online programs for translating
into virtually any language.

Box 12.1 Sample Card for Someone With a Gluten

Intolerance Who Is Traveling to Norway

I have a problem eating gluten, and it makes me ill if I consume

any gluten-containing foods. Please make certain that none of the
foods you give me to eat contain any of the following:

Barley
Bulgur
Oats (oats themselves do not contain gluten, but are often
processed in plants that produce gluten-containing grains and
may be contaminated. If you give me oats, they must
specifically be gluten-free oats)
Rye
Seitan
Triticale and Mir (a cross between wheat and rye)
 Gluten may also show up as ingredients in barley malt, chicken
broth, malt vinegar, some salad dressings, veggie burgers (if not
specified gluten-free), and soy sauce. Gluten may even hide in
many common seasonings and spice mixes.

Norwegian Translation

Jeg har et problem å spise gluten, og det gj⊘r meg syk hvis jeg
bruker noen glutenholdige matvarer.
Listen av glutenholdig korn slutter ikke på hvete. Andre lovbrytere
er:

bygg
bulgur
havre (havre seg selv ikke inneholder gluten, men blir ofte
bearbeidet i planter som produserer glutenholdige korn og kan
vμre forurenset)
rug
seitan
rughvete og Mir (en krysning mellom hvete og rug)

Gluten kan også dukke opp som ingredienser i byggmalt,

kyllingbuljong, malt eddik, noen salatdressinger, veggisburgere
(hvis ikke angitt glutenfri), og soyasaus. Gluten kan skjule i mange
vanlige krydder og kryddermikser.

Minimizing Jet Lag

Even seasoned travelers suffer from jet lag, which can make the
athlete feel ill, lowers appetite, and can keep the athlete from
getting a good night’s sleep (59). Jet lag has two primary forms: (i)
travel involving small but consecutive trips, causing multiple shifts in
usual eating patterns, and (ii) travel involving one large trip that
crosses multiple time zones, causing a major change in eating and
sleeping behaviors. Traveling across multiple time zones affects the
normal circadian rhythms and is associated with sleeplessness, poor
concentration, irritability, depression, disorientation, light-
headedness, loss of appetite, and GI distress (102). Airline crews
have reported sleeplessness in ∼60% to 70% of cases after crossing
a time zone, with only ∼30% of the crews reporting sleeplessness by
the third day following travel (54). The direction of travel also makes
a difference on the time it takes to recover from jet lag. It has been
estimated that more than twice the time is required to adapt to
flights traveling toward the west than flights traveling toward the
east (104). Jet lag significantly interferes with performance when
traveling across time zones. Often this performance reduction is due
to insufficient sleep that, by itself, can result in a 10% reduction in
the expected performance (54). The change in ___location resulting
from travel can negatively influence the athlete circadian rhythm,
which refers to the daily biologic clock that controls cells through the
production of enzymes and hormones (46).
A review of the impact of sleep and circadian rhythm on athletic
performance suggests the following (13, 92):

The evidence on the impact of sleep deprivation on athletic

performance is mixed. Current findings suggest that exercise
requiring a combination of short-term and high-power output
appears to be mainly unaffected. However, endurance
performance appears to be negatively impacted following sleep
deprivation.
Travel-associated desynchronization of circadian rhythms
resulting from passing multiple time zones may be impacted if
the time of the athletic endeavor is different than the athlete is
accustomed to, relative to the athlete’s “biologic” time.
Regardless of sport, athletic performance is likely to be closer to
the athlete’s norm if it is in the afternoon or evening, rather than
in the morning.
Sports requiring more technical skills may be better when
performed earlier in the day than skills demanding more power.
Performing in warmer environments may mediate this effect.
The loss of sleep is a risk factor for exercise-related injuries.

Jet Lag

Also referred to as desynchronosis and circadian dysrhythmia, it is

associated with physiologic changes that result because of
changes in circadian rhythm. These conditions include loss of
sleep, changes in appetite, and severe fatigue, all of which may
influence athletic performance. The severity of jet lag is related to
the direction of flight (going west adjusts faster than going east)
and number of time zones crossed.
 Although these factors may seem minor, the margin of athletic
prowess between competing athletes is often very small, making it
important for athletes to have sufficient time to normalize the
circadian clock, an important factor in athletic success. It is also
important to consider that sleep loss impacts individuals differently,
although most athletes who have been evaluated on this issue
report that they feel as if they require more effort to do the same
task when sleep deprived than when well rested (25).
As indicated earlier, many athletic endeavors may be negatively
affected by alterations in the circadian rhythm, with sport-specific
studies suggesting a performance impact in soccer, cycling, and
swimming (56, 75, 87). The alteration in circadian rhythm may
affect:

Leg strength (62)

Back strength and leg flexor strength (17)
Jump height and peak power (91)
Anaerobic (power/speed) tasks (48)
Aerobic tasks (86)

Suggested changes to adapt to the jet lag associated with

crossing time zones include the following (46, 81, 52, 85):

In advance of travel, the athlete should try to live on the new

time zone schedule through gradual (1 hour/day) shifts in the
time of sleep.
An attempt should be made to mimic light exposure to the light
exposure to be experienced at the new destination.
Arrive at the destination at least 1 day early for each time zone
crossed. Athletes should plan on arriving 1 week prior to the
event for flights crossing more than six time zones. Where
financial limitations and/or scheduling problems keep athletes
from arriving sufficiently early, they should try to get on the local
schedule quickly, but with as much rest as possible prior to the
event.
Short naps of ∼20–30 minutes may be useful in helping athletes
recover from the typical sleep deprivation that occurs with
travel.
Eat meals at regular times after arriving at the new destination.
This will aid adjustment to the new time zone.
 Never put off eating when hungry, so have some snacks readily
available.
Drink plenty of liquids. Plane cabins are notoriously dry, and
dehydration is the cause of many complaints, including
headaches and mild constipation.
Consume ample fluids to help maintain a good state of hydration
(water, sports beverages, fruit juices, etc.). If traveling to a
___location where the water is of unknown quality, consume only
bottled water.
Food safety is an important issue: Avoid consumption of raw
foods or foods that are only minimally cooked (i.e., raw eggs,
eggs with soft yolk). Peel fruits and vegetables that have been
washed in the local water supply.
Avoid alcohol during and after the flight. Besides the negative
metabolic alterations that alcohol causes, it is also a diuretic that
can increase water loss. There is no logical reason for any
athlete to consume alcoholic beverages at any time, particularly
when traveling or when close to a competition.
Engage in social activity or exercise after the flight. This will help
to reduce the stress associated with travel.
The sooner the athlete can eat and sleep on the new destination
schedule, the more quickly the athlete will feel ready to perform
athletically.
Maintaining a frequent eating and drinking schedule (eating
something about every 3 hours) is an important strategy for
helping the athlete adjust to the new environment. Bringing
snacks to get started is useful to ensure food availability until a
good source of snacks can be found after arrival at the new
___location.

Travel Location
Travel locations in the United States and Western Europe have foods
that are familiar for American athletes. American-style breakfast
cereals and breads/rolls/crackers are easily found in grocery stores.
Food preparation is also likely to be highly familiar, but with some
variations. Coffee, for instance, has many common variants in
virtually every eating establishment (i.e., espresso, Turkish/Greek,
café latté, French press, Americano). If accustomed to drinking
coffee in the morning, the athlete should become familiar with the
terms to ensure receipt of the accustomed coffee style.
 When traveling abroad, athletes should have the following items
available even if the food and water supply are safe and familiar
(67):

Power cord adapters and converters to fit the power supply of

the country you are traveling to
An in-cup electric heater
A water-filter pump
Supply of shelf-stable foods (Table 12.2)

Table 12.2 Examples of Shelf-Stable Foods

Available for Travel
Carbohydrates Proteins Fats Condiments
Instant rice Chicken pouch Olive Jam
oil
Instant mashed Tuna pouch Honey
potato
Pasta Salmon pouch Peanut
butter
Couscous Shelf-stable tofu Mustard
Quinoa Soy or whey protein Vegemite
powder
Dry breakfast Powdered and liquid Spices and
cereal (granola, meal replacements herbs
etc.)
Instant oats Milk powder Salt and
pepper
Dried crackers, rice (Nuts) (Nuts)
cakes, biscuits
Whole grain
tortillas
Dehydrated
vegetables
Dried fruit (raisins,
etc.)

Source: Parker-Simmons S, Andrew K. The traveling athlete. In: Maughan RJ, editor.
Sports Nutrition. London: John Wiley & Sons, Ltd.; 2014. p. 415–24.
 Powdered sports beverage packets to make 20 quarts of
beverage
Two quarts of bottled water

Food Safety Considerations

The food safety concerns differ with each country and these
differences, coupled with the athlete’s travel-related stress and
fatigue, may predispose the athlete to illness. These illnesses may
be due to food/water contamination from bacteria, viruses,
parasites, and chemicals (Table 12.3). Even different levels of
bromide or fluoride, purposely added to the water supply to make it
safe and/or to enhance health, may result in GI distress. Common
health problems that are of food and beverage origin most often
result in diarrhea, but infectious hepatitis, typhoid fever, and cholera
may also be the result of consuming unsafe foods and beverages.
Well-established strategies to lower the risk of developing a food or
water-borne illness include (18, 67):

Table 12.3 Common Foodborne Illnesses

Microorganism/Illness Source Common Prevention
Foods
Involved
Salmonellosis Intestinal Raw and
(Salmonella) tract of undercooked Cook animal
humans eggs, poultry, foods
and meat, fish, thoroughly
animals dressings, Prevent cross-
pies, cream contamination
desserts,
dairy
products
Campylobacteriosis Intestinal Undercooked
(Campylobacter tract of meat, poultry, Cook animal
jejuni) animals, fish, raw dairy foods
soil, and products thoroughly
water Prevent cross-
contamination
Table 12.3 Common Foodborne Illnesses
Microorganism/Illness Source Common Prevention
Foods
Involved
Listeriosis (Listeria Intestinal Raw milk,
monocytogenes) tract of cheese made Good
animals, from raw sanitation
soil milk, Use only
cabbage, pasteurized
undercooked dairy products
meat and Cook meat
poultry, hot and poultry
dogs, and thoroughly
smoked fish Prevent cross-
contamination
Limit
refrigerator
storage —
watch “use-
by” dates

Vibriosis (Vibrio Seawater Undercooked

species) (especially seafood, Cook all
during including seafood
warmer oysters, thoroughly
months) shrimp, crabs, Prevent cross-
and clams contamination
Keep cold
foods cold
(below 40°F)

Hemorrhagic colitis Intestinal Undercooked

(Escherichia coli tract of meats and Cook meats
O157-H7) animals poultry, thoroughly
and ground beef, Prevent cross-
humans raw milk and contamination
cheeses, Keep cold
unpasteurized foods cold
apple juice (below 40°F)
and cider
Table 12.3 Common Foodborne Illnesses
Microorganism/Illness Source Common Prevention
Foods
Involved
Shigellosis (Bacillary Intestinal Salads,
dysentery; Shigella tract of seafoods, Good
species) humans milk, dairy sanitation
and products, Minimize
primates poultry, contact of
potato salad, hands with
parsley food
Keep cold
foods cold
(below 40°F)

Fruits and vegetables: Uncooked fruits and vegetables may be

carriers of field manure/sewage used as fertilizer to grow the
plants, and water used to wash the fruits and vegetables may
also be contaminated. Cutting/peeling contaminated fruits and
vegetables may result in the contamination (bacteria, etc.)
entering the food. Ideally, vegetables should be fully cooked to
resolve any contamination issue, and fresh fruits should be
cleaned thoroughly with bottled water and, if available,
vegetable wash (soap) prior to pealing, cutting, or eating.
Meats, poultry, seafood, dairy: Animal foods are common carriers
of bacteria and, potentially, other contaminating substances. To
reduce the possibility of eating these contaminants, all animal
foods should be fully cooked to eliminate any possibility of
foodborne illness. Many cuisines often serve foods that are
uncooked or undercooked (i.e., sushi and other raw seafood,
steak tartare), and these should be avoided. Eggs are an ideal
medium for bacterial growth, so should be fully cooked (firm to
the touch, with no liquid albumin or yolk). See Table 12.4 for safe
minimum internal food temperatures.

Table 12.4 Safe Minimum Internal

Temperatures (as Measured With a
Food Thermometer)
Food Type
Table 12.4 Internal Temperature
Safe Minimum Internal
Temperatures (as Measured With a
Food Thermometer)

Food Type Internal Temperature

Beef, pork, veal, and 145°F with a 3 min rest time
lamb (chops, roasts,
steaks)
Ground meat 160°F
Ham, uncooked (fresh 145°F with a 3 min rest time
or smoked)
Ham, fully cooked (to 140°F
reheat)
Poultry (ground, 165°F
parts, whole, and
stuffing)
Eggs Cook until yolk and white are firm
Egg dishes 160°F
Fin fish 145°F or flesh is opaque and separates
easily with fork
Shrimp, lobster, and Flesh pearly and opaque
crabs
Clams, oysters, and Shells open during cooking
mussels
Scallops Flesh is milky white or opaque and firm
Leftovers and 165°F
casseroles

Source: United States Department of Commerce, U.S. National Weather Service

[Internet]. Available from: https://www.weather.gov. Accessed May 16, 2018.

Environmental temperature and cleanliness: The athlete should

use his or her senses and good logic to determine if the
environment where foods are available for purchase is clean,
and foods are appropriately stored in temperature-controlled
containers. Foods from street vendors, open buffets, and
markets that appear to be and smell unclean have a high risk of
providing foods that may induce foodborne illness and should be
avoided.
Pasteurization: Pasteurization is a process used with milk, juice,
and canned foods for killing bacteria and denaturing enzymes
that enable bacterial growth. Consumption of unpasteurized milk
and dairy products or juices may dramatically increase risk of
developing a foodborne illness, so should be totally avoided.
Only a few countries, including the United States and Australia,
mandate the pasteurization of dairy foods, requiring that
athletes specifically look for the Radura symbol (Figure 12.2) as
a sign that the food has been pasteurized.

FIGURE 12.2: International Radura symbol of pasteurization.

Water: Unless the water supply has been well established as

clean and safe for human consumption, athletes should become
accustomed to reliance on bottled water for drinking, brushing
teeth, and cleaning fresh fruits. As ice typically comes from the
local water supply, which may not be clean, it is also best to skip
consumption of beverages that contain ice. Athletes should also
be aware of the importance of avoiding the consumption of
water that may happen passively, as while swimming in a pool
and/or while showering. Camping stores have small portable
water filters that remove both parasites and bacteria. Where
 bottled water is not available, drinking water that has been
filtered is an excellent alternative.
Personal hygiene: Athletes should develop the habit of carefully
washing hands with soap and water prior to handling or
consuming foods. Where this is not possible, carrying a small
bottle of hand sanitizer is an appropriate alternative so that
hands can be cleaned regardless of where the food will be
consumed.
Sharing foods: Avoid sharing foods where the food the athlete is
eating may be touched and contaminated by someone who has
not properly washed his or her hands. For instance, putting
shared food into separate bowls rather than consuming food
from a shared bag is a safer strategy.
Food storage: When storing foods, keep foods (i.e., meats, dairy)
that may become hazardous if kept between 40°F and 140°F
(4.4°C to 60°C) out of that temperature zone. The food storage
area should be clean and used only for storing foods, and the
wrappers/packages of stored foods should be clean and
undamaged.

Important Factors to Consider: Special Food Concern

It has been reported that beef tainted with a banned steroid

(clenbuterol) and consumed by competing athletes resulted in a
large proportion of positive urine tests in tested samples, including
in the Tour de France winner, Alberto Contador, who was
suspended but insisted that the positive test was the result of
unknowingly consuming tainted food (89). Clenbuterol is added to
the feed of cattle, poultry, and pigs in some locations to enhance
growth of both muscle and fat (84). Although illegal in many
countries for this purpose, not all countries have laws banning its
use or sufficient testing protocols to determine whether
clenbuterol has been used. Professional football players were
recently warned that high meat consumption while abroad may
result in a positive blood or urine test for clenbuterol, a banned
substance. The memo by the National Football League to the
players stated: “Players are warned to be aware of this issue when
traveling to Mexico and China. Please take caution if you decide to
consume meat, and understand that you do so at your own risk”
(26).
Eating Locations
Travel inevitably keeps athletes from eating when and where they
would like to eat, requiring that sufficient planning take place prior
to the trip to ensure that athlete performance is not compromised
because of poor food selection or poorly timed meals. On those
occasions when even the best planning cannot account for all
contingencies, the traveling athlete must be willing to make
requests when ordering food.

Table 12.5 What to Eat, What Not to Eat;

What to Drink, What Not to Drink
When Traveling to Other
Countries
Eat Do Not Eat

Food that is cooked and Food served at room temperature

served hot

Food from sealed Food from street vendors

packages

Hard-cooked eggs Raw or soft-cooked (runny) eggs

Fruits and vegetables Raw or undercooked (rare) meat

you have washed in or fish
safe water or peeled
yourself

Pasteurized dairy Unwashed or unpeeled raw fruits

products and vegetables

Condiments (such as salsa) made

with fresh ingredients
 Salads

Flavored ice or popsicles

Unpasteurized dairy products

Bushmeat (monkeys, bats, or

other wild game)

Drink Do Not Drink

Water, sodas, or sports Tap or well water

drinks that are bottled
and sealed (carbonated
is safer)

Water that has been Fountain drinks

disinfected (boiled,
filtered, treated)

Ice made with bottled Ice made with tap or well water
or disinfected water

Hot coffee or tea Drinks made with tap or well

water (such as reconstituted
juice)

Pasteurized milk Unpasteurized milk

These recommendations are particularly important during travel to developing countries.

Source: United States Department of Health and Human Services, Centers for Disease
Control and Prevention. Warning Signs and Symptoms of Heat-Related Illness [Internet].
Available from: https://www.cdc.gov/disasters/extremeheat/warning.html. Accessed July,
2017.
 Airport restaurants have many options, but the foods are often
high in fat and/or high in sugar. When possible, athletes should
select foods that are not fried and foods high in complex/starchy
carbohydrates. For instance, a baked potato would be preferred over
French fries. As another example, a hungry athlete may want to
order a double-patty hamburger, but would be better ordering two
regular hamburgers because that would provide twice the
carbohydrate (hamburger buns). Pasta, bread, vegetables, and salad
are all good sources of carbohydrate that are typically low in fat.
Athletes should be willing to ask for a food substitution on plates
that include meat/fish, vegetable, and starch. For instance, asking
for sautéed fish instead of deep fat fried–battered fish may not be
possible, but the athlete would never know without asking.
Restaurants in transportation centers (airports, train stations,
seaports, etc.) may be less likely to make a requested substitution to
satisfy the request because they know they will probably never see
the patron (or his or her business) again. Despite the possibility that
the request may not be fulfilled, the athlete should request exactly
what he or she would like. Even when ordering a baked potato,
asking that all the toppings be provided on the side rather than on
the potato is important. (See Table 12.5 from the Centers for Disease
Control and Prevention for Safe and Risky foods and beverages while
traveling.)

High-Altitude and Cold Environments

Performing physical work at high altitude presents enormous

challenges that result from lower oxygen availability, lower air
pressure, and lower temperature. Air temperature decreases by
∼1°C for every 150 m above sea level, and this lower temperature is
typically also associated with lower humidity (98). The lower oxygen
availability results in automatic physiologic responses, including
higher heart rate, vasodilation, and hyperventilation, that are
intended to sustain tissue oxygen availability (39). Although the
human system can adapt to doing work in higher elevations, this
adaptation takes time to achieve. Women have improved exercise
performance when compared with men under hypoxic (high-altitude)
conditions (30, 66). Athletes sometimes move quickly from lower to
higher altitude to enhance oxygen-carrying capacity. However, doing
this without appropriate adaptation may result in high-altitude
illness such as headache, nausea, and premature fatigue, all of
which can negatively influence food and fluid consumption that may
result in tissue loss that lowers cold tolerance (100). See Table 12.6
for the major nutritional issues associated with ascent to higher
altitudes.

Table 12.6 Major Nutritional Issues Associated With

Ascent to Moderately Higher Altitudes
(1,500–3,000 m)
Issue Problem Recommendation
Appetite Rapid ascent to Acute mountain sickness
altitudes exceeding typically self-resolves in 2–
2,000 m is associated 4 d. Athletes should make
with symptoms of every attempt to stay
acute mountain active and eat foods and
sickness, which is fluids up to the maximal
associated with tolerance limit.
nausea-induced loss of
appetite.
Fluids Diuresis (increased Take weight before and
urine production) after exercise to
occurs at high altitude, determine water loss (16
resulting in higher oz = 1 lb), and drink
dehydration risk. sufficient fluids to
minimize loss. Do not
drink excess fluids.
Carbohydrates Carbohydrates are Try to consume high-
utilized at a faster rate carbohydrate
at high altitude, foods/beverages as often
potentially increasing as possible, including
the risk of glycogen before, during, and after
depletion and faster workouts.
fatigue.
Table 12.6 Major Nutritional Issues Associated With
Ascent to Moderately Higher Altitudes
(1,500–3,000 m)
Issue Problem Recommendation
Iron High altitude increases Regular consumption of
red blood cell foods high in iron helps to
manufacture satisfy iron needs. For
(erythropoiesis) as the athletes who are unable or
body attempts to unwilling to consume high-
improve the capture of iron foods (red meats,
environmental oxygen. etc.), consumption of an
This process increases iron supplement with
the iron requirement, vitamin C may be useful
with an initial decrease prior to and during
in stored iron (ferritin) exposure to high altitude.
as red blood cells are Cooking in an iron skillet
increased. Note: also adds iron to the
Producing sufficient consumed foods. However,
additional red blood also need to be sure that if
cells to enhance Fe supplementation is
oxygen-carrying done that the athlete is
capacity is a slow monitored closely in the
process that may take process to avoid Fe
weeks to months to toxicity!
achieve.

Source: From Cheuvront SN, Ely BR, Wilber RL. Environment and exercise. In: Maughan RJ,
editor. Sports Nutrition. London: Wiley Blackwell; 2014. p. 425–38, with permission.

High Altitude

Refers to any altitude significantly higher than that the athlete is

accustomed to. Typically, high altitude is up to 2,500 m, very high
altitude is up to 5,500 m, and extreme altitude is above 5,500 m.
The lower oxygen air concentration at high altitude results in
adaptive physiologic events, including erythropoiesis to improve
oxygen-carrying capacity.

High-Altitude Illness
 Refers to a group of syndromes, including acute mountain
sickness, high-altitude cerebral edema, and high-altitude
pulmonary edema that may occur when training at an altitude to
which a person has not well adapted.

Maintaining body fluid balance in extreme cold is just as difficult

as maintaining fluid balance in hot and humid environments, with
both increased urinary flow and voluntary dehydration potential
contributing factors to dehydration. The practical aspect of keeping
drinking fluids from freezing is a challenge in higher (and colder)
altitudes and makes proper hydration even more difficult. As a
result, cold-weather exposure creates significant dehydration risk. It
is common for soldiers in cold environments to lose up to 8% of body
weight from dehydration, for several reasons (28):

Difficulty obtaining adequate amounts of potable water

High levels of water loss (particularly if excess clothing is worn
or heavy equipment is being carried)
Increased respiratory water loss
Cold-induced diuresis

High-Altitude Training
There is less oxygen at higher altitudes, requiring that athletes
adapt to the altitude prior to undergoing serious training activities.
The higher the altitude, the lower the level of available oxygen. By
definition, different degrees of high altitude are defined as follows:

High altitude: 1,500–2,500 m (e.g., Mount Washington, NH, USA,

is 1,917 m)
Very high altitude: 2,500–5,500 m (e.g., Mont Blanc, France/Italy,
is 4,810 m)
Extreme altitude: Anything above 5,500 m (e.g., K6, Pakistan, is
7,282 m)

Anaerobic events with lower reliance on oxidative metabolism

may actually see some performance enhancement at higher
elevations because of lower air resistance/atmospheric pressure. In
addition, muscle strength and maximal muscle power are not
negatively affected at high altitude provided that muscle mass is
maintained (30). It has been estimated that at an altitude of Mexico
City (2,250 m), the lower air resistance imparts a 0.07 s advantage
over a 100 m sprint (50, 51). The reduced oxygen availability at high
altitude, however, may be negatively affected, despite the lower air
resistance (29, 70).
Lower oxygen concentrations at progressively higher altitudes
require that athletes take a graduated approach to training at high
altitudes for an efficient and illness-free adaptation. Those involved
in higher altitude training can expect both faster respiration and
faster heart rate because of the lower level of oxygen being pulled
into the lungs with each breath. Only achieving a greater red blood
cell (RBC) concentration, associated with higher oxygen-carrying
capacity, will mediate the faster breathing and heart rate, but it
often takes weeks for the higher RBC concentration to result in
normal breathing and heart rate. Several nutrition factors are
associated with production of new RBCs, including maintenance of
energy balance coupled with sufficient intake of iron, folic acid, and
vitamin B12. Most athletes find that consumption of an iron-rich
healthy diet satisfies these requirements, but athletes who consume
little or no meat may be at risk of compromising their ability to make
sufficient new RBCs. These athletes may require supplementation
and/or a major change in dietary intake to help ensure an
appropriate adaptive response to high altitude. The maintenance of
energy balance and adequate nutrient intake is also compromised
by the loss of appetite that is common at high altitudes (Figure
12.3).
FIGURE 12.3: Nutritional requirements for high altitudes and cold
environments.

Heat loss in cold environments occurs through convection and

conduction, but body temperature can be maintained through
several means (55). The degree to which body heat is lost is
lessened through vasoconstriction of the peripheral veins. Although
this results in lower heat loss, it may also predispose individuals to
frostbite of the fingers and toes. To lessen this risk of frostbite, cold-
induced vasodilation is initiated about 10 minutes following initial
exposure to the cold. The result is alternating vasoconstriction and
vasodilation that not only helps to sustain core temperature but also
fluctuates temperatures of feet and hands to lower frostbite risk
(61).
Another system for sustaining core body temperature is
shivering, an involuntary central nervous system–induced
mechanism that occurs when core body temperature drops by 3°C to
4°C (38, 99). Shivering involves quick muscle contractions that
result in a large increase (2.5 times higher than normal) in total
energy expenditure, mainly from higher muscle glycogen (stored
carbohydrate) utilization (96). Cold stress also increases muscle
glycogen utilization as a result of increased plasma catecholamines,
epinephrine, and norepinephrine (105). These systems for sustaining
core body temperature are largely carbohydrate (glycogen)
dependent, mandating that carbohydrate replacement be
considered a highly important nutrition strategy when exercising at
high altitudes and in the cold (27).
It should be noted that the reduced muscle mass associated with
aging makes it more difficult for older individuals to adapt as quickly
to high altitude and colder environments than for younger
individuals. This is due to the lower heat production associated with
lower musculature, both from exercise and from shivering (106).

Important Factors to Consider

High altitude is less likely to negatively impact high-intensity

(anaerobic) activity than lower-intensity (aerobic) activity.
The higher the altitude, the lower the oxygen availability, and
the greater the negative impact on aerobic activity.
 The adaptation to high altitude appears to be slower in women
than in men, as it relates to the increased production of RBCs, and it
appears that supplementation with dietary iron in women enhances
the production of RBCs more than in men (36). Other studies
assessing gender differences at high altitude (4,300 m) suggest that,
after 12 days of acclimatization, sympathetic nerve activity is similar
in both men and women (58). It has also been found that high-
altitude hypophagia (reduction in food intake), which is a common
initial response of travel to high altitude (in the case of this study,
Pikes Peak at 4,300 m), is similar in both men and women (36).
Many experienced athletes, including skiers and mountain
climbers, who spend significant time at high altitude are aware of
the potential for nausea, confusion, and easy fatigue when working
at high altitude. It takes time to adapt to this relatively hypoxic
environment, mainly by improving the capacity to deliver oxygen to
working tissues through development of more RBCs. High-altitude
exposure increases oxidative stress, and it is estimated that most
humans are 80% acclimatized after 10 days at altitude and ∼95%
acclimatized by 45 days at altitude (40, 63).
Common occurrences when at a higher altitude include faster
breathing, shortness of breath, higher urination frequency, and more
trouble sleeping than the person is accustomed to. The lower
barometric pressure of high altitude lowers the oxygen concentration
of every breath, forcing a more frequent breathing pattern in an
attempt to pull in the same level of oxygen. It is impossible to obtain
the same oxygen at high altitude when compared with sea level, no
matter how rapid the breathing pattern. As a result, physical work
will be more difficult and fatigue will occur more quickly at high
altitude. Poor adaptation to high altitude from an excessively fast
rate of ascent, inadequate carbohydrate consumption, or excess
exertion will result in altitude sickness, which includes headaches,
vomiting, anorexia, malaise, and nausea (6).
The common high-altitude illness syndromes include the following
(20, 41) (note: there are also drug-related treatments, including
dexamethasone, not mentioned in the treatment recommendations
below):

Acute mountain sickness: A related disorder, acute mountain

sickness commonly occurs at altitudes exceeding 2,000 m
(6,600 feet), produces symptoms of nausea, dyspnea on
exertion and at rest, poor sleep, ataxia, headache, altered
 mental state, lassitude, fluid retention from greater antidiuretic
hormone production, and cough (47, 79). It is thought to be the
least serious and most common of the syndromes.
Treatment: Involves cessation of ascent, rest, and
acclimatization to the current altitude/cold.
Prevention: Ascent slowly, with a maximum of 600 m/day
(2,000 feet/day); avoid excess exertion; and avoid direct
transport (e.g., helicopter, ski lifts) to elevations greater than
2,750 m (9,000 feet).
High-altitude cerebral edema: Symptoms of high-altitude
cerebral edema, which can progress rapidly and result in death
within a matter of a few hours, include gait ataxia (walking like
someone intoxicated), confusion, psychiatric changes, and
changes of consciousness that may progress to deep coma (35).
Treatment: Immediate descent to ∼1,000 m (3,300 feet) and
provide oxygen if available. If available and if the descent is
delayed, should use portable hyperbaric chamber.
Prevention: Ascent slowly, with a maximum of 600 m/day
(2,000 feet/day); avoid excess exertion; avoid direct
transport (e.g., helicopter, ski lifts) to elevations greater than
2,750 m (9,000 feet).
High-altitude pulmonary edema: The cause(s) of high-altitude
pulmonary edema (fluid in the lungs) are not well understood,
but it is known that it rarely occurs at altitudes below 2,400 m
(8,000 feet). Failure to treat this disorder immediately, typically
by immediate descent, may result in death. Symptoms result
from a lower oxygen–carbon dioxide exchange and include
extreme fatigue, gurgling breaths, breathlessness at rest,
tightness of the chest, cough with possible bloody sputum, and
blue/gray lips and/or fingernails (21).
Treatment: Provide oxygen immediately and descend 500–
1,000 m (1,600–3,300 feet) or more. If delayed descent, use
portable hyperbaric chamber.
Prevention: Slow ascent with a maximum of 600 m/day
(2,000 feet/day); sleep at lower altitude; avoid overexertion.

Studies assessing athletes in a high-altitude adventure race have

found that 4.5% had altitude illness at the race onset; 14.1% had
altitude illness during the race that required medical treatment; and
14.3% withdrew from the race because of altitude-related illness
(90). It appears that the most significant nutrition-related changes
are typically found at altitudes greater than 6,000 m. These include
changes in eating patterns (typically hypophagia) with an associated
loss of body weight and a negative nitrogen balance that is
associated with loss of lean mass (34). As indicated earlier, illness
occurring at high altitude should be treated by descent to a lower
altitude and by administering oxygen, if available. Worsening
symptoms should be taken seriously, with no delay in descent, as
these symptoms may rapidly progress to high-altitude cerebral
edema or high-altitude pulmonary edema, both of which are life-
threatening (31).
Body composition makes a difference in high-altitude sickness
risk, with obese individuals more likely to suffer from acute mountain
sickness (78). However, those with periodic high-altitude exposures
appear to adapt and reduce the symptoms of acute mountain
sickness, regardless of body composition (9). Other strategies,
including magnesium supplementation and ginkgo biloba
supplementation, have been tried for reducing acute mountain
sickness, but without success (7, 22). The combined impact of acute
mountain sickness symptoms is a severe appetite depression with a
concomitant reduction in foods and fluids. The high caloric
requirements and fluid consumption difficulties of cold weather,
combined with the anorexia of high altitude, create the two most
serious problems of work at high altitude: maintenance of weight
and fluid balance. Even those who are part of well-organized
mountain-climbing expeditions and regularly exposed to high
altitude typically fail to consume sufficient calories, resulting in body
weight reduction. An assessment of participants in a Himalayan trek
found that body weight was significantly reduced by the end of the
trek, and energy intake was significantly lower at high altitude than
at low altitude (53). Despite a greater need for energy, it has been
found that food intakes are typically 10%–50% lower at high altitude,
depending on the speed of the ascent. (See Chapter 8 for strategies
on predicting energy requirements.) This also appears to be true
when people are in a hypobaric (lower air pressure) chamber and not
exposed to severe cold (80). Individuals at high altitude must make
a conscious effort to consume more food, often with forced eating, to
obtain enough energy to satisfy physiologic needs (Box 12.2) (11).

Box 12.2 Sample Foods and Considerations for High-

Altitude Eating
 Sample Foods for High-Altitude Treks

Breakfasts: granola or energy bars, Pop-Tarts, oatmeal, bagels,

hot sweet rice, couscous, grapenuts, hot cocoa, tea, and cider
Lunches: crackers (wheat thins, Ritz, Cheez-Its), cookies,
bagels or rolls, jerky, sausages, cheese sticks, nuts, candy
bars, dried fruits, flavored juice drink mixes, fruit leather, fig
bars, hard candy, trail mix
Dinners: cocoa, cider, soups, hot Jello, and teas as the first
course; freeze-dried meals with rice, noodles, vegetables;
instant rice, stuffing, or mashed potatoes; pudding or mousse
for desserts

How High Altitude Affects Cooking

At altitudes above 3,000 feet, preparation of food may require

changes in time, temperature, or recipe. The reason is the lower
atmospheric pressure due to a thinner blanket of air above. At sea
level, the air presses on a square inch of surface with 14.7 lb
pressure; at 5,000 feet with 12.3 lb pressure; and at 10,000 feet
with only 10.2 lb pressure — a decrease of about 1/2 lb per 1,000
feet. This decreased pressure affects food preparation in two ways:

Water and other liquids evaporate faster and boil at lower

temperatures.
Leavening gases in breads and cakes expand more quickly.

As atmospheric pressure decreases, water boils at lower

temperatures. At sea level, water boils at 212°F. With each 500-
feet increase in elevation, the boiling point of water is lowered by
just under 1°F. At 7,500 feet, for example, water boils at about
198°F. Because water boils at a lower temperature at higher
elevations, foods that are prepared by boiling or simmering will
cook at a lower temperature, and it will take longer to cook.
High-altitude areas are also prone to low humidity, which can
cause the moisture in foods to evaporate more quickly during
cooking. Covering foods during cooking will help retain moisture.

Why Cooking Time Must Be Increased

As altitude increases and atmospheric pressure decreases, the
boiling point of water decreases. To compensate for the lower
boiling point of water, the cooking time must be increased. Turning
up the heat will not help cook food faster. No matter how high the
cooking temperature, water cannot exceed its own boiling point —
unless if using a pressure cooker. Even if the heat is turned up, the
water will simply boil away faster and whatever is being cooked
will dry out faster.

High Altitudes Affect How Meat and Poultry Are Cooked

Meat and poultry products are composed of muscle, connective

tissue, fat, and bone. The muscle is ∼75% water (although
different cuts of meat may have more or less water) and 20%
protein, with the remaining 5% representing a combination of fat,
carbohydrates, and minerals. The leaner the meat, the higher the
water content (less fat means more protein, thus more water).
With such high water content, meat and poultry are susceptible
to drying out while being cooked if special precautions are not
taken. Cooking meat and poultry at high altitudes may require
adjustments in both time and moisture. This is especially true for
meat cooked by simmering or braising. Depending on the density
and size of the pieces, meats and poultry cooked by moist heat
may take up to one-fourth more cooking time when cooked at
5,000 feet. Use the sea-level time and temperature guidelines
when oven-roasting meat and poultry, as oven temperatures are
not affected by altitude changes.

Use a Food Thermometer

A food thermometer is the only way to measure whether food has

reached a safe internal temperature. In a high-altitude
environment, it is easy to overcook meat and poultry or scorch
casseroles. To prevent overcooking meat and poultry (which will
result in dry, unappetizing food) or to prevent undercooking (which
can result in food poisoning), check food with a food thermometer.

Where to Place the Food Thermometer

Meat: When taking the temperature of beef, pork, lamb, and veal
roasts, steaks, or chops, the food thermometer should be placed in
 the thickest part of the meat, avoiding bone and fat. When the
food being cooked is irregularly shaped, such as with a beef roast,
check the temperature in several places.
Cook all raw beef, pork, lamb and veal steaks, chops, and
roasts to a minimum internal temperature of 145°F as measured
with a food thermometer before removing meat from the heat
source. For safety and quality, allow meat to rest for at least 3
minutes before carving or consuming. For reasons of personal
preference, consumers may choose to cook meat to higher
temperatures.
Cook all raw ground beef, pork, lamb, and veal to an internal
temperature of 160°F as measured with a food thermometer.
Poultry: A whole turkey, chicken, or other poultry is cooked to a
safe minimum internal temperature of 165°F as measured with a
food thermometer. Check the internal temperature in the
innermost part of the thigh and wing and the thickest part of the
breast. For reasons of personal preference, consumers may choose
to cook poultry to higher temperatures.
For optimum safety, do not stuff whole poultry. If stuffing whole
poultry, the center of the stuffing must reach a safe minimum
internal temperature of 165°F.
If cooking poultry parts, insert the food thermometer into the
thickest area, avoiding the bone. The food thermometer may be
inserted sideways if necessary. When the food is irregularly
shaped, the temperature should be checked in several places.

Source: United States Department of Commerce, U.S. National Weather Service

[Internet]. Available from: https://www.weather.gov/. Accessed May 16, 2018.

There is a reduction in fat-free mass at altitudes above 5,000 m,

likely due to the combined results of hypophagia (typically 30%–50%
decrease in energy consumption) and an increase in energy
expenditure (up to 1.85–3.0 times greater than at sea level in Mount
Everest climbers) (103). Skeletal muscle represents a large
proportion of normal total body protein turnover and typically there
is homeostasis, with approximately the same amount of muscle
protein gained as that lost. At high altitude, it appears that hypoxia
is largely responsible for greater skeletal muscle loss than recovery,
both because of the effects it has on reducing appetite and
increasing energy metabolism (10). It should be noted that a
reduction in total energy intake also results in the reduction in
protein intake, the combination of which can have an impact on
muscle protein status. It is well established that relatively higher
protein intake (1.8 vs. 0.9 g/kg) is useful in sustaining skeletal
muscle status when coupled with a total energy intake restriction
(68). Given the difficulty of maintaining a sufficient calorie and
protein intake when at high altitude and the fact that higher total
protein intakes are thermogenic, requiring an additional 20%–30% of
total calories for absorption and metabolism, providing a protein
supplement relatively high in branched-chain amino acids
(particularly leucine) may be a useful strategy for sustaining skeletal
muscle mass (103).
Sweat loss in extremely cold environments can equal that of hot
and humid environments, primarily because of the insulated clothing
being worn. Moderate to heavy exercise in typically insulated winter
clothing results in sweat loss estimated to be nearly 2 L of sweat per
hour (28). The primary strategy to ensure adequate hydration is to
have enough fluids readily available to allow for frequent
consumption of appropriate quantities. This strategy is not easy to
achieve, however, because in cold, high-altitude environments
drinks can freeze unless there is a well-planned strategy for keeping
the drinks fluid. Another problem is that fluids have a high density
and are heavy to transport in sufficient quantities to satisfy needs. A
potential option is to obtain fluids locally by melting and purifying ice
and snow, but this process takes a great deal of time and a high
level of heating fuel. This strategy is estimated to require more than
6 hours and 2 L of gas to melt enough ice/snow to satisfy fluid
requirements for one person (28).

Meeting Energy and Nutrient Needs in the Cold at High

Altitude
The main goal of exercising in a cold environment is to sustain
normal core body temperature, which requires greater energy
requirement. Energy expenditures at high altitude and cold are
significantly higher (commonly 2.5–3.0 times greater) than at sea
level. The energy requirement is sufficiently high that it is difficult to
satisfy energy needs in this environment, resulting in loss of muscle
and weight (76, 101). Frequent eating at timed intervals, with a
focus on high-carbohydrate foods, is important because
carbohydrates take less oxygen to metabolize for energy than either
fat or protein (Table 12.7). Insufficient carbohydrate may also result
in low blood sugar, which negatively affects the central nervous
system, resulting in mental confusion and disorientation. It has been
found that some mountaineers prefer carbohydrates and may
develop a dislike of fat (64). It has also been found, however, that
many individuals at high altitude maintain existing food preferences
and do not shy away from higher fat foods, despite a reduction in
total food intake as a result of a lowering of the sense of taste (77).
The negative energy balance common at high altitude results in
muscle and weight loss that reduces both strength and endurance
and also the capability to produce sufficient heat to sustain core
body temperature. Athletes at high altitude should have as a
primary goal the consumption of sufficient energy, regardless of the
energy substrate distribution. A secondary goal would be the
consumption of as much carbohydrate as is tolerated. None of this is
easy to achieve, as even the time it takes to prepare/cook meals
doubles for each 1,500 m (5,000 feet), as water boils at a lower
temperature. Prepackaged, high-carbohydrate, moderate-protein
foods are appropriate choices for most meals, with cooked meals
reserved for times when there is adequate water and preparation
time.

Table 12.7 Nutrition Considerations for Exercise in Cold

Environments
Factor Issue Recommended Action
Fluid High levels of body Athletes should weigh
water loss occur even themselves before and
in cold weather after exercise to
because of the heat- determine the volume of
preserving properties water lost that was not
of insulated clothing. If adequately replaced. For
insufficient clothing is every pound lost, 16 oz of
worn, the lowering of fluids should be consumed
core temperature during the activity to
results in diuresis. sustain preexercise weight
(1 kg weight = 1,000 mL
fluid).
Table 12.7 Nutrition Considerations for Exercise in Cold
Environments
Factor Issue Recommended Action
Carbohydrates Hypothermia (body Athletes should focus on
temperature below consuming high-
35°C) occurs when carbohydrate foods prior
heat dissipation to exercise to ensure
exceeds heat optimizing glycogen
production, with stores. Carbohydrates
shivering and other should be consumed
symptoms. Energy during exercise to sustain
metabolism relies blood sugar and mental
heavily on function and to provide
carbohydrate as a fuel, fuel to working muscles so
and shivering is mainly as to diminish muscle
fueled by glycogen glycogen utilization.
(stored carbohydrate).

Source: From Cheuvront SN, Ely BR, Wilber RL. Environment and exercise. In: Maughan RJ,
editor. Sports Nutrition. London: Wiley Blackwell; 2014. p. 425–38, with permission.

Vitamins and Minerals

Vitamin and mineral consumption should be considered well in
advance of attempting to go to a high-altitude/cold environment.
Iron status should be evaluated and determined to be excellent, with
normal levels of iron stores (ferritin) prior to going to high altitude. It
does little good to take supplemental iron while actively on a climb,
as erythropoiesis (the process of making new RBCs) takes weeks and
months to improve iron status (8). Oxidative stress may be higher in
hot and cold environments, so consumption of foods that are good
sources of antioxidants should be considered (5). A study of
oxidative stress in humans at high altitude found that those
receiving an antioxidant mixture had lower markers of oxidative
stress than those receiving single antioxidant supplements. If taking
supplements, it appears that periodic consumption of a variety of
antioxidants that include ascorbic acid, β-carotene, selenium, and
vitamin E results in a better outcome than consuming a daily dose of
a single antioxidant (12). (See Chapters 5 and 6 for specific
information on vitamins and minerals, and Chapter 13 for
information on supplements and ergogenic aids.)
Fluids
Having sufficient fluids available to consume in cold high-altitude
environments is difficult but an absolute necessity to ensure that the
individual can survive the environment. To ensure adequate fluid
availability, each person should have easy access to a minimum of 2
L of fluids per day, with double that amount (4 L) the preferred
volume (33). Consider that physical work in this environment may
cause the loss of 2 L of sweat per hour. Climbers have developed a
basecamp strategy, where large amounts of food, water, fuel, and
other materials are moved to the highest possible altitude using
helicopters or animal packs. Climbers then go from the basecamp to
a higher altitude carrying just enough food and fluid to satisfy needs
for the climb from the basecamp. Ideally, fresh potable water should
be available at the basecamp as using snow and ice as a water
source increases necessary resources in fuel, pots, stoves, etc. There
are also reports that a diarrhea-causing intestinal parasite, Giardia
lamblia, is present in high-altitude regions (64). Therefore, local fluid
sources should be used only in emergencies, and preferably only if
high-quality purification devices are available.
To avoid having fluids freeze, athletes should carry drinking fluids
inside insulated clothing they wear, and also keep fluids inside
sleeping bags when sleeping. It has been suggested that adding a
small amount of glycerol has the double benefit of improving fluid
retention while also reducing the risk that the water will freeze. As
glycerol is a 3-carbon molecule metabolized like carbohydrate, it
also adds a source of needed carbohydrate energy to the consumed
fluid (28). (Note: Glycerol added to water was used for many years
by endurance athletes competing in hot and humid environments.
The effect of glycerol is to enhance water retention, resulting in a
superhydrated state prior to the activity, which enables longer
sustained sweat rates to dissipate the environmental and metabolic
heat. Glycerol, however, has now been placed on the banned
substance list by the World Anti-Doping Agency, so it should not be
used by any athlete performing in sanctioned events.)
Athletes often consume less fluid while physically active than
needed to sustain a state of normal hydration. This voluntary
dehydration is likely to be a more serious problem when at high
altitude, as appetite and the sensation of thirst are both blunted
(28). To avoid this problem, athletes at high altitude should practice
consuming fluids on a fixed time schedule, whether they feel thirsty
or not (60). Consumption of smaller volumes at higher frequency
may also reduce the need to urinate, which is more likely to occur
following consumption of a large volume at one time. (Please see
Chapter 7 for additional information on hydration.)

High Heat and Humidity Environments

It is difficult to dissipate the heat created from the metabolism of

energy (humans are only ∼30% efficient in converting burned fuel to
muscular movement, with the remaining 70% heat creation) in
addition to the heat of the environment imposed on the body on a
hot day (15). This is even more difficult on a humid day, as sweat
rates must increase because of the difficulty in evaporating sweat
(the primary heat-removing system) into air that has a high water
content (Figure 12.4). Humans cannot continually acquire the heat of
exercise and the environment, as that would result in dangerously
high core body temperature. Ultimately, there must be a balance
between the production of heat plus the environmental heat, and
the removal of excess heat to maintain core body temperature
(Table 12.8).
FIGURE 12.4: Risks of exercise in high temperatures and
environments with high humidity. Heat danger increases with
humidity. (Data from United States Department of Commerce, U.S.
National Weather Service [Internet]. Available from:
https://www.weather.gov/. Accessed May 16, 2018.)

Table 12.8 Nutrition Considerations for Exercise in

Hot/Humid Environments
Factor Issue Recommended Action
Fluid High environmental Anyone exercising in a
temperatures, hot/humid environment
particularly when should weigh themselves
coupled with high before and after exercise
humidity, increase the to determine the amount
sweat rate. Failure to of fluid that was not
match fluid adequately replaced
consumption with during the exercise. The
sweat loss lowers total goal is to help the athlete
body water and blood understand the additional
volume, with a amount of fluid that should
resultant lowering of be consumed during
the sweat rate. As the physical activity to
environmental and minimize the weight (i.e.,
metabolic heat cannot fluid) loss. Anything in
be retained (it must be excess of a 2% body
dissipated), a lowering weight loss is associated
of the sweat rate is with a reduction in
inevitably associated performance and may
with a slowing or place the athlete at risk of
cessation of physical heat illness.
activity.
 Table 12.8 Nutrition Considerations for Exercise in
Hot/Humid Environments
Factor Issue Recommended Action
Carbohydrates Maintenance of blood Athletes should train with
sugar during physical a sports beverage that
activity is important to contains ∼6%–7%
sustain central nervous carbohydrate solution.
system function and as Frequent consumption of
a source of needed fuel this fluid will help to
to working muscles. sustain blood sugar levels
During intense physical and has been established
activity, blood sugar to be well-tolerated by the
may drop to below- gastrointestinal tract.
normal levels in less
than 1 h. In a stressful
high-heat/humidity
environment, blood
sugar may drop more
quickly.
Electrolytes High sweat rates are Consumption of a sports
associated with faster drink that contains
losses of sodium appropriate concentrations
chloride and of electrolytes (typically
potassium. Poor blood ranging from 100 to 200
sodium status is mg sodium/240 mL) can
associated with low help to counteract the loss
blood volume, lower of electrolytes in sweat. It
stroke volume, and is also important for
lower sweat rates. athletes to consume salt
with meals to help ensure
normal blood sodium
levels.

Source: Cheuvront SN, Ely BR, Wilber RL. Environment and exercise. In: Maughan RJ, editor.
Sports Nutrition. London: Wiley Blackwell; 2014. p. 425–38.

The greater the amount of energy burned per unit of time, the
greater the heat production and the greater the amount of excess
heat that must be removed (83). Therefore, athletes who are unable
to adequately remove the excess heat through the evaporation of
sweat have only one option: lower the production of heat by
lowering the energy burned per unit of time (i.e., to slow down). It is
now well established that heat stress results in earlier fatigue (i.e.,
shorter amount of time to exhaustion) and a reduction in exercise
intensity (i.e., to burn less energy and create less heat per unit of
time), and acclimatization to the heat improves performance (14).
However, even with acclimatization, there are risks of exercising in
hot and humid environments, including heat illness such as
sunstroke, heat exhaustion, and heat stroke (Table 12.9).

Table Warning Signs and Symptoms of Heat-Related

12.9 Illness
Heat- What to Look For What to Do
Related
Illness
Heat
stroke High body Call 911 right away — heat
temperature stroke is a medical
(103°F or emergency
higher) Move the person to a cooler
Hot, red, dry, or place
damp skin Help lower the person’s
Fast, strong temperature with cool cloths
pulse or a cool bath
Headache Do not give the person
Feeling dizzy anything to drink
Nausea
Feeling
confused
Losing
consciousness
(passing out)
Table Warning Signs and Symptoms of Heat-Related
12.9 Illness
Heat- What to Look For What to Do
Related
Illness
Heat
exhaustion Heavy sweating Move to a cool place
Cold, pale, and Loosen your clothes
clammy skin Put cool, wet cloths on your
Fast, weak pulse body or take a cool bath
Nausea or Sip water
vomiting
Muscle cramps Get medical help right away if:
Feeling tired or
weak You are throwing up
Feeling dizzy Your symptoms get worse
Headache Your symptoms last longer
Fainting than 1 h
(passing out)

Heat
cramps Heavy sweating Stop physical activity and
during intense move to a cool place
exercise Drink water or a sports drink
Muscle pain or Wait for cramps to go away
spasms before you do any more
physical activity

Get medical help right away if:

Cramps last longer than 1 h

You’re on a low-sodium diet
You have heart problems

Source: United States Department of Health and Human Services, Centers for Disease
Control and Prevention. Warning Signs and Symptoms of Heat-Related Illness [Internet].
Available from: https://www.cdc.gov/disasters/extremeheat/warning.html. Accessed July,
2017.

Regardless of the sport, environmental heat stress has a negative

impact on performance, with studies demonstrating this impact on
cyclists, marathon running, and soccer (23, 32, 65). However,
athletes who have well acclimatized to the heat, typically over the
course of 2 weeks, experience improved performance (72, 83). It
should also be noted that athletes who acclimatize to the heat are
not likely to experience improved performance in a cool climate (42).
To some extent, the well-conditioned athlete who has experience
exercising in the heat may adapt the exercise intensity early to
produce less metabolic heat, knowing that the environmental
temperature will have an impact on performance. This was found in
experienced runners competing in warm weather endurance events,
who selected a slower pace at the onset of the race, whereas less-
acclimatized/experienced runners begin the race at a faster pace
only to find that they must quickly slow down because of the
difficulty to adequately dissipate the acquired heat (24). This
suggests that at least a portion of the benefit derived from
acclimatizing to exercise in the heat is to have an improved
understanding of its impact, allowing the athlete to appropriately
modify exercise/racing strategy.

Heat Illness

Refers to a group of syndromes, including heat exhaustion, heat

cramps, and heat stroke, that most likely result from prolonged
exposure to hot and humid environments that athletes have not
been well adapted to. Nutritional factors, including failure to
adequately replace fluid, electrolytes, and carbohydrate, will
exacerbate the likelihood that heat illness, in one of its forms, may
occur.

Summary

Advance planning is important for athletes who travel, with no

assumptions about food/beverage availability necessary to
satisfy the needs of athletes. As a safety measure, critical items
(key foods, sports beverage powders, etc.) should be brought
along to ensure availability.
Athletes should be discouraged from trying new foods at the
travel ___location until after the event to reduce the potential for an
 unwanted food reaction. Ample time should be built into the trip
to ensure acclimatization to the new environment. As a general
rule, the athlete should arrive 1 day early for each time zone
crossed, up to a maximum of 7 days. Ample time should be
made available for sufficient rest, and every effort should be
made to get on the schedule of the new ___location as quickly as
possible.
Athletes should allow 1–2 weeks to become acclimated to a high-
altitude environment. Training during the acclimatization period
should be lower in volume and intensity so as to reduce the risk
of altitude sickness.
Especially for long-duration predominantly aerobic events,
athletes should learn to make necessary adjustments in speed
because of the lower oxygen availability. Athletes sometimes live
at high altitude and train at lower altitude to enhance RBC
formation. This provides a competitive advantage when
competing at lower elevations because of the greater oxygen-
carrying capacity.
When training in a cold environment, the athlete should dress to
stay warm. A failure to do so increases the risk of developing low
body temperature with associated shivering, which is glycogen
dependent, and may increase the risk of frostbite and other
health problems.
Athletes in high heat environments should allow ample time,
typically 1–2 weeks, to adapt to the heat. Training duration and
intensity should be adjusted until the athlete has become
acclimatized. If training for competition, athletes should do the
more serious activity (i.e., higher duration and/or intensity)
during the coolest portion of the day (typically early morning),
and try to become acclimated to the heat with more moderate
activity during the middle of the day when it is the warmest.
Goals, expectations, and strategies for competing in high heat
should be adjusted to avoid heat stress disorders.

Practical Application Activity

Using on-line maps and the internet, and the on-line food analysis
system used in previous chapters, do the following to see if you
can make a food/beverage plan if you were a competing athlete:
For High-Altitude/Cold-Weather Competition

1. Select a high-altitude (minimum 1,500 meters elevation)

competition site (eg. Val d’Isére. France; Aspen, Colorado, etc.)
for a cold-weather winter sport such as cross- country or
down-hill skiing.
2. Find a hotel near the competition site where you could stay,
keeping in mind that you should get there a minimum of 1 day
early for each time-zone you crossed. (i.e., if you crossed 3
time-zones, you should be there 3 days before the competition
begins, or even more days if you have not previously
acclimated to the high altitude.)
3. Locate restaurants and, if available, grocery stores near the
hotel where you can eat/buy food and beverages.
4. Analyze the foods available in the nearby restaurants (go
through the online menu) and grocery stores with an eye
toward cost (do you think you could afford it?), nutrient
content (is it too high in fat?; is the carbohydrate content
appropriate?, etc.), and familiarity (better to eat foods you are
familiar with).
a. Make a list of food items in the restaurant(s) and highlight
those that satisfy your nutritional and cost criteria.
b. Indicate which foods are available for breakfast, lunch, and
dinner.
c. Where will you get snacks and beverages to consume? Are
there nearby grocery stores that have what you need/like?
Can you take foods with you from the restaurants? If so,
make a list of what you can purchase.
5. Using known nutritional stresses associated with cold-
weather/high-altitude environments and based on the lists
created above, make a list of foods/beverages/beverage
powders, etc. that you will need to bring with you.
The amounts you will need to bring should be based on the
number of days you have to be there to acclimate to the local
time zone.

For Sea-Level/Hot and Humid Competition

1. Select a hot-humid competition site at close to sea level (eg.

Athens, Greece; Rio de Janeiro, Brazil, etc.) for a sport such as
soccer or marathon.
 2. Use the same procedure as described above, but consider the
nutritional stresses associated with hot and humid weather
environments to create your food and beverage lists, where
you will obtain what you need, and what you will need to bring
with you.

Chapter Questions

1. Which of the following travel diets are associated with improving

cellular tryptophan levels, which help to enhance serotonin and
improve a sense of relaxation and improved sleep?
a. Higher protein and lower carbohydrate
b. Higher fat and higher protein
c. Lower protein and higher carbohydrate
d. Lower fat, higher protein, and higher carbohydrate
2. To enhance epinephrine (adrenalin) production and alertness
through an enhanced uptake of tyrosine, the athlete could
consume a diet that is:
a. Higher protein and lower carbohydrate
b. Higher fat and higher protein
c. Lower protein and higher carbohydrate
d. Lower fat, higher protein, and higher carbohydrate
3. Diets that increase the amount of time it takes for athletes to
adapt to a new environment are:
a. Higher protein and lower carbohydrate
b. Higher fat, with excess energy
c. Lower protein and higher carbohydrate
d. Lower fat, higher protein, and higher carbohydrate
4. Because air travel is dehydrating, athletes should keep sipping on
fluids, particularly wine and beer, during the flight to maintain a
moist mouth and throat.
a. True
b. False
5. It is important for athletes who have changed multiple time zones
to:
a. Try to maintain the schedule from the original time zone until at
least 48 hours have passed to help the body adjust.
b. Quickly get on the local schedule as soon as possible, as this
helps the body adjust to the new time zone.
 c. Sleep upon arrival for a minimum of 10 hours to help the body
adjust from the travel.
d. Eat and drink foods and beverages that are familiar as soon as
possible after arriving in the new time zone to help the GI tract
adjust.
6. It takes ∼______day(s) for each time zone change to fully adjust to
the new time zone.
a. 4
b. 3
c. 2
d. 1
7. The change in circadian rhythm associated with travel may
negatively affect the following:
a. Leg strength
b. Jumping
c. Anaerobic activity
d. Aerobic activity
e. All the above
8. Although pasteurization is necessary for dairy foods produced in
the United States, because bacterial infections in cows is far less
common in Western Europe, it is not necessary to consume
pasteurized dairy products when traveling to Western Europe.
a. True
b. False
9. Banned steroids are sometimes used in animal feed that can
result in a positive blood/urine test if the athlete consumed meat
that was fed this feed.
a. True
b. False
10. High-altitude environments may impact all of the following,
except:
a. Increased appetite
b. Diuresis
c. Faster glycogen depletion
d. Erythropoiesis

Answers to Chapter Questions

1. c
2. a
3. b
4. b
5. b
6. d
7. e
8. b
9. a
10. a

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CHAPTER OBJECTIVES
Explain the general problems associated with excess
consumption of nutrients related to competitive absorption,
cellular utilization, and excretion.
Know the potential ergogenic benefits of caffeine and the optimal
consumption strategies to achieve these benefits.
List the potential dangers associated with consumption of
ergogenic aids that target athletes.
Understand how to find listings of banned substances for athletes
competing in sanctioned events.
Know the difference between nutritional and nonnutritional
ergogenic aids.
Describe the interaction effects between taking a nutrient
supplement and the activity (mechanical loading) required to
achieve a benefit that incorporates the consumed nutrient.
Discuss the reasons why achieving a normal vitamin D status is
important for optimizing performance.
Understand how gut health is an integral and important
component of maintaining health and athletic performance, and
how prebiotics, probiotics, and synbiotics may help to achieve a
healthy microbiome.
List the possible ways that a misappropriation of perceived
benefit may result from taking common protein-related
supplements, including whey protein, branched-chain amino
acids (BCAAs), β-alanine, and creatine.

Case Study
John was always at the cutting edge of everything having to do
with the athletic endeavor. He had the latest shoes, wore water-
releasing shirts to enhance sweat evaporation and cooling, and
scoured the athlete magazines for anything new that could
improve his cycling performance. One day he read that a half-
liter of beet juice consumed about an hour or two prior to
exercise could significantly improve exercise time to fatigue.
Perfect — he had been worried about taking supplements
because there are problems that are periodically written about in
the press, but this was FOOD. Beet juice! What could be better
than that? He immediately went to his local grocery store and
purchased his first case of organic beet juice in quart bottles.
The next day, about 2 hours before his exercise bout, he
chugged down a half-liter of beet juice, and he could not wait to
see the improvement. Nothing changed. He reached his fatigue
point within 30 seconds of his usual time — but no matter, he
had a whole case of beet juice and he was not about to give up.
So, for the next 4 days he followed the same procedure, but also
with no improvement. He thought perhaps it was because he was
already an elite cyclist that it would take more beet juice to make
a discernible difference in performance, so he increased the
volume by 100%, and drank an entire liter before practice. He
was convinced that this was his “magic bullet” to help
differentiate him from his fellow cyclists. This continued for a
month, with several cases of beet juice being consumed in ever-
increasing quantity and frequency, but to no avail. There was
simply no improvement in performance. He was not only not
doing better, but also his muscles were getting sorer and he
actually felt weaker than before.
Finally, he decided to do what he should have done at the
start and sat down for a conversation with his cycling club’s
sports dietitian. It took about 30 seconds for the dietitian to
figure out the problems by just asking a few questions. The
dietitian asked, “Do you use antibiotic mouth wash?” “Why yes,
every day!” said John. The dietician responded, “Well, that’s why
the beet juice is not working. The bacteria in your mouth that
convert dietary nitrate to nitrite are not there because you have
wiped out the bacteria with the mouthwash, so the conversion
does not occur and there is no benefit.” The dietitian pointed out
that, to make matters worse, the high volume of beet juice that
was being consumed was taking away from all the other foods
that John should have been eating, so the right mix of nutrients
was no longer present to enhance muscle recovery and reduce
muscle soreness. John was stunned at his compounded mistakes,
but he decided not to persevere. He gave up the antibacterial
mouthwash for 1 month, started drinking half a quart of beet
juice before practice, and his performance started to improve.
Getting things right, he thought afterward, may be more
complicated than just drinking some beet juice.

CASE STUDY DISCUSSION QUESTIONS

1. What would be the best strategy for consuming beet juice to

improve exercise performance?
2. If a half-liter of beet juice is being consumed prior to
exercise, are there any nutritional concerns that might arise
by substituting beet juice for something else that may also
be good to consume prior to exercise?
3. Oral bacteria are an important part of the dietary nitrate
conversion to nitrite. What would you do to ensure that oral
bacteria are available to help in this conversion?
4. In this case study, overconsumption of beet juice may have
created a nutritional imbalance by substituting beet juice for
other important foods. Humans require a balance of needed
nutrients and foods to help sustain the immune system, to
ensure normal metabolism, and to maintain optimal
production of hormones and enzymes. What kind of foods
and beverages should this athlete be consuming throughout
the day to help ensure good health?
5. It is increasingly evident that the gut microbiome (bacteria
that inhabit the gastrointestinal [GI] tract) are intimately
involved in each of these functions, yet the modern diet may
not optimally support the microbiome. Ask yourself:
a. What foods do you consume that help the bacteria in
your GI tract flourish?
b. What foods do you consume that provide live bacteria
that contribute to the health of the GI tract?
c. What foods do you consume that provide food for the
bacteria in your GI tract and also some healthful
bacteria?
 d. What dietary changes would you need to make to
improve the GI tract microbiome?

Introduction

Competitive athletes are often interested in finding ways to be

quicker and stronger with improved endurance. Since the time of the
ancient Olympic Games, athletes have tried new training regimens
and focused on consuming different foods and beverages with
different intake patterns to improve performance (Table 13.1). The
food patterns have evolved from focusing on cheese and vegetables
to focusing on meat and fat, all with an eye toward improving
performance more quickly. In more recent times, with our enhanced
understanding of the human metabolic system and the chemicals we
refer to as vitamins and minerals, athletes are increasingly turning to
the use of these nutrients in a purified form rather than relying on
obtaining them from foods. In addition, the improved understanding
of metabolic pathways has enabled the creation of substances that
can stimulate specific desired pathways to obtain the desired
outcome.

Table Historical Evolution of Sports Nutrition

13.1
Diogenes Wrote that Greek athletes trained originally on dried
Laertius figs, moist fresh cheese, and wheat. The pattern then
(died ad changed to focus on meat.
222)
Epictetus Wrote that Olympic champions avoided desserts and
(2nd cold water and consumed wine sparingly.
century ad)
Philostratus Spoke badly about the athletic diet during his era,
(born 170 which was based on white bread sprinkled with poppy
ad) seeds and fish and pork.
Greek and Used certain wines, herbal teas, and mushrooms to
Roman enhance performance.
Gladiators
 (105 bce to
404 ce)
Americans Consumed beefsteak with an average daily intake of
at Berlin 125 g of butter (1,125 kcal!), three eggs, custard for
Olympic dessert, and 1.5 L of milk, with ad libitum intake of
Games breads, fresh vegetables, and salads.
(1936)
Atlanta Highly varied menu served at the athlete cafeteria
Olympic that included fresh vegetables and dips, fruits,
Games cheeses, breads, salads, pasta, rice, fruits, soups,
(1996) meats and seafoods, cooked vegetables, desserts, and
beverages.

Sources: Grivettti LE, Applegate EA. From Olympia to Atlanta: a cultural–historical

perspective on diet and athletic training. J Nutr. 1997;127(5S):860S–8S; Momaya A, Fawal M,
Estes R. Performance-enhancing substances in sports: a review of the literature. Sports Med.
2015;45(4):517–31.

Interestingly, the more that is known about what truly works to

improve performance, the more scientists and practitioners are
learning that there is no good substitute for regular consumption of a
good distribution of health-promoting foods and beverages at the
right time and in the right amounts to optimize performance. What
also has been found is that many of the products advertised as
performance enhancing (i.e., ergogenic aids) have problems, either
because they contain banned substances that are not on the label or
because they expose tissues to excess nutrients in a single dose. We
are increasingly learning that, for optimal nutrition, more than
enough is not better than enough. As an example, a recent study
found that long-term multivitamin use fails to prevent major
cardiovascular disease events in men, regardless of baseline
nutritional status (117), and a study assessing dietary supplement
use in older women found a higher mortality rate in those taking
multivitamin, vitamin B6, folic acid, iron, zinc, or copper supplements
(103). This is an important consideration before recommending high-
dose vitamin supplements or ergogenic aids to athletes. It is also
important to consider that a “food-first” approach is recommended
by professional organizations that focus on athlete health, including
the Academy of Nutrition and Dietetics, Dietitians of Canada, The
National Athletic Trainers Association, and the American College of
Sports Medicine (12, 137).
 Nutritional Supplements

The Dietary Supplement Health and Education Act (DSHEA) of

1994 of the United States defines a dietary supplement as a food
product that is in addition to the total diet (140). The DSHEA clarifies
that a dietary supplement cannot be represented as a conventional
food or as the sole item of a meal or diet and should not be viewed
as a partial or complete meal replacement. According to the DSHEA,
a dietary supplement must contain at least one of the following:

Vitamin
Mineral
Herb or other botanical substance
Amino acid
A substance that supplements the diet by serving to increase the
total dietary intake
Metabolite
Concentrate
Constituent
Extract
Combinations of any of the above ingredients

The DSHEA definition was not found to be satisfactory when

applied to athletes as it does not clarify whether it is in addition to a
“healthy” diet and has resulted in the following definition (97):

A food, food component, nutrient, or nonfood compound that is

purposefully ingested in addition to the habitually consumed diet
with the aim of achieving a specific health and/or performance
benefit.

Dietary supplements may come in a number of forms, including

nutrient-enriched foods (e.g., in the United States, grains are
enriched with folic acid); formulated foods that are intended to make
it easy for athletes to consume before, during, or after exercise (e.g.,
gels, sports bars, electrolyte/carbohydrate drinks); single nutrients
consumed as a pill/capsule that are consumed in addition to foods;
and combinations of these (97).
 Dietary Supplement

Also referred to as a nutrient supplement, this is a high

concentration of nutrients provided as a pill, capsule, or powder
that is consumed orally (not put on skin, etc.) that provides high
doses of vitamins, minerals, or related ingredients (i.e.,
phytonutrients, metabolites, extracts). The Food and Drug
Administration (FDA) defines dietary supplements as “products
which are not pharmaceutical drugs, food additives like spices or
preservatives, or conventional food.”

Dietary Supplement Health and Education Act

This US federal legislation of 1994 defines and regulates dietary

supplements. Under this legislation, supplements are regulated by
the FDA for “good manufacturing practices.”

Under the DSHEA legislation, each manufacturer of a dietary

supplement is responsible for the safety of the product (i.e., no
governmental oversight), but the dietary supplement manufacturer
is not responsible for performing product safety testing, and it is not
responsible for confirming/proving that the dietary supplement
actually performs in a way that is consistent with claims made about
the product. Therefore, although dietary supplements targeting
athletes are often marketed as improving both health and
performance, there is often little proof that this is the case. Although
they may, and often do, contain essential vitamins, minerals, and
amino acids, they may also contain other substances that are not
essential nutrients such as yohimbe, ma huang, ginkgo, and other
herb-based substances.
The purpose of drugs is to cure, treat, or prevent disease, and
they must undergo intensive testing to determine optimal dosing,
effectiveness, drug–drug and drug–nutrient/food interactions, and
safety for FDA approval before a drug can be made available to the
public. Dietary supplements, however, are not required to undergo
any of these testing protocols before entering the marketplace. The
general procedure if a new ingredient is proposed to be added to a
dietary supplement is for the product manufacturer to gather
relevant information on the ingredient to make a determination on
safety and effectiveness and submit that determination to the FDA
75 days before the dietary supplement is made available to the
public. Following this 75-day period, the new ingredient in the dietary
supplement can be made available for public consumption if there is
no FDA intervention to do so.
Ergogenic aids are those substances and/or activities that are
performance enhancing (i.e., create an ergogenic effect) and may
take many forms, including physiologic aids, psychological aids,
biomechanical aids, pharmacologic aids, and nutritional aids.
Ergogenic aids are substances that have ergogenic effects (i.e., are
performance enhancing) and are, therefore, ergolytic:

Physiologic ergogenic aid: An activity, typically provided by an

athletic trainer or strength and conditioning coach, that improves
the body’s physiology (i.e., more muscle for a body builder) that
has the effect of improving athletic performance.
Psychological ergogenic aid: A strategy, typically provided by a
sports psychologist, that improves the athlete’s mental state
(i.e., relaxation technique) that has the effect of improving
athletic performance.
Biomechanical ergogenic aid: Any equipment or worn device
(i.e., muscle wraps, streamlined swim suits) that has the effect of
improving athletic performance.
Pharmacologic ergogenic aid: A substance that has a drug or
hormonal effect (i.e., caffeine, anabolic steroids) and has the
effect of improving athletic performance through enhanced
musculature, blood flow, oxygen delivery, or other effect.
Nutritional ergogenic aid: A supplement, food, or beverage that,
when consumed at specific times and amounts (i.e., vitamin D,
beet juice, sports drinks, creatine), has the effect of enhancing
athletic performance through improved endurance and/or power
or muscle recovery.

Ergogenic Aid

A substance/strategy/technique that is used for the purpose of

improving/enhancing athletic performance. The nutritional
ergogenic aids are substances and nutrients that are food derived
(e.g., beet juice), which can positively influence metabolism and
muscle function, to improve performance. Other ergogenic aids are
 in the realm of pharmacologic aids (i.e., drugs), physiologic aids
(i.e., exercise equipment), or psychological aids (i.e., strategies to
improve focus, attention span).

Ergogenic Effect

A performance-enhancing effect observed through the

consumption of an ergogenic aid or through a positive performance
enhancement observed as a result of an exercise and/or nutritional
protocol. (It is possible to achieve an ergogenic effect without
consumption of a specific ergogenic substance.)

Ergolytic

Any substance or activity that can impair/reduce athletic

performance. For instance, consumption of a substance that
interferes with energy metabolism would be considered ergolytic,
as would overtraining, which may also have a negative impact on
performance.

The focus of this chapter is nutritional ergogenic aids consumed in

the form of dietary supplements that are taken in addition to the
normal and usual dietary intake of foods and fluids. As explained
earlier, an ergogenic aid refers to a nutrient or related substance
that is performance enhancing, but this term is often loosely used, as
claims of performance enhancement are frequently made without
evidence. The term nutritional ergogenic aid describes a substance
that enters a known nutritional metabolic pathway, or it consists of
one or more nutrient. As an example, consumption of carbohydrates
at the right time is known to improve performance, logically making
carbohydrate a nutritional ergogenic aid. Creatine is a known
component of food that enters a known metabolic pathway and may
improve sprint performance, so it could also be considered a
nutritional ergogenic aid. Nonnutritional ergogenic aids, such as
anabolic steroids, refer to products that have no food origin, are not
nutrients, and have no known nutritional properties.
Although claims that supplements have ergogenic properties can
be made in the United States without evidence or verification by the
FDA (62), the relatively new Office of Dietary Supplements of the
National Institutes of Health (NIH) has excellent fact sheets on
supplement effectiveness and usage recommendations (Figure 13.1).
This NIH office can be accessed at https://ods.od.nih.gov/. Table 13.2
contains a sample of a fact sheet provided by the Office of Dietary
Supplements on supplements advertised as enabling weight loss.

FIGURE 13.1: Prevalence of supplement use in the United States.

(From Hoyte CO, Albert D, Heard KJ. The use of energy drinks, dietary
supplements, and prescription medications by United States college
students to enhance athletic performance. J Community Health.
2013;38:575–80; LifeART. Lippincott Williams & Wilkins. Copyright
2018. All rights reserved.)

Table 13.2 Common Ingredients in Weight-Loss Dietary

Supplements
Ingredient Proposed Evidence of Evidence of
Mechanism of Efficacy Safety+
Action
Table 13.2 Common Ingredients in Weight-Loss Dietary
Supplements
Ingredient Proposed Evidence of Evidence of
Mechanism of Efficacy Safety+
Action
Bitter orange Increases Small clinical Some safety
(synephrine) energy trials of poor concerns reported
expenditure and methodologic Reported adverse
lipolysis, acts as quality effects: Chest pain,
a mild appetite Research anxiety, and
suppressant findings: increased blood
Possible effect pressure and heart
on resting rate
metabolic rate
and energy
expenditure;
inconclusive
effects on
weight loss
Caffeine (as Stimulates Short-term Safety concerns
added central nervous clinical trials not usually
caffeine or system, of reported at doses
from increases combination less than 400 mg/d
guarana, kola thermogenesis products for adults,
nut, yerba and fat Research significant safety
mate, or oxidation findings: concerns at higher
other herbs) Possible doses
modest effect Reported adverse
on body effects:
weight or Nervousness,
decreased jitteriness,
weight gain vomiting, and
over time tachycardia
Table 13.2 Common Ingredients in Weight-Loss Dietary
Supplements
Ingredient Proposed Evidence of Evidence of
Mechanism of Efficacy Safety+
Action
Calcium Increases Several large No safety concerns
lipolysis and fat clinical trialsreported at
accumulation, Research recommended
decreases fat findings: No intakes (1,000–
absorption effect on body 1,200 mg/d for
weight, adults)
weight loss, orReported adverse
prevention of effects:
weight gain Constipation,
based on kidney stones, and
clinical trialsinterference with
zinc and iron
absorption at
intakes above
2,000–2,500 mg for
adults
Chitosan Binds dietary Small clinical Few safety
fat in the trials, mostly concerns reported,
digestive tract of poor could cause
methodologic allergic reactions
quality Reported adverse
Research effects: Flatulence,
findings: bloating,
Minimal effect constipation,
on body indigestion,
weight nausea, and
heartburn
Table 13.2 Common Ingredients in Weight-Loss Dietary
Supplements
Ingredient Proposed Evidence of Evidence of
Mechanism of Efficacy Safety+
Action
Chromium Increases lean Several No safety concerns
muscle mass; clinical trials reported at
promotes fat of varying recommended
loss; and methodologic intakes (25–45
reduces food quality mcg/d for adults)
intake, hunger Research Reported adverse
levels, and fat findings: effects: Headache,
cravings Minimal effect watery stools,
on body constipation,
weight and weakness, vertigo,
body fat nausea, vomiting,
and urticaria
(hives)
Coleus Enhances Few short- No safety concerns
forskohlii lipolysis and term clinical reported
(forskolin) reduces trials Reported adverse
appetite Research effects: None
findings: No known
effect on body
weight
Conjugated Promotes Several Few safety
linoleic acid apoptosis in clinical trials concerns reported
adipose tissue Research Reported adverse
findings: effects: Abdominal
Minimal effect discomfort and
on body pain, constipation,
weight and diarrhea, loose
body fat stools, dyspepsia,
and (possibly)
adverse effects on
blood lipid profiles
Table 13.2 Common Ingredients in Weight-Loss Dietary
Supplements
Ingredient Proposed Evidence of Evidence of
Mechanism of Efficacy Safety+
Action
Ephedra (ma Stimulates Several short- Significant safety
huang, central nervous term clinical concerns reported;
ephedrine) system, trials of good banned as a
increases methodologic dietary supplement
thermogenesis, quality, many ingredient
reduces of ephedra Reported adverse
appetite combined effects: Anxiety,
with caffeine mood changes,
Research nausea, vomiting,
findings: hypertension,
Modest effect palpitation, stroke,
on short-term seizures, heart
weight loss attack, and death
Fucoxanthin Increases Studied only No safety concerns
energy in reported but not
expenditure and combination rigorously studied
fatty acid with Reported adverse
oxidation, pomegranate- effects: None
suppresses seed oil in one known
adipocyte trial in
differentiation humans
and lipid Research
accumulation findings:
Insufficient
research to
draw firm
conclusions
Table 13.2 Common Ingredients in Weight-Loss Dietary
Supplements
Ingredient Proposed Evidence of Evidence of
Mechanism of Efficacy Safety+
Action
Garcinia Inhibits Several short- Few safety
cambogia lipogenesis, term clinical concerns reported
(hydroxycitric suppresses food
trials of Reported adverse
acid) intake varying effects: Headache,
methodologic nausea, upper
quality respiratory tract
Research symptoms, and
findings: Little gastrointestinal
to no effect on symptoms
body weight
Glucomannan Increases Several Significant safety
feelings of clinical trials concerns reported
satiety and of varying with tablet forms,
fullness, methodologic which might cause
prolongs gastric quality, esophageal
emptying time mostly obstructions, but
focused on few safety
effects on concerns with
lipid and other forms
blood glucose Reported adverse
levels effects: Loose
Research stools, flatulence,
findings: Little diarrhea,
to no effect on constipation, and
body weight abdominal
discomfort
Table 13.2 Common Ingredients in Weight-Loss Dietary
Supplements
Ingredient Proposed Evidence of Evidence of
Mechanism of Efficacy Safety+
Action
Green coffee Inhibits fat Few clinical Few safety
bean extract accumulation, trials, all of concerns reported
(Coffea modulates poor but not rigorously
arabica, glucose methodologic studied; contains
Coffea metabolism quality caffeine
canephora, Research Reported adverse
Coffea findings: effects: Headache
robusta) Possible and urinary tract
modest effect infections
on body
weight
Green tea Increases Several No safety concerns
(Camellia energy clinical trials reported when
sinensis) and expenditure and of good used as a
green tea fat oxidation, methodologic beverage, contains
extract reduces quality on caffeine; some
lipogenesis and green tea safety concerns
fat absorption catechins with reported for green
and without tea extract
caffeine Reported adverse
Research effects (for green
findings: tea extract):
Possible Constipation,
modest effect abdominal
on body discomfort,
weight nausea, increased
blood pressure,
liver damage
Table 13.2 Common Ingredients in Weight-Loss Dietary
Supplements
Ingredient Proposed Evidence of Evidence of
Mechanism of Efficacy Safety+
Action
Guar gum Acts as bulking Several Few safety
agent in gut, clinical trials concerns reported
delays gastric of good with currently
emptying, methodologic available
increases quality formulations
feelings of Research Reported adverse
satiety findings: No effects: Abdominal
effect on body pain, flatulence,
weight diarrhea, nausea,
and cramps
Hoodia Suppresses Very little Some safety
(Hoodia appetite, published concerns reported;
gordonii) reduces food research in increases heart
intake humans rate and blood
Research pressure
findings: No Reported adverse
effect on effects: Headache,
energy intake dizziness, nausea,
or body and vomiting
weight based
on results
from one
study
Pyruvate Increases Few clinical Few safety
lipolysis and trials of weak concerns reported
energy methodologic Reported adverse
expenditure quality effects: Diarrhea,
Research gas, bloating, and
findings: (possibly)
Possible decreased high-
minimal effect density lipoprotein
on body levels
weight and
body fat
Table 13.2 Common Ingredients in Weight-Loss Dietary
Supplements
Ingredient Proposed Evidence of Evidence of
Mechanism of Efficacy Safety+
Action
Raspberry Alters lipid Studied only No safety concerns
ketone metabolism in reported but not
combination rigorously studied
with other Reported adverse
ingredients effects: None
Research known
findings:
Insufficient
research to
draw firm
conclusions
White kidney Interferes with Several Few safety
bean breakdown and clinical trials concerns reported
(Phaseolus absorption of of varying Reported adverse
vulgaris) carbohydrates methodologic effects: Headache,
by acting as a quality soft stools,
“starch blocker” Research flatulence, and
findings: constipation
Possible
modest effect
on body
weight and
body fat
Yohimbe Has Very little Significant safety
(Pausinystalia hyperadrenergic research on concerns reported
yohimbe) effects yohimbe for Reported adverse
weight loss effects: Headache,
Research anxiety, agitation,
findings: No hypertension, and
effect on body tachycardia
weight;
insufficient
research to
draw firm
conclusions
Source: United States Department of Health and Human Services, National Institutes of
Health, Office of Dietary Supplements. 2017. Available from:
https://ods.od.nih.gov/factsheets/WeightLoss-HealthProfessional. Accessed May 17, 2018.

Why Do Athletes Take Supplements?

There are multiple factors that differentiate athlete supplement use
both by frequency and by magnitude of intake. There are differences
in intake by sport, level of training, age (greater with higher age), sex
(higher in men), and perceptions of what is “normal” for the sport
(97, 98). There are also a number of reasons why athletes take
nutrient-based and other supplements, including (97):

To influence potential or current nutritional deficiency that could

have an impact on athletic performance and/or health.
For the convenient consumption of nutrients and energy before,
during, and after an exercise bout when the consumption of
regular foods and beverages is not possible or less convenient.
To attain a performance enhancement, through improved
training, improvement in body composition, lower muscle
soreness and improved recovery, and/or lower injury/illness risk.
To derive financial benefit from sponsoring a product or because
the consumed products are freely available.
To follow the supplement usage behavior of other athletes who
they admire.
To take steps that they believe will result in developing a lower
risk of a nutrient deficiency.

Athletes are competitors who want to win. It is logical, therefore,

that athletes will do what they believe will legally give them a
winning edge. They train to improve physiologic adaptation to the
sport, and they want to do the right things nutritionally to maximize
the training benefit and diminish the potential negative side effects
of training, such as muscle soreness. The marketing efforts that
target supplement use in athletes emphasize that these supplements
can provide precisely the things that the athlete desires: better
health, more speed, more power, better endurance, bigger muscles,
and a greater chance to win (38, 66).
A review of multiple studies assessing dietary supplement intake
in athletes found that elite athletes were far more likely than nonelite
athletes to take dietary supplements (66) (Figure 13.1). It was found
that the prevalence of use in men and women was similar, but that a
greater proportion of women took iron, whereas a greater proportion
of men took protein, creatine, and vitamin E (66). The common
reasons that athletes take dietary supplements include (66, 126):

The supplement has a direct beneficial effect on exercise

performance.
The supplement will help the athlete recover from exercise.
To help maintain health, as compensation for a diet that is
believed to be inadequate in fulfilling the needs of an athlete.
To satisfy what is believed to be heavy nutrient demands that are
created by regular training.
Because an admired and successful athlete is taking them, and
at least a portion of the athlete’s success is believed to be based
on the consumption of the dietary supplement(s).

Do Dietary Supplements Help?

Several reviews have suggested that performance is not improved
with the intake of vitamin supplements/ergogenic aids in athletes
who consume a balanced diet providing sufficient energy, but there
may be some circumstances that warrant dietary supplement intake
if consumption of a balanced diet is not possible (37, 83, 88, 90, 91):

Pregnant and lactating women have higher requirements for

many nutrients, including iron and folic acid (see recommended
dietary allowance [RDA] table), so are at higher risk for
deficiency. The need for folic acid in women of childbearing age
is now well established to lower the risk of having a baby with a
neural tube defect (e.g., spina bifida or anencephaly). To
minimize this risk, the United States has instituted a program for
fortifying cereal grains with folic acid (147).
Athletes appear to be at higher risk of iron deficiency than
nonathletes as a result of foot-strike hemolysis, iron sweat loss,
and increased iron losses in urine and feces (see Chapter 6).
Therefore, athletes may require iron intakes greater than the
RDA. For athletes with iron deficiency or iron deficiency anemia,
as measured by serum ferritin, hemoglobin, and hematocrit,
supplemental intake of iron may be required. However, oral
supplements of iron should not be taken without the presence of
deficiency, and supplements should only be taken with the direct
supervision of a health professional (97).
 Approximately 10%–30% of older adults experience lower gastric
production of intrinsic factor, which is necessary for the
absorption of B12. The Institute of Medicine recommends
consumption of sublingual vitamin B12 supplements for anyone
over the age of 50 to lower the risk of B12 deficiency and
associated megaloblastic anemia (58).
Vegans (i.e., those who consume no meat, fish, or dairy products)
are at greater risk than omnivores and lacto-ovo vegetarians for
developing vitamin B12 deficiency because animal foods are the
natural source of vitamin B12. Vitamin supplementation with
vitamin B12 and/or consumption of breakfast cereals fortified with
vitamin B12 can lower the risk of developing a deficiency (58).
Consumption of antibiotics may diminish intestinal bacteria and
lower the bacterial production of vitamin K, which is necessary
for normal blood clotting and bone health. Supplemental intake
of vitamin K and the consumption of probiotics to help return the
gut microbiome to a normal state may diminish the risk of
deficiency (79, 105).
People who are lactose intolerant and avoid dairy products as a
result of this condition may be at risk for vitamin B2 (riboflavin),
vitamin D, and calcium deficiency. As a result, they may benefit
from the consumption of supplements containing these nutrients
(89, 141).
Because of a high variability in calcium absorption and calcium
loss via urine and feces, assessment of bone mineral density
may be the only effective means of determining the adequacy of
long-term calcium consumption. Athletes should have daily
intakes that are ∼1,500 mg/day from a combination of foods and
supplements (if necessary to achieve this level of intake), with
good vitamin D status to ensure normal calcium absorption (see
Chapter 6). Poor bone density that predisposes an athlete to
fracture is a complex issue, involving energy intake adequacy,
maintenance of good energy balance, adequate calcium intake,
and adequate vitamin D status (97).

Dietary Supplement Intake in Athletes

There are clearly multiple nutrients that are related to exercise
performance, both directly and indirectly (Table 13.3). Ideally, these
nutrients would be best provided through the consumption of a
balanced diet, but it is clear that many athletes now consume
supplements with the hope of positively influencing athletic
performance. It has been found that a high proportion of elite
adolescent athletes consume dietary supplements daily, with some
of these athletes required to consume dietary supplements by their
sporting organization. Supplements commonly consumed in this elite
adolescent athlete population include creatine, protein, and
magnesium, with the belief that these supplements are needed to
improve performance, that failure to take them may be harmful to
health or that failure to take supplements will result in illness (33). A
study of Canadian athletes found that 87% of assessed athletes (N =
440, including 63% women and 37% men) took at least three dietary
supplements over the previous 6 months, including sports drinks,
multivitamin and mineral supplements, high-carbohydrate sports
bars, protein powder, and meal replacement products (84).

Table 13.3 Vitamins and Minerals:

Exercise Relationships
Nutrient Major Function Deficiency
Thiamin (vitamin B1) Metabolism of Weakness,
carbohydrates poor
and amino acids endurance,
muscle loss,
weight loss
Riboflavin (vitamin B2) Oxidative energy Weakness,
metabolism, photophobia,
electron altered
transport in nervous
adenosine system
triphosphate function,
(ATP) production altered skin
and mucous
membranes
(cheilosis,
angular
stomatitis,
inflamed
nasolabial
folds, swollen
tongue)
Table 13.3 Vitamins and Minerals:
Exercise Relationships
Nutrient Major Function Deficiency
Niacin (vitamin B3) Oxidative energy Irritability,
metabolism, diarrhea,
electron dermatitis
transport in ATP
production
Pyridoxine/pyridoxal/pyridoxamine Gluconeogenesis, Dermatitis,
(vitamin B6) protein swollen
metabolism tongue,
(deamination convulsions
and
transamination
reactions)
Cyanocobalamin (vitamin B12) Formation of red Macrocytic
blood anemia,
cells/hemoglobin neurologic
symptoms
Folic acid Formation of red Macrocytic
blood anemia, early
cells/hemoglobin, fatigue
formation of
nucleic acids
Ascorbic acid (vitamin C) Antioxidant, Poor appetite
protein (potentially
(connective resulting in
tissue collagen) other
synthesis, micronutrient
improve iron deficiencies),
absorption early fatigue,
poor wound
healing
Retinol (vitamin A) Antioxidant, Loss of
maintains appetite, poor
disease immunity, eye
resistance, vision problems
Table 13.3 Vitamins and Minerals:
Exercise Relationships
Nutrient Major Function Deficiency
α-Tocopherol (vitamin E) Antioxidant Nerve and
muscle
damage
Chromium Glucose Glucose
metabolism intolerance,
(insulin poor blood
sensitivity) glucose
control, early
fatigue
Iron Hemoglobin Anemia, poor
synthesis, concentration,
oxygen delivery poor immune
to tissues system, early
fatigue
Magnesium Energy Muscle
metabolism, weakness and
nerve cramping,
conduction, nausea,
muscle irritability
contraction
Zinc Immune system Poor
health, immunity,
glycolysis, poor appetite
nucleic acid (potentially
synthesis, resulting in
carbohydrate other
metabolism, micronutrient
sense of smell deficiencies),
and taste skin rashes,
diarrhea

More information on these vitamins and minerals can be found in Chapters 5 and 6.
Source: Lukaski H. Vitamin and mineral status: effects on physical performance. Nutrition.
2004;20:632–44.

The general recommendations for athlete vitamin

supplementation include (83, 89, 137) the following:
 There is little evidence to suggest that it is common for
physically active individuals to suffer from inadequate dietary
intakes of vitamins and minerals. Athletes at highest risk are
those with restricted intakes (i.e., vegetarian athletes, athletes
on calorie-restricted diets).
Some physically active people/athletes, including ballet dancers,
gymnasts, long-distance runners, and wrestlers, may have
inadequate exposure to vitamins and minerals because they limit
energy consumption in an attempt to meet sport-specific weight
requirements or to satisfy aesthetic requirements of the
sport/activity.
Physically active people should consume a wide variety of foods
to optimize exposure to vitamins, minerals, and phytonutrients to
eliminate the requirement for dietary supplements.
Only people with a biologically confirmed nutrient deficiency are
likely to benefit from the consumption of the deficient nutrient
through dietary supplements.
Athletes with questions about the adequacy of their diet should
meet with an appropriately credentialed licensed/registered
dietitian to help determine how well nutrient needs are satisfied,
rather than self-prescribe dietary supplements.

Potential Risks of Dietary Supplements and

Ergogenic Aids

Some products sold as ergogenic aids often have an unknown origin

(the substances in the package are not clearly indicated), contain no
known nutrient, and have no substance that is known to enter a
nutritional pathway. To make matters even more confusing, several
studies evaluating the composition of ergogenic aids that have
marketing programs targeting athletes have found that a large
proportion of the products have significantly less of the active
ingredient than advertised (20). Potentially dangerous and career
damaging is the finding in several studies that a number of
ergogenic aids targeting athletes contain banned substances not
listed on the label (41). This may also be the cause of a certain
amount of misattribution related to the product. The athlete believes
he or she is simply taking a certain proprietary mix of vitamins and
finds that, incredibly, his or her muscle mass starts to enlarge. The
athlete attributes this change to the vitamin mix, when it may
actually be due to the anabolic steroid that the athlete unknowingly
has been taking with the vitamin mix. Current doping rules are clear:
The athlete is responsible for what he or she consumes, and should
the athlete compete in a sanctioned event and have a positive urine
test for a banned substance, that athlete cannot claim ignorance
that what he or she was consuming contained a banned substance
(96). Given that between 40% and 70% of athletes use supplements,
with 10%–15% of supplements containing banned substances, this
should be a real concern for athletes (106). This concern is made
worse by the relative absence of regulation and enforcement of
issues that would help to ensure athletes and the public that dietary
supplements are safe to consume (111).
Athletes should be concerned with excessive supplement use and
the potentially adverse reactions from high doses of different
supplements. Although consistent adverse reactions to taking dietary
supplements have not been documented (57), the widespread use of
dietary supplements by elite athletes, with no apparent health or
performance benefits, suggests a need for educational programs
focused on dietary supplement use in athletes (78). The amount,
quantity, and combinations of dietary supplements used by athletes
have raised a concern about the potential risk of side effects (78).
It is difficult to discern whether certain consumed substances
have a performance-enhancing effect. Where improvements are
seen, it is possibly due to a placebo effect: The athletes taking the
supplement believe it will help, so it actually helps even though there
is no biochemical basis for the improvement. In other cases,
improvements may occur because the product is filling a need that is
missing from the foods that an athlete commonly consumes. For
instance, body builders often consume insufficient energy, forcing a
larger than desired proportion of the consumed protein to be used to
satisfy energy needs rather than tissue building needs. The protein
supplements that are consumed by body builders help to satisfy the
energy requirement and enable a greater proportion of protein to be
available for muscle protein synthesis. The benefit of the protein may
be due to the larger energy (i.e., kcal) intake rather than protein per
se, suggesting that simply eating more energy would help to better
satisfy the protein requirement and would be a less expensive and
equally effective means of sustaining and/or enlarging the muscle
mass (16). Of course, there must also be physical stress in
conjunction with sufficient energy/nutrients to encourage the
muscular adaptation that bodybuilders seek (Figure 13.2). It simply is
not feasible for performance enhancement to occur without the
combination of mechanical loading (i.e., exercise) and sufficient
nutrients.

FIGURE 13.2: Physical activity (loading) plus adequate nutrient

consumption is necessary to achieve the desired body/performance
adaptation. Simply taking a supplement achieves nothing. (Adapted
from Coyle EF. Workshop on the Role of Dietary Supplements for
Physically Active People. Bethesda (MD): National Institute of Health,
Office of Education; 1996. p. 22.)

Placebo

In research, a placebo contains no active ingredient but is typically

indistinguishable from a pill/capsule/drink that contains the active
ingredient. The placebo allows the researcher to make a clear
statistical differentiation between the observed effects of the
consumed active ingredient and the placebo. The placebo effect
refers to a phenomenon in which a placebo can have an effect,
despite the fact that it has no active ingredient, because the
person taking it believes or has the expectation that the placebo
will be useful.

Although athletes may feel that consumption of dietary

supplements/ergogenic aids permits them to eat less carefully, the
literature is increasingly clear that these products do not take the
place of a good diet. At best, if a supplement or ergogenic aid were
to provide any benefit, the athlete must have a special need that a
well-balanced diet that is consumed in a way that sustains a good
energy balance fails to meet. There are few such substances, so the
athlete must be cautious as the costs of these products are high, the
benefits are limited, and the potential adverse effects are real.
Ideally, rather than focusing on a “magic bullet” to enhance
performance, athletes should take a realistic approach. Nothing is
better than the consumption of a balanced intake of foods and
beverages that provides sufficient energy and nutrients to support
growth, activity, and tissue maintenance.
What follows is a review of nutritional supplements/ergogenic aids
commonly consumed by athletes. Not included are a number of
supplements that are available to athletes, but that do not yet have
the popular acceptance of those reviewed. These include
epicatechins from dark chocolate, niacin (vitamin B3) found in meats,
the antioxidant and muscle protectant resveratrol found in red wine,
the cellular metabolism regulator phosphatidic acid, and the muscle
protein simulator ursolic acid. As of the writing of this book, there are
insufficient studies to clearly discern if these substances do or do not
have a performance-enhancing effect.

Nutritional Supplements and Ergogenic Aids

Commonly Consumed by Athletes

Caffeine
Caffeine is a trimethylxanthine and one of several methylxanthines
found in coffee, tea, cola, chocolate, and a variety of other foods and
beverages (Table 13.4). As a supplement, caffeine is a stimulant with
established benefits for endurance, supramaximal, and sprint
athletic endeavors (97). It is one of the most popularly consumed
food and beverage ingredients, with a large proportion of the adult
population consuming caffeine-containing products (14). For
athletes, these products include caffeine-containing beverages, gels,
and gums, many of which have been tested for efficacy as ergogenic
substances (127). Although most studied with endurance athletes,
caffeinated products are also commonly used by athletes in high-
intensity and team sports (15). Caffeine has two primary effects: (i)
as an adenosine antagonist, it is a central nervous system stimulant
and (ii) it is a muscle relaxant, resulting in a lower level of perceived
effort and lowering the feeling of pain and fatigue associated with
exercise (127, 134). Although caffeine is generally considered safe to
use when consumed within the range of 3–13 mg/kg, athletes should
be cautious to avoid taking other stimulants and/or alcohol when
consuming high levels of caffeine (15). For endurance athletes
consuming relatively moderate quantities of 3–6 mg/kg of anhydrous
caffeine in pill or powder form, typically consumed about 60 minutes
prior to exercise, it has been found to be an effective ergogenic aid
by increasing time to fatigue (39). Caffeine doses of <3 mg/kg
provided before and during exercise as part of a carbohydrate-
containing beverage have also been found to be effective in
increasing time to fatigue (127). Low doses of caffeine (100–300 mg)
when consumed after the first 15–80 minutes of physical activity
have been found to improve cycling time trial performance by 3%–
7% (133). Doses of caffeine greater than 9 mg/kg do not appear to
have a performance-enhancing effect and may result in negative
side effects, including anxiety, restlessness, and nausea (15).

Table 13.4 Caffeine Content of Commonly Consumed

Foods and Beverages
Food/Beverage Serving Caffeine Content (mg)
Ground coffee 12 oz 50–100
Black tea 8 oz 30–80
Green tea 8 oz 35–60
Herbal tea 8 oz 0
Cola 20 oz 50–65
Root beer, most 12 oz 0
brands
Ginger ale 12 oz 0
Common energy Varies 30–134+
drinks
Caffeinated Varies 20–150
snack foods
Over-the-counter 1 capsule 200
caffeine
Caffeine powder 1/16 tsp 200
Caffeine citrate ½ tsp 415
solution
Source: Center for Science in the Public Interest. Available from: https://cspinet.org/.
Accessed May 17, 2018.

As with all drugs, caffeine has a reduced-dose effect (i.e., it is less

effective when consuming caffeine in the same amounts chronically,
as the athlete adapts to this level of intake), so abstaining from
heavy caffeine intake for at least 7 days prior to consuming it for a
competition will enhance the potential ergogenic benefit (93). Not all
athletes respond to caffeine, as it has been found that some athletes
have a genetic inability to respond to its potential ergogenic
properties, regardless of the caffeine ingestion strategy (148).
Concern has been raised that excess consumption of caffeine may
result in unwanted side effects, including tremor, anxiety, and a
higher heart rate (134). It should be noted that the National
Collegiate Athletic Association (NCAA) prohibits the consumption of
large quantities of caffeine that result in urinary caffeine levels
exceeding 15 mcg/mL. This would require in excess of 700 to 900 mg
caffeine (∼5–7 cups of coffee) consumed in a relatively short period
of time to reach this level (127). Athletes competing in NCAA-
sanctioned events should know that caffeine-containing products
may not have the caffeine or other stimulant content disclosed on
the product label (137).
There is little reason to consume arbitrarily high levels of caffeine,
as the maximal benefit appears to be reached at a level of 6 mg/kg
body mass (Figure 13.3) (45). Even lower doses (<3 mg/kg) appear
capable of imparting an ergogenic benefit for specific performance
benefits (71). It is thought that low-dose caffeine intake may have
certain other benefits, including potentially fewer side effects and a
better mood state (127).
FIGURE 13.3: Effects of ingesting no caffeine (0) or 3, 6, or 9 mg/kg
body mass of caffeine (dose) on running time to exhaustion at 85%
of maximum oxygen uptake. Data are means ± standard error (n =
8). Bars with different letters are significantly different, and bars with
the same letters are not significantly different. (From Graham TE,
Spriet LL. Metabolic, catecholamine and exercise performance
responses to varying doses of caffeine. J Appl Physiol. 1995;78:867–
74.)

Although caffeine use is typically associated with improved

endurance time to exhaustion, there is some limited information on
the impact of caffeine on power/anaerobic work. Athletes who
ingested caffeine at a level of 5 mg/kg lifted significantly more
weight and performed a significantly higher number of bench press
repetitions when compared with consumption of a placebo (35). This
same study also found that consumption of caffeine resulted in
greater vigor and less fatigue on a mood state score questionnaire
than for those consuming the placebo.

Carbohydrates (Gels, Drinks, Foods)

Carbohydrate has a critically important role in physical activity and is
the macronutrient that provides the greatest amount of dietary
energy in most people. In high-intensity, primarily anaerobic,
exercise, carbohydrate is the primary fuel used by the muscles, as it
has the capacity to be metabolized for energy anaerobically. In low-
intensity but long-duration exercise, fat may be the primary fuel, but
fat requires carbohydrates to burn completely (104). However,
because carbohydrate storage is limited (∼100 g glycogen in liver;
∼400–500 g glycogen in muscles), it is typically the limiting energy
substrate in physical activity. That is, carbohydrate is likely to “run
out” more quickly than either fat or protein, and when carbohydrate
runs out it is difficult to continue exercising (143). In a recent review
of 50 of 61 (82%) studies assessing carbohydrate supplementation
on exercise performance of varying durations, it was found to have
statistically significant performance benefits (131).
One strategy to help ensure that carbohydrate stores do not run
out during exercise is to begin exercise with glycogen stores at their
maximal level. This strategy, commonly referred to as glycogen
loading, has as its goal the storage of as much carbohydrate in the
tissues as they can hold. The traditional or classical regimen for
carbohydrate loading (referred to as the Astrand regimen for the
person who first described it) achieves maximal muscle glycogen
stores by first completely depleting the muscles of glycogen (50).
This is followed by a phase in which muscle glycogen is restored to
maximal levels through the consumption of a high-carbohydrate diet
while avoiding activity that may be glycogen depleting (i.e., high-
intensity activity). Although successful in optimizing glycogen tissue
stores, this regimen is no longer recommended because of the
potential dangers associated with glycogen depletion, which include
irregular heartbeats and a sudden loss of blood pressure (BP) (7).

Carbohydrate Loading

A strategy for maximizing muscle glycogen stores in advance of an

athletic event. Typically, this involves consumption of relatively
high carbohydrate while reducing activities (i.e., higher intensity)
that may use muscle glycogen for several days.
 Sherman/Costill method is the commonly recommended method
for carbohydrate loading. This method was developed after the
Astrand regimen and was found to be safer than the Astrand method
but equally effective in optimizing glycogen storage. This approach is
based on maintaining carbohydrate stores at all times and avoiding
carbohydrate depletion. Using the recommended Sherman/Costill
method, the athlete should do the following (28):

Regularly consume a diet that is 55%–65% of carbohydrate daily,

which is slightly increased to 60%–70% of carbohydrate in
preparation for competition. This represents a carbohydrate
intake of ∼7–12 g/kg of body mass/day.
For 4–7 days prior to competition, exercise (particularly intense
exercise) should be gradually reduced to avoid using up a
significant amount of muscle glycogen. During this tapering
phase, a high-carbohydrate intake is maintained.

It has been found that this method is equally effective in

maximizing glycogen stores as the Astrand regimen, but it avoids the
difficulties associated with glycogen depletion. It should be noted
that glycogen storage increases water storage in a 1:3 ratio (i.e., for
every gram of stored glycogen, the body stores ∼3 g of water).
Athletes should consider carefully if their sport would benefit from
glycogen loading, as this strategy may improve endurance, but may
also add some degree of initial muscle stiffness. Where flexibility and
high strength:weight ratio are important (e.g., gymnastics, figure
skating, diving), maximizing glycogen stores may not be desirable
(50).
The type of carbohydrate consumed does appear to make a
difference. Glucose polymer products, including polycose (an easily
digestible carbohydrate polymer with rapid absorption) and
maltodextrins (a polysaccharide manufactured from starch via partial
hydrolysis that is easy to digest and absorb), are found in several
sports beverages and sports gels and are easily digested into
glucose and appear to be effective in glycogen production, as are
starches from pasta, bread, rice, and other cereal grains (29, 104).
To summarize, the following strategies should be followed to
optimize carbohydrate availability (19, 102, 137):

To optimize muscle glycogen storage in preparation for an

event/exercise or to recover muscle glycogen following exercise.
 7–12 g of carbohydrate/kg body mass/day.
Rapid recovery of muscle glycogen following exercise when there
are fewer than 8 hours available to recover prior to the next
exercise bout.
1–1.2 g/kg carbohydrate immediately following exercise,
repeated every hour until a regular meal schedule is
resumed.
There is evidence that consumption of carbohydrate as small
snacks every 15–60 minutes may be advantageous early in
the recovery period following exercise.
Preevent meal before a prolonged exercise session.
1–4 g/kg carbohydrate consumed 1–4 hours prior to exercise.
Carbohydrate consumption during moderate-intensity or
intermittent exercise 1 hour or longer in duration.
Insufficient total energy consumption, even with a relatively high
consumption of carbohydrate, will result in diminished glycogen
stores.
Exercise duration ∼1 hour: small amounts of carbohydrate
from a sports beverage providing 6%–7% carbohydrate
solution. There is also evidence that mouth rinsing with a
carbohydrate drink may provide some benefit.
Exercise duration greater than 90 minutes: 0.5–1.0 g/kg/hour
(30–60 g/hour).
Exercise duration greater than 4 hours: ∼1.5–1.8 g/minute of
multiple transportable carbohydrates (i.e., the consumed
carbohydrate contains more than a single source of
carbohydrate. For instance, it is better to have a combination
of sucrose and glucose than the caloric equivalent of glucose
alone to optimize intestinal carbohydrate receptors).
Typical daily intake. (Assumes carbohydrate is spread out over
the day, with consumption that optimizes carbohydrate
availability before, during, and immediately after exercise.)
Athletes performing a light training program.
3–5 g/kg/day
Athletes with moderate exercise program.
5–7 g/kg/day
Endurance athletes with 1–3 hours moderate to higher
intensity training.
7–12 g/kg/day
Athletes with extreme exercise of long duration (greater than
4–5 hours), such as Tour de France.
 A minimum of 10–12 g/kg/day

β-Alanine
Exercise results in reduced muscle energy substrates, including
adenosine triphosphate (ATP), phosphocreatine (PCr), and glycogen,
and an accumulation of metabolites, including adenosine
diphosphate and H+, and also magnesium (Mg2+), with a greater
potential for cell-damaging free radicals (4). It appears that the
dipeptide carnosine helps to limit muscular fatigue by buffering the
accumulating H+. Carnosine consists of the two amino acids β-
alanine and histidine and increases with the consumption of β-
alanine (10, 132). The effect of the increased buffering capacity is to
enable an improvement in high-intensity exercise performance (97).
There are dietary sources of β-alanine, primarily from the meat of
predominantly anaerobic animals, such as poultry, or from animals in
low-oxygen environments, such as whales. Providing a standard
supplemental dose of >800 mg β-alanine may result in unpleasant
side effects that include skin rashes and/or transient paresthesia
(tingling of the skin). However, this can be managed through
consumption of slow-release tablets of β-alanine that may also be
effective in elevating carnosine (130, 132). It appears that intake of
3–6 g/day (0.8–1.6 g every 3–4 hours) for 10–12 weeks increases
cellular buffering capacity by 50%–85% (121, 132). Interestingly, the
muscle carnosine loading effect of supplemented β-alanine appears
to be more pronounced in trained versus untrained muscles, but the
effectiveness of supplemental β-alanine in producing a performance
enhancement appears harder to realize in athletes who are already
well trained (5, 8). Although there is a large between-athlete
variation in performance benefit, athletes consuming β-alanine as
per the usual protocol generally realize performance benefits ranging
from 0.2%–3.0% during continuous and/or intermittent exercise
lasting 30 seconds to 10 minutes (97).

Nitrate and Other Nitric Oxide Stimulators

Supplementation of dietary nitrate and other products, including
citrus flavonoids, that increase plasma nitrite concentration or
directly increase the production of nitric oxide. Nitric oxide (NO) has
multiple functions, all of which are important for competitive
athletes. These functions include (59, 107, 128):
 Regulation of blood flow and BP (vasodilation)
Muscle contractility
Glucose homeostasis
Calcium homeostasis
Mitochondrial respiration and biogenesis

Nitric Oxide

Commonly abbreviated as NO, this substance is a powerful

vasodilator that improves oxygen delivery to cells. The improved
oxygen delivery has the effect of lowering heart rate and BP, as the
heart does not have to work as hard to deliver the required
oxygen. In children and adolescents, there is a robust L-arginine
pathway for producing NO. With aging, this pathway is not as
active and BP rises. However, consumption of high-nitrate foods
(i.e., beet juice) results in higher nitric acid, improved oxygen
delivery, and lower BP.

It was originally thought that NO was only generated through

oxidation of the amino acid L-arginine in a reaction catalyzed by
nitric oxide synthase (NOS) (100). However, it has since been found
that NO may also be produced from consumed foods through
reduction of nitrate to nitrite, and then nitrite to NO (34). This
pathway is particularly important in conditions of low oxygen
availability, including high oxygen demand in skeletal muscle during
exercise. It has also been found that supplementation with citrus
flavonoid, an antioxidant and also a stimulator of NO production, has
a positive impact on exercise performance. Using a double-blind,
randomized study of healthy trained males, 4 weeks of
supplementation with 500 mg citrus flavonoid resulted in a
significant improvement in power production (time trial on cycle
ergometer) when compared with a placebo (107).
Nitrate in foods, particularly beets and green leafy vegetables,
can be reduced to nitrite by oral bacteria, resulting in higher plasma
nitrite concentrations. The higher plasma nitrite concentration serves
as reservoir for NO production (85). Beet juice and vegetable juices
are preferred because they have better surface area contact than
solid foods between the food-derived nitrate and the oral bacteria
(63).
 Several studies have investigated whether dietary nitrate
supplementation may have an impact on the physiologic response to
exercise. In one such study, it was found that 3 days of sodium
nitrate supplementation (0.1 mmol/kg/day) reduced resting BP and
oxygen cost of submaximal cycle exercise (75). Other studies found
that enhancing NO bioavailability through the dietary intake of
beetroot juice reduced resting BP, reduced the oxygen cost of
submaximal exercise by 5%, and extended the time to exhaustion
during high-intensity exercise by 16% (2). Interestingly, food nitrate
supplementation also reduces the oxygen cost of submaximal
exercise and may also enhance exercise tolerance and performance
(59, 74). Other recent studies have found that acute dietary intake of
0.5 L of beetroot juice before 4 km and 16.1 km cycle time trial
performance in competitive cyclists resulted in greater power output
for same oxygen uptake, and a 2.7% reduction in time to complete
both time trial distances (72, 73, 144). It was determined that this
effect can be maintained for at least 15 days if supplementation at
the same dose (∼0.5 L beetroot juice) is continued. Importantly,
nitrate-depleted beetroot (placebo) was found to have no effect,
suggesting that nitrate is a key bioactive component of beetroot
juice. As a word of caution, because nitrate is converted to nitrite by
oral bacteria, use of antiseptic mouthwash may inhibit NO
production. A recent study assessed BP in 19 healthy volunteers
during an initial 7-day control period, followed by a 7-day treatment
period with a chlorhexidine-based antiseptic mouthwash (63). The
antiseptic mouthwash treatment significantly reduced oral nitrite
production by 90% and plasma nitrite levels by 25% compared with
the control period. This resulted in a significant increase in systolic
and diastolic BP. Results of this study suggest that oral bacteria play
an important role in plasma nitrite levels and in the physiologic
control of BP.

Creatine
Creatine supplementation, typically as creatine monohydrate, has
been found to improve performance of repeated bouts of high-
intensity exercise with short recovery periods (137, 145). In addition,
studies have found that creatine supplementation may enhance the
adaptive response to exercise, including an increase in lean mass
and strength (97, 118). PCr serves as a storage depot for maintaining
ATP levels during high-intensity activities, such as sprinting, which
can quickly deplete ATP. Creatine is made from three amino acids,
and it joins with phosphorus to make PCr (112). It is believed that
saturating muscles with creatine will enhance the ability to maintain,
through effective resynthesis, the high-energy compound ATP,
thereby delaying fatigue in high-intensity activities (104). There is
also some evidence that creatine supplementation may lower
oxidative stress and markers of tissue inflammation (32). Humans
mainly synthesize creatine in the liver and other metabolically active
tissues from the amino acids arginine, glycine, and methionine, and
we can also obtain preformed creatine from meats (6). However,
normal cooking reduces the availability of preformed creatine in the
diet, and given the ever-increasing importance of fully cooking meat
products to reduce the chance of bacterial infection, the amount of
creatine delivered by the diet is likely to be small. Because of a net
lower intake of preformed creatine from meat and typically lower
protein intakes that provide the amino acids necessary for creatine
synthesis, pure vegans may be at risk for low intakes of creatine (13,
137).
Creatine is now one of the most popular performance-enhancing
supplements taken by athletes (27). A typical creatine loading
regimen involves an initial loading phase of 20 g/day, divided into
four equal daily doses of 5 g/dose, for 5–7 days, followed by a
maintenance phase of 3–5 g/day for differing periods of time (1 week
to 6 months) (6). Recent studies suggest that creatine monohydrate
supplementation at doses of 0.1 g/kg body weight that is combined
with resistance training improves the potential for a performance
benefit (27). Earlier studies have suggested that taking daily creatine
supplements results in muscle tissue saturation of creatine after 5
days (49). This finding suggests that creatine should not be taken for
longer than 5 days, with some studies suggesting that taking
creatine supplements 5 days per month is adequate to saturate
muscle tissue (95). There is also evidence that consuming the
creatine monohydrate supplement with additional protein and
carbohydrate (∼100 calories protein + ∼100 calories carbohydrate)
may improve the uptake of creatine by cells because of the higher
insulin response from the additional energy substrates (129).
Although no negative health effects have been documented with
creatine supplementation (using the recommended intake protocol)
for up to 4 years, athletes should be aware that the long-term safety
of creatine monohydrate supplementation has never been tested on
children, adolescents, or adults (122). Creatine supplementation is
associated with acute weight gain from water retention (0.6–2 kg
following creatine loading), which may cause difficulties for athletes
in weight-sensitive sports, and there are also reports that creatine
may cause GI discomfort (67, 113, 137). In a study comparing
creatine monohydrate supplementation with a supplement of 250
kcal carbohydrate for 5 days using a repeated jump height test, it
was found that the carbohydrate group performed as effectively as
the creatine monohydrate group, but without the added weight gain
associated with creatine consumption (67). Creatine
supplementation has also been linked to transient renal (kidney)
dysfunction (115). It was found that the athlete with renal
dysfunction had been taking oral creatine supplements to prepare for
the soccer season. He had not been exceeding the recommended
doses, and once he stopped the supplements renal function
recovered. It has been advised that high-dose (>3–5 g/day) creatine
supplementation should not be used by those with preexisting renal
disease or those with a potential risk for renal dysfunction (i.e.,
diabetics, hypertensives) (65). A test of kidney function would,
therefore, be logical in advance of creatine supplementation.

Sodium Bicarbonate/Sodium Citrate

Supplementation with sodium bicarbonate or sodium citrate
enhances extracellular buffering capacity, with performance
improvements observed in athletic events that would otherwise be
affected by acid-based disturbances, typically associated with
anaerobic glycolysis and including repeated high-intensity sprints
and high-intensity events lasting 1–7 minutes (18, 70). Researchers
have found that both sodium bicarbonate and sodium citrate have a
buffering effect on the acidity (lactic acid) that is primarily created
not only in anaerobic sports but also in team sports that involve
repeated sprinting, allowing for prolonged maintenance of force or
power (24, 101). Because many activities involve mainly anaerobic
metabolic processes, it would appear that some athletes could derive
a benefit from consumption of these buffers.
The typical consumption protocol for sodium bicarbonate and
sodium citrate is to consume 200–400 mg/kg ∼1–2 hours prior to
exercise (125). However, there are reported GI problems related to
consumption of sodium bicarbonate that may include vomiting and
diarrhea, but these may be somewhat mediated through coingestion
of small high-carbohydrate snacks (17, 24, 137). These negative side
effects from taking sodium bicarbonate should give athletes reason
to be cautious before taking this potential ergogenic aid. As an
alternative, sodium citrate appears to result in less GI distress, but
the tolerance of this supplement should also be tested prior to use at
a competition (97, 119).

Branched-Chain Amino Acids

BCAAs include valine, leucine, and isoleucine and can be oxidized
directly by muscle tissue to derive energy (3). Dairy proteins appear
to have benefits relative to other protein sources, perhaps largely
due to the relatively high leucine content and the high digestibility
and absorption qualities of the BCAAs in dairy products (110). BCAA
metabolism appears to be elevated in endurance activities, and
there appears to be an energy balance component to BCAA
availability because plasma concentrations are affected by changes
in total energy availability as well as the intake of protein, fat, and
carbohydrate (1). It is theorized that intense physical activity may
break down muscle tissue at a fast rate, but that supplementation
with BCAA minimizes this muscle degradation and results in
improved fat-free mass (68). It has also been theorized that
supplemental intake of BCAA may result in central fatigue by
releasing more tryptophan to cross the blood–brain barrier, which
stimulates the production of serotonin (40). Serotonin induces sleep,
suppresses appetite, and induces physiologic fatigue. However, a
recent study assessing the effects of BCAA supplementation on
fatigue found no significant effects on central fatigue (116), and it
was previously found that the coingestion of carbohydrate with BCAA
appears to minimize central fatigue (31).
A number of studies assessing the supplemental intake of BCAA
on athletic performance have mixed results. The studies combining
BCAA with carbohydrate appear to have more improvement than the
BCAA alone, whereas some studies found that carbohydrate alone
provided the ergogenic benefit while combining BCAA with
carbohydrate resulted in performance improvements (3).
Supplementation of BCAA is typically in the range of 20–25 g
(equivalent to 80–100 kcal). The findings suggest that athletes
consuming good-quality protein with sufficient carbohydrate are
likely to achieve the same or more benefit than might be derived
from the consumption of BCAA supplements alone.
Prebiotics/Probiotics1
The health-enhancing impact of exercise occurs through several
mechanisms, including the positive impact it has on the immune
system, its anti-inflammatory impact, and its metabolism-improving
effects (64). Recent studies on the gut microbiome suggest a major
role on immunity and metabolism, and disruption of the gut
microbiome can result in chronic inflammatory disease that can
negatively affect athletic performance (69). As a result, gut-microbial
modulating therapies, including prebiotics and probiotics, are gaining
popularity among athletes (Table 13.5).

Table Prebiotics, Probiotics, and Synbiotics

13.5
Prebiotics Nondigestible Prebiotics are a type of dietary fiber that
food passes through the upper GI tract
components indigested providing substrate for
that help the colonic bacteria. Prebiotics are naturally
growth and found in many foods including:
activity of artichokes, onion, garlic, asparagus, and
beneficial leeks
bacteria (i.e.,
food for
beneficial
bacteria)
Probiotics Live bacteria Common probiotics include
that provide a Lactobacillus and Bifidobacterium,
health benefit which naturally occur in a range of
when foods including: yogurts (with active live
consumed in cultures), kefir, kombucha, kimchi, and
adequate natto
amounts (i.e.,
good bacteria)
Synbiotics Combination Synbiotics provide both the beneficial
of prebiotics bacteria to the GI tract and the
and probiotics substrate (i.e., food) to help the bacteria
thrive in the colon. Examples of
synbiotic foods include live culture
yogurt with sliced nectarine; beans and
fresh sour dill pickles; kefir and cashew
 nuts; greens sautéed with garlic and
sour cream added

Microbiome

Also referred to as the microbiota, microbiome refers to the

microbial organisms that inhabit the GI system and have many
functions related to human health, including the immune system,
hormone production, and metabolism. The microbiome may be
degraded through antibiotics and/or consumption of foods that fail
to support the bacteria (i.e., prebiotics), and/or fail to provide
bacteria such as Lactobacillus and Bifidobacterium found in live
culture yogurts and other fermented foods (i.e., probiotics).

Prebiotics and probiotics work via modifying the community of

bacteria that resides in the large intestine, termed the gut
microbiota, which has been shown to play a pivotal role in health and
disease. There is a growing body of evidence suggesting this
therapeutic target may benefit athletes through influencing immune
function, reducing gut mucosal permeability, and decreasing the
systemic inflammatory response associated with intense exercise
(86). Beyond exercise-specific targets, prebiotics and probiotics may
also have other benefits in athletes including reducing stress-related
symptoms such as insomnia, poor concentration, anxiousness,
depression, and fatigue (22). There is also evidence, using a
randomized double-blind placebo protocol, that Lactobacillus casei
Shirota, a common bacterium in probiotic capsules, may help to
reduce upper respiratory tract infection incidence in athletes (42).
Common probiotic foods include yogurt, kefir, sauerkraut, pickles,
tempeh, kimchi, and kombucha tea. Where regular consumption of
these foods is not possible, athletes can find a wide array of probiotic
capsules that are available for sale.
1
Special thanks to Megan Rossi, PhD, RD for providing information for this section on
prebiotics and probiotics. Dr. Rossi is a research associate in Diabetes and Nutritional
Sciences at King’s College, London and is a specialist in the area of the gut microbiome.

Vitamin D
Vitamin D affects multiple body systems and may impact muscle
soreness, muscle recovery, calcium homeostasis, bone mineral
density, and other skeletal and extraskeletal cellular processes that
include cardiopulmonary function (139). It is this increasing
understanding about vitamin D that has resulted in an enhanced
interest in vitamin D and the multiple roles it plays in athletic
performance (see Table 13.6).

Table Forms of Vitamin D Supplements

13.6
Vitamin Ergocalciferol Vitamin D2 is produced by plants with
D2 (from plants) exposure to ultraviolet radiation. The
vitamin D2 content of foods may be
increased through postharvest ultraviolet
light irradiation. This also occurs in soy
milk, almond milk, and coconut milk, which
is exposed to ultraviolet light to increase
the vitamin D2 content.
Vitamin Cholecalciferol This is the most biologically active form of
D3 (from animals) vitamin D for humans and appears to be
the superior supplemental form as it has
better absorption and utilization than
vitamin D2. In humans, sunlight exposure
of the fat layer under the skin converts
cholesterol to vitamin D3.

Sources: Lehmann U, Hirche F, Stangl GI, Hinz K, Westphal S, Dierkes J. Bioavailability of

vitamin D(2) and D(3) in healthy volunteers, a randomized placebo-controlled trial. J Clin
Endocrinol Metab. 2013;98(11):4339–45; Logan VF, Gray AR, Peddie MC, Harper MJ,
Houghton LA. Long-term vitamin D3 supplementation is more effective than vitamin D2 in
maintaining serum 25-hydroxyvitamin D status over the winter months. Br J Nutr.
2013;109(6):1082–8.

Recent studies have found that vitamin D–deficient athletes are at

higher risk for all types of skeletal fracture, but also increases in total
body inflammation, infectious illness, and muscle function (76). A
study assessing vitamin D supplementation found that vitamin D2
and D3 supplementation was safe and it protected against acute
respiratory tract infection (92). A study of 98 young athletes and
dancers found that 73% of the assessed athletes were vitamin D
deficient and that athletes involved in indoor sports had nearly
double the prevalence of vitamin D deficiency when compared with
athletes in outdoor sports (26). Interestingly, it was found in the
1950s that athletes exposed to ultraviolet light that produces vitamin
D improved athletic performance, primarily through lower muscle
soreness and improved muscle recovery (17). Both the faster
recovery in muscle soreness and improved muscle recovery are likely
a function of increased muscle protein synthesis, which is enhanced
with good vitamin D status (9, 146). It should be noted that darker
skinned athletes are likely to require more sunlight (ultraviolet B
[UVB]) exposure than light-skinned athletes to derive the same
vitamin D–forming benefit. It has been estimated that light-skinned
individuals require up to 40% less UVB exposure to achieve the same
vitamin D status than darker-skinned individuals, placing darker-
skinned athletes at higher risk of deficiency, assuming equivalence in
food intake (48).
The problem is clear: Vitamin D production during the winter, in
athletes living in areas with changing seasons, is nearly absent and
forces athletes to rely on vitamin D stores that were acquired during
the summer. Dietary vitamin D is relatively low, and in athletes who
train and compete indoors all year, the acquisition of vitamin D even
during the summer is inadequate, placing them at high risk for
fractures (55, 76). The Institute of Medicine classifies adequate
vitamin D as a serum value of >50 nmol/L, inadequate vitamin D as
30 to 50 nmol/L, and vitamin D deficiency as <30 nmol/L (139).
However, there is no clear consensus for the level of serum vitamin
D (25-hydroxyvitamin D) that is associated with an optimal level,
deficiency, or insufficiency in athletes (77). Typically, UVB exposure
contributes to 80%–90% of serum vitamin D, whereas dietary
sources contribute 10%–20% (108). There is now good evidence that
supplemental consumption of vitamin D in athletes with serum
vitamin D below 40 nmol/L is a performance-improving strategy. It
appears that >40 ng/mL serum vitamin D is needed for fracture
prevention in athletes, with no additional benefits observed with
serum vitamin D >50 nmol/L (124). Vitamin D supplemental doses
vary widely, ranging from 1,000 to 50,000 IU, with typical
supplemental doses in the range of 1,000–2,000 IU. The European
Food Safety Authority recently stated that 4,000 IU is the maximum
reasonable dose for vitamin D supplementation (36). Daily
supplementation above this level should involve careful monitoring
of serum vitamin D to avoid toxicity (51). Even among older adults
experiencing muscular and strength declines, providing 1,000 IU of
ergocalciferol per day for 2 years was found to significantly increase
muscle strength and size (120). Studies of supplemented and
nonsupplemented athletes demonstrate performance improvement
in the vitamin D–supplemented group, particularly in athletes living
in northern climates (25). However, given the potential for toxicity,
vitamin D supplementation should be undertaken under the guidance
of a health professional.

Green Tea
Past studies suggest that consumption of antioxidants, either
through antioxidant foods or through supplementation, may be
protective against exercise-associated oxidative stress and muscle
damage (11, 114). There have also been studies suggesting that
antioxidant-supplemented athletes may not adapt well to training,
predisposing them to a greater degree of oxidative damage (23, 44,
135). This study illustrates how difficult it is to find a performance
benefit as a result of antioxidant consumption: A double-blind,
randomized, placebo-controlled crossover study assessing two 4-
week periods with either a green tea extract (980 mg polyphenols
daily) or a placebo on sprinters found that the green tea extract
prevented oxidative stress following repeated cycle sprint tests (60).
This is a finding consistent with previous studies assessing green tea
extract (61, 109). However, this study also found that there was no
observed reduction in exercise-induced muscle damage, and there
was no improvement in sprint performance as a result of the green
tea extract.

Supplements to Enhance the Immune System

A number of nutritional supplements are consumed for the purpose
of enhancing immune function in athletes. These include vitamins C
and E, zinc, and other substances not previously covered in this
chapter, including bovine colostrum, glutamine, echinacea, and
omega-3 fatty acids. A summary of their potential action and
effectiveness is provided in the following sections (97).

Vitamin C
Vitamin C (ascorbic acid) is involved in removing reactive oxygen
species (ROS) and is involved in immune function. There is limited
evidence that supplemental vitamin C may help to prevent upper
respiratory symptoms, and no supporting evidence that
supplementation with >200 mg/day vitamin C is useful in treating or
resolving upper respiratory symptoms.
Vitamin E
Vitamin E is involved in removing ROS and is involved in immune
function. There is no evidence that vitamin E supplementation aids
immune function, with some evidence that high doses may increase
oxidative damage and increase upper respiratory symptoms.

Zinc
This mineral is required as an enzyme cofactor for immune cells, with
a deficiency associated with impaired immunity. There is evidence
that zinc deficiency occurs in athletes. There are claims that zinc
supplementation may reduce the incidence of upper respiratory
symptoms, but only moderate research supports that it is useful for
treating upper respiratory symptoms. For a zinc supplement to be
useful, it should be consumed within 24 hours of the onset of upper
respiratory symptoms for the duration of the illness. Potential side
effects include hypogeusia (low taste sensation), dysgeusia (altered
taste sensation), and nausea.

Bovine Colostrum
This is the first milk produced by a cow following delivery of a calf
and includes antibodies, growth factors, and other chemicals
involved in immunity. There is limited support for use of bovine
colostrum, with some information suggesting that it is capable of
helping to sustain salivary antimicrobial proteins following heavy
exercise. (These salivary antimicrobial proteins typically decrease
following heavy exercise.) More research support is required to better
understand the usefulness of bovine colostrum supplementation.

Glutamine
This nonessential amino acid is used as a source of energy for
immune cells. Following prolonged exercise and heavy training,
glutamine availability is reduced. There is no evidence that
consumption of glutamine supplements before and after exercise
benefits immune function. There is limited evidence that there may
be a reduction in upper respiratory symptoms following endurance
events in athletes who supplement with glutamine.

Echinacea
This is a herbal extract that claims to enhance immune function, but
there is limited support for this claim. Recent studies suggest that
there is no effect of echinacea on infection incidence or severity.
Omega-3 Fatty Acids
Omega-3 fatty acids are found in cold water fish oils and flax seeds
and may influence immune function. Claims are also made that it has
anti-inflammatory effects following exercise. There is no evidence
that omega-3 fatty acids reduce upper respiratory symptoms in
athletes and limited support suggesting that it lowers inflammation
following muscle-damaging eccentric exercise. There is some
evidence that supplementation improves cognitive function in
healthy older adults, but it is unclear if this effect benefits younger,
healthy athletes with either health or athletic performance.

Energy Drinks
The popularity of energy drinks has grown dramatically since their
introduction over 30 years ago. It has been reported that a large
proportion of college students consume energy drinks for a variety of
reasons, including insufficient sleep, more energy, greater alertness
to study, driving for a long time, to mix with alcohol while partying,
and to treat a hangover (87). Collegiate athletes also commonly
consume energy drinks, which are high in caffeine, sugars, and other
substances including vitamins, herbal extracts, and amino acids,
because of the belief that they are performance enhancing (52).
Children and adolescents, a marketing target for energy drinks, are
also heavy consumers of this product (123, 136). Although popular,
serious concerns have been raised regarding the potential negative
effects of consuming energy drinks because they have an extremely
high concentration of caffeine, typically in the range of 30–134
mg/100 mL. (The maximum FDA recommended limit for caffeine is
20 mg/100 mL.) Some low-volume energy “shots” provided in small
containers have a concentration of caffeine that is up to 12 times the
FDA recommended limit (54). There are multiple concerns associated
with energy drinks, including (43, 47, 52–54):

Many energy drinks contain ingredients (B-vitamins,

glucuronolactone, ginseng extract, guarana, ephedra, yohimbe,
ginkgo, kola nut, theophylline, herbs, and/or L-carnitine) for
which the health consequences, when consumed alone or in
combination, are not well understood.
There is evidence for an ergogenic benefit for caffeine, but the
optimal functional dose demonstrating a performance
enhancement is typically in the range of 3–6 mg/kg. Most energy
drinks have caffeine concentrations that far exceed this range.
 There have been documented reports of adverse effects from
consumption of energy drinks while engaged in physical activity,
including palpitations, agitation, tremor, and GI upset. The acute
effects of energy drink consumption include the following:
Abnormal endothelial function, suggestive of an
inflammatory effect that could negatively impact
cardiovascular function.
Elevated norepinephrine levels, resulting in high BP and a
fast increase in blood sugar from rapid liver glycogen
breakdown. This dramatic lowering of liver glycogen may
make it difficult for an athlete to sustain normal blood sugar
during an event, with associated lowering of mental acuity
and reduced muscle function.
Sudden death has been documented in individuals who have
consumed energy drinks in conjunction with exercise.
Abnormal neurologic symptoms that include epileptic
seizures, reversible cerebral vasoconstriction, and
intracerebral hemorrhage.
GI effects that include diarrhea, nausea, and vomiting.
Acute renal failure and metabolic acidosis.
Higher obesity risk, which is likely the result of an acute
excess glucose uptake by tissues, resulting in higher tissue
fat manufacture.
Acute psychosis, including mind-racing, restlessness,
jitteriness, trouble sleeping, and greater likelihood of risk-
taking behavior.
Fatalities have been reported in individuals who combine
energy drinks with alcohol.

Because children are typically smaller than adults, children

consuming a standard container of an energy drink will receive a
higher relative dose of the contents, resulting in even greater
frequency of the adverse effects described above. As a result, the
American College of Sports Medicine’s position on energy drinks is
that they should not be consumed by children or adolescents for any
reason or purpose (52). In addition, it is important to note that the
American College of Sports Medicine also recommends that health
care providers, athletic trainers, sports medicine physicians, personal
trainers, should educate their patients or clients about energy drink
use and potential adverse events (52). The goal is to provide
sufficient science-based information about the potential adverse
effects of energy drinks that athletes and clients can make an
informed choice about whether to consume them.

Summary

There is an expanding, wide array of products that manufacturers

imply will result in athletic performance enhancement:

On balance, it appears that the most effective performance

enhancement that athletes can achieve will result from exposure
to a wide array of nutrients from a varied and well-balanced diet,
maintenance of good energy balance throughout the day and, in
particular, during the athletic endeavor, and sustaining a well-
hydrated state.
Certain supplements, such as vitamin D and/or carbohydrate,
help to fulfill what may be difficult for some athletes to obtain
because of the nature of the sport (e.g., indoors away from
sunlight), or a tradition that encourages low body weight through
restrictive eating.
There may well be a benefit for some supplements for certain
athletes, such as creatine monohydrate for power athletes. But
athletes should consider carefully if the money spent on creatine
would be better spent on good-quality foods that can help
maintain a satisfactory energy balance (Figure 13.4).
FIGURE 13.4: Common supplements with strong evidence of
performance effect (green); moderate evidence of performance
effect (amber); or lack of evidence of performance effect or
prohibited substance. (From Close GL, Hamilton DL, Philp A,
Burke LM, Morton JP. New strategies in sport nutrition to increase
exercise performance. Free Radic Biol Med. 2016;98:144–58.) *
ZMA refers to a supplement containing zinc, magnesium and
vitamin B-6.

Importantly, anyone purchasing a consumable item should

expect that the label contains an accurate list of the ingredients
and the amounts of each contained within each serving.
There is evidence, however, that this is not the case with all
supplement products, that a significant proportion of them
contain World Anti-Doping Agency banned substances not listed
on the label, and that protein powders were found to be
contaminated with lead at a level considered unhealthy (94, 96).
Other reports found excessive levels of heavy metals (arsenic,
lead, and mercury) in protein powders and drinks (96).
 Male body builders from Iran who were taking combinations of
dietary supplements were found to develop hepatitis as a result
of product contamination (138).
Athletes who decide to consume a ergogenic aid/supplement
should proceed cautiously. Although the risks may be small, the
risk exists.
Athletes should not rely on the person or company selling the
supplement to provide an unbiased view of what it may do. They
should have a conversation with an appropriately credentialed
health professional to determine if there are any negative
aspects to the supplement to be taken.
Athletes should take objective measures on whether the
consumed supplement is actually benefiting them in the
expected way, and whether there are any negative side effects
(i.e., GI discomfort) that may be attributed to the consumed
product.
Of the ergogenic aids reviewed in this chapter, the ones with the
greatest promise are food or sunshine based: vitamin D,
carbohydrate, food-based probiotics, and naturally occurring
nitrate (i.e., beet juice). Athletes should consider these first
before experimenting with other products.
The benefits achieved from consumption of a well-balanced diet
coupled with regular doses of sunlight may well eliminate the
desire to look elsewhere to improve performance.

Practical Application Activity

Using the procedure described in earlier chapters, create a

spreadsheet with calcium, iron, and folic acid (folate) consumed
from foods and beverages in a typical day by accessing the online
USDA Food Composition Database
(https://ndb.nal.usda.gov/ndb/search/list).

1. If your intake is low in any of these nutrients, modify your diet

to see what foods you would require to help ensure an
adequate intake of these nutrients.
2. Now take a typical multivitamin supplement that you find on
the internet that targets athletes and add the
nutrients/amounts listed on the label into the spreadsheet for
each of the three nutrients.
 3. Add the recommended intake into your daily intake and
analyze these nutrients again.
4. Find what the possible problems and benefits are with daily
consumption of this level of nutrient intake by looking up the
nutrients on the Office of Dietary Supplements of the NIH
website (https://ods.od.nih.gov/).

Chapter Questions

1. Athletes commonly take dietary supplements because they

believe the supplement
a. Will improve athletic performance
b. Will help to satisfy the nutritional needs associated with heavy
training
c. Will help them become successful like the athlete who is taking
the same supplement
d. All the above
e. A and B only
2. The term ergogenic aid refers to a substance that
a. Improves flexibility
b. Is performance enhancing
c. Helps to satisfy the need for energy during physical activity
d. Helps an athlete achieve a good night’s sleep
3. A nutritional ergogenic aid
a. Must be a known vitamin
b. Must be a substance naturally and normally consumed in foods
c. Must be a protein that improves energy metabolism
d. Must be a mineral that enhances blood volume and aids the
sweat rate
4. A significant proportion of ergogenic aids and vitamin supplements
that target athletes in advertisements contain banned substances
that are not listed on the label.
a. True
b. False
5. The placebo effect refers to
a. The benefit derived from a consumed substance that
unexpectedly resulted in a cellular improvement in energy
metabolism.
 b. The performance benefit derived from a consumed substance
that had no biologic benefit, but resulted in an improvement
because the athlete believed it would help.
c. The improvement in exercise performance resulting from regular
consumption of an ergogenic aid rather than periodic/irregular
consumption.
d. The synergistic performance benefit derived from the intake of
two different substances when the intake of either substance by
itself results in no benefit.
6. The performance benefit derived from an increase in protein
consumption may be the result of an improved energy balance
resulting from the protein rather than any other protein-specific
anabolic function.
a. True
b. False
7. Of the following, which is not a known primary effect of caffeine in
athletes?
a. It stimulates the central nervous system
b. It increases muscle mass
c. It lowers perceived effort during exercise
d. It lowers the feeling of pain and fatigue associated with exercise
8. The maximal performance benefit from caffeine is reached at an
intake level of
a. 3 mg/kg
b. 3 g/kg
c. 6 mg/kg
d. 15 mg/kg
9. Regular consumption of carbohydrate at a level of _________ is
useful for optimizing muscle glycogen storage in preparation for a
sporting event.
a. 7–12 g/kg/day
b. 3–4 g/kg/day
c. 15–20 mg/kg/day
d. 15–20 g/kg/day
10. Beetroot juice has been shown to improve _________ availability.
a. NOS
b. Nitric oxide
c. L-Arginine
d. Red blood cell concentration

Answers to Chapter Questions

1. d
2. b
3. b
4. a
5. b
6. a
7. b
8. c
9. a
10. b

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CHAPTER OBJECTIVES
Recognize the relationships between nutrition, physical
activity, and disease risks.
List the general ways that physical activity influences
nutritional requirements.
Demonstrate an understanding for the reasons why physical
activity and nutrient/energy consumption should be
dynamically linked.
Identify the exercise recommendations of the Centers for
Disease Control and Prevention (CDC), World Health
Organization (WHO), and American College of Sports
Medicine (ACSM) for children and adults.
Recognize the specific disease-reducing impact of good
nutrition and regular physical activity.
Appraise the impact of inactivity and poor nutrition on risk
for common chronic health disorders, including heart
disease, diabetes, cancer, and poor bone health.
Identify major points of current dietary guidelines for
Americans.
Discuss consequences of low-calorie weight loss diets
specific to the prevalence of obesity and associated health
problems.
Explain the basis for different types of dietary fat and
respective risk for heart disease.
Differentiate behaviors of disordered eating frequently
observed in athletes.
 Case Study

John was an amazing football player in high school and in

college. People would watch him play and would comment
about how he could suddenly change direction and go just as
fast sideways and backward as he could go forward. This
quickness made him an ideal defensive back, being able to
suddenly move to the ball carrier for a clean tackle.
Everyone who knew anything about football noticed, and
even those who were just casual onlookers would comment,
“Who is that guy?” His college team made the playoffs, in no
small part because of his amazing capacity to shut down
running plays. He was so observant and intuitive that he
even managed a few quarterback sacks during his final
season. The professional ranks were looking at him as a
great rookie prospect. He was not just an athlete; he was a
scholar-athlete with superb grades. Some people thought it
came easy to him, but they did not know the hours he spent
studying and the time he spent in the weight room making
sure he was always in top academic and physical condition.
After his last collegiate football season successfully
ended, he was recruited to join his favorite professional team
with an amazing offer, which he accepted. He was now a
professional player, working to make the playing squad of a
historically successful team. One of his first interactions with
the defensive coach was interesting. The coach was
concerned that John was 10 lb lighter than anyone else in the
same position, and told him that to be successful he needed
to put on some “weight” and that 10 lb would make all the
difference in his survivability as a defensive back. John
thought that was curious, because his weight had not
changed in 4 years, a stable 180 lb. He was recruited and
offered a contract at his current weight, but now they
wanted him to be 190 lb. OK, he thought, the defensive
coach must know best, so he looked at some strategies for
how he could increase his weight.
 Easy — he would eat more than usual (mainly protein) at
breakfast and dinner to put on some muscle weight and
spend a bit more time in the gym to work out. He was
getting bigger, but it was mainly in his belly and not his
muscles. For the first time in his life he started hearing
coaches yell at him, “Can’t you move faster?” One of his
fellow players suggested that he take some vitamin E, as it
was suggested that vitamin E would help to reduce the
muscle soreness he was feeling, and that within 1 week he
would likely feel great. It did not work and he continued
getting sore and prematurely fatigued. This was not the way
he wanted to start his professional career. There was only
one thing to do — ask to speak with the defensive coach.
John started the discussion by saying that he would prefer to
stay at his accustomed weight and, if that did not work
during the season, then he would be happy to work to add
weight. The defensive coach was speechless, but managed
an “OK.” He was sure that his 180-lb player would perform
poorly over the course of the season, but felt that maybe
that would be an important lesson for John to learn. John
made the starting lineup, and then started piling up enough
positive stats that there was talk that he might be rookie of
the year. Weight change was no longer discussed.

CASE STUDY DISCUSSION QUESTIONS

1. What are the potential difficulties associated with

increasing muscle weight in an already fit athlete?
2. Is there any evidence that supplemental vitamin E intake
is useful for reducing muscle soreness?
3. Is greater consumption of protein the only nutritional
consideration when trying to increase muscle mass?

The traditions in many sports sometimes interfere with

athletes achieving both good health and good performance.
Some traditions may be more obviously bad than others. For
instance, telling a small female gymnast that she has to lose
even more weight before a major competition is obviously
bad, but being small in gymnastics has been a long-time
 tradition in the sport. The common tradition of many athletes
exercising prior to the consumption of breakfast may also
diminish the benefit derived from the exercise as a result of
low energy availability and/or exercising in a low blood sugar
state. Think about some of these traditions in the different
sports listed below, and see if you can identify some that
may interfere with good nutrition practices and have a
negative impact on performance. Where both genders
participate in the sport, indicate if you think there is a
nutrition tradition that is different in male and female sports,
and whether these nutritional differences have an impact on
performance.

Volleyball (men and women)

American football (men only)
Basketball (men and women)
Soccer (men and women)
Long-distance running (men and women)
Sprinting (men and women)
Weight lifting (men and women)
Bodybuilding (men and women)
Rhythmic gymnastics (women only)
Artistic gymnastics (men and women)

Introduction

Physical activity, when performed correctly and with appropriate

nutritional support, has many potential health benefits, including
(150):

Increased longevity
Improved muscle strength
Lower risk of cardiovascular disease
Lower risk of type II diabetes
Stronger bones
Lower risk of certain cancers
 Improved immune system
Improved mental health
Healthier weight

For anyone involved in physical activity, this requires that the

increased energy and nutrient needs associated with exercise
are satisfied. Although a seemingly simple task, ensuring that
cellular needs are met may be more complex than it originally
appears. Energy requirements must be satisfied in “real time”
rather than randomly, and the intake of the energy substrates,
carbohydrate, protein, and fat, should be considered as well. An
athlete who requires between 1.2 and 2.0 g/kg of protein should
consider how to best satisfy this need by planning how to
consume both the total requirement and the optimal distribution
of protein during the day. Consumption of carbohydrate, protein,
and fluids available immediately postexercise is a well-
established strategy for optimizing muscle protein synthesis
(MPS) and improving muscle recovery, but this requires
planning and ensuring that the appropriate foods and beverages
are available when the athlete needs them the most.

Mineral requirements: Physical activity is associated with

greater loss of some minerals via sweat and urine, and
intense physical activity may interfere with the retention of
some minerals. Established strategies for athletes work
nicely in helping to ensure mineral adequacy. For instance,
consumption of electrolyte-containing sports beverages
during physical activity helps to offset the loss of minerals in
sweat. Both male and female athletes are known to be at
higher risk of iron deficiency and iron deficiency anemia,
suggesting a greater need for iron. Ideally, anyone involved
in regular physical activity should have iron status assessed
at regular yearly intervals to determine if the foods
consumed are satisfying iron needs.
Fluid requirements: Because more energy is being
metabolized as a result of the physical activity, more
metabolic heat is being created that must be dissipated. The
primary mechanism for this heat dissipation is the
production of sweat, which can volumetrically exceed a
 human’s capacity to easily replace it. As a result, athletes
should make their state of hydration a high priority by
initiating exercise in a well-hydrated state, learning to drink
frequently and early (before the sensation of thirst occurs),
and drinking enough fluids after exercise to offset the weight
loss (i.e., body water loss) resulting from the exercise.
Dehydration, underhydration, and euhydration describe
different states of hydration.

Energy Substrate

A nutrient that can be metabolized to provide cellular energy.

In human nutrition, the energy substrates are carbohydrate (4
calories/g), protein (4 calories/g), and fat (9 calories/g). Alcohol
is also capable of providing energy (7 calories/g), but because
it also interferes with B-vitamin metabolism and, thus,
interferes with normal energy metabolism, it is not usually
considered an energy substrate.

Muscle Protein Synthesis

This represents the desired adaptive response to exercise,

which is the desire to synthesize muscle in a way that allows
adaptation to the exercise being performed, with the ultimate
aim of improving exercise performance. Providing nutrients in
the right amounts, of the right kind, and at the right times
enables enhanced MPS.

There is a clear interaction between physical activity and

nutrition, and physically active people who understand these
basic principles will help to ensure that the activity they do will
contribute to rather than detract from a state of good health.
Physical activity affects:

Energy requirement: Physical activity increases energy

expenditure, which must be satisfied through consumption of
more foods, or the resulting energy balance deficit may
 result in loss of muscle, loss of bone density, and a relative
increase in fat mass. The downregulation of lean mass (a
logical survival adaptation to adjust to the insufficient
provision of energy) and upregulation of fat mass may cause
athletes in weight or appearance sports (i.e., wrestling,
gymnastics, figure skating) to further reduce energy intake,
leading to eating disorders and multiple health risks (36, 93,
104).
Energy substrate requirements: Physical activity increases
the utilization of carbohydrate and places greater demands
on protein to sustain, repair, and increase musculature.
Consumption of carbohydrate and protein foods in the right
amounts and at the right times helps to satisfy these needs.
Vitamin requirements: Physical activity alters the
requirement for certain vitamins, particularly for B-vitamins,
which are involved in energy metabolism. The foods
containing the energy substrates typically also contain these
B-vitamins, provided the foods consumed are of reasonably
good quality. For instance, the simple carbohydrate sucrose
(table sugar) provides a source of energy but is devoid of
any B-vitamins that are needed for its metabolism. On the
other hand, starchy carbohydrates derived from rice,
potatoes, breads, and so forth contain the vitamins needed
for the energy they provide.

Dehydration

Represents a condition of inadequate body water, commonly

caused by insufficient fluid consumption that fails to match
fluid and electrolyte loss through sweat and urine, or
conditions that result in high body water and electrolyte loss,
including diarrhea and vomiting.

Underhydration

Often used synonymously with dehydration, referring to a state

of inadequate body water.
 Euhydration

Refers to a state of normal body water content, with normal

body water in both the intercellular and extracellular spaces.

Supplementation of vitamins and minerals is not needed for

athletes consuming sufficient energy from a variety of foods
(143). However, it is common for athletes to treat the
recommended nutrient intakes as minimum requirements,
despite the fact that there is an ever-increasing body of evidence
suggesting that excessive consumption of nutrients through
high-dose supplements may create more problems than it
resolves (97). Evidence of vitamin toxicity, even for water-
soluble vitamins that were once thought to be benign at any
level of intake (after all, you just “urinate away the excess”), is
now well documented. As an example, too much vitamin B6 may
result in the same peripheral neuropathy, with loss of sensation
in the fingers and toes, that is associated with vitamin B6
deficiency; and too much vitamin C (>2,000 mg/day) may result
in diarrhea or, worse, may increase the risk of kidney stones (66,
140, 144, 159). (Note: The adult recommended dietary
allowance [RDA] for vitamin B6 is 1.3 mg/day with the tolerable
upper intake level set at 100 mg/day, and supplements
commonly provide 100 mg or more. Combined with the vitamin
B6 consumed from foods, the tolerable upper intake level for
vitamin B6 is likely to be exceeded in those consuming
supplements. The adult RDA for vitamin C is between 75 and 90
mg/day, and supplements commonly provide 1,000 mg or more.
Combined with the vitamin C consumed from foods, it is possible
for the tolerable upper intake level of 2,000 mg to be exceeded
in those consuming supplements.) Excess iron intake may result
in higher cancer risk, as much of the iron consumed goes
unabsorbed and irritates the intestines to increase colon cancer
risk (101, 160). In addition, the competitive absorption of iron
and zinc may result in reduced zinc absorption with increased
risk of zinc deficiency in people who chronically consume iron
supplements (126). Put simply, the nutrition paradigm that
“more than enough is not better than enough” is important to
remember, but it is also important to consider that the daily
requirement for a nutrient is not meant to be consumed at a
single time with a single dose, but should be consumed through
multiple meals throughout the day. As an example, studies on
the water-soluble vitamin folic acid have found that consuming a
high level in a single dose through supplementation rather than
distributing the daily requirement throughout the day may
accelerate the progression of preneoplastic lesions, increasing
colorectal, prostate, and other cancer risks (Figure 14.1) (44, 72,
78, 86, 149). Perhaps more than for any other reason, this is
precisely why meals and snacks with good-quality foods and
beverages should be considered a better strategy for exposing
tissues to needed nutrients than supplements (87).

FIGURE 14.1: It is not logical to try to provide all the nutrients

that tissues require at one time.

Vitamin Toxicity
 Refers to a level of vitamin intake that exceeds cellular
capacity and may lead to toxicity symptoms, which vary by
vitamin. The dietary reference intakes provide a tolerable
upper intake level, which is the upper limit for human
consumption to avoid risk of vitamin toxicity.

Although increasing physical activity may add a greater

challenge for how to best satisfy nutritional requirements, every
major health organization has concluded that staying active
through regular involvement in physical activity or sport is a
critically important component of lifelong health. It is also
important to start exercising early. The WHO, the CDC, and the
Exercise is Medicine, a global health initiative of the ACSM, all
recommend exercise strategies for children, adolescents, and
adults to enhance cardiorespiratory and muscular fitness, bone
health, and cardiovascular and metabolic health biomarkers.
These recommendations include the following (5, 152, 165, 166):

Children and youth should accumulate at least 60 minutes of

moderate- to vigorous-intensity physical activity daily.
Amounts of physical activity greater than 60 minutes provide
additional health benefits.
Most of the daily physical activity should be aerobic.
Vigorous-intensity activities should be incorporated,
including those that strengthen muscle and bone, at least
three times per week.

Regarding the vigorous-intensity activities, bone-loading

activities can be performed as part of playing games, running,
turning, or jumping. It is generally recommended that 60
minutes of exercise be accumulated (does not need to be
continuous) per day (e.g., two exercise bouts of 30 minutes each
per day). It is also encouraged that those with disabilities should
work with health care providers to find strategies that will also
encourage daily physical activity. For those who are not currently
active, the recommendation is gradually to increase activity to
achieve the goal of 60 minutes per day. The benefits of doing so
are clear:
 develop healthy musculoskeletal tissues (i.e., bones,
muscles, and joints);
develop a healthy cardiovascular system (i.e., heart and
lungs);
develop neuromuscular awareness (i.e., coordination and
movement control) to help avoid a neuromuscular
disorder;
maintain a healthy body weight;
reduce psychological symptoms of anxiety and depression;
and
reduce unhealthy behaviors, such as smoking and drug and
alcohol abuse, and improve academic performance.

Musculoskeletal

Refers to skeletal muscles, the skeleton, and related tendons,

ligaments, joints, and connective tissues that enable body
movement.

Neuromuscular Disorder

Refers to disorders affecting nerve control of muscles under a

person’s direct control (i.e., arms and legs). Often of genetic
origin, neuromuscular disorders may also be the result of poor
nutritional status affecting the immune system.

Important Factors to Consider

The importance of physical activity in reducing chronic

disease is clear. Worldwide, it is estimated that attributable
contribution to chronic disease as a result of physical
inactivity is an increase in:
the global burden of disease from coronary heart
disease;
type II diabetes; and
breast and colon cancer cases.
 Inactivity is the 4th leading cause of premature mortality
worldwide, or about 3.3 million deaths per year. On the
other hand, regular physical activity:
reduces the risk of developing Alzheimer disease;
lowers the risk of all-cause, cardiovascular, and cancer-
specific mortality in adults with higher levels of muscle
strength; and
leads to higher academic performance in children and
adults.
Despite these health concerns of being physically inactive:
More than half of adults in the United States (56%) do
not meet the recommendations for sufficient physical
activity set forth by the 2008 Physical Activity
Guidelines for Americans.
U.S. adolescents and adults spend almost 8 hours a
day in sedentary behaviors, and as much as 36% of
adults engage in no leisure-time physical activity at all.
Source: American College of Sports Medicine. Exercise is Medicine: Fact Sheet.
Available from:
https://www.exerciseismedicine.org/assets/page_documents/EIM%20Fact%20Sheet
%202014_update%20March%202018.pdf. Accessed July 25, 2018.

Dietary Guidelines for Americans, 2015–2020

Exercise alone cannot resolve chronic disease prevalence, as

there is also a strong nutritional and genetic relationship to
disease risk. Ideally, physical activity and nutrition should be
considered as integrated and dynamically related factors that
should be considered together. Although the prevalence of
infectious diseases has dropped, that of noncommunicable
diseases related to lifestyle, including exercise and nutrition, has
increased sharply (Box 14.1).

Box 14.1 Facts About Nutrition and Physical Activity–

Related Health Conditions in the United States
Overweight and Obesity

For more than 25 years, more than half of the adult

population has been overweight or obese.
Obesity is most prevalent in those aged 40 years and older
and in African-American adults and is least prevalent in
adults with highest incomes.
Since the early 2000s, abdominal obesity has been present
in about half of U.S. adults of all ages. Prevalence is higher
with increasing age and varies by sex and race/ethnicity.
In 2009–2012, 65% of adult females and 73% of adult
males were overweight or obese.
In 2009–2012, nearly one in three youth aged 2–19 years
were overweight or obese.

Cardiovascular Disease and Risk Factors

Coronary heart disease

Stroke
Hypertension
High total blood cholesterol
In 2010, cardiovascular disease affected about 84 million
men and women aged 20 years and older (35% of the
population).
In 2007–2010, about 50% of adults who were of normal
weight and nearly three-fourths of those who were
overweight or obese had at least one cardiometabolic risk
factor (i.e., high blood pressure [BP], abnormal blood lipids,
smoking, or diabetes).
Rates of hypertension, abnormal blood lipid profiles, and
diabetes are higher in adults with abdominal obesity.
In 2009–2012, almost 56% of adults aged 18 years and
older had either prehypertension (27%) or hypertension
(29%).
In 2009–2012, rates of hypertension among adults were
highest in African-Americans (41%) and in adults aged 65
years and older (69%).
In 2009–2012, 10% of children aged 8–17 years had either
borderline hypertension (8%) or hypertension (2%).
 In 2009–2012, 100 million adults aged 20 years or older
(53%) had total cholesterol levels >200 mg/dL; almost 31
million had levels >240 mg/dL.
In 2011–2012, 8% of children aged 8–17 years had total
cholesterol levels >200 mg/dL.

Diabetes

In 2012, the prevalence of diabetes (type I plus type II) was

14% for men and 11% for women aged 20 years and older
(more than 90% of total diabetes in adults is type II).
Among children with type II diabetes, about 80% were
obese.

Cancer

Breast cancer
Breast cancer is the third leading cause of cancer
death in the United States.
In 2012, an estimated 3 million women had a history of
breast cancer.
Colorectal cancer
Colorectal cancer is the second leading cause of
cancer death in the United States.
In 2012, an estimated 1.2 million adult men and
women had a history of colorectal cancer.

Bone Health

A higher percent of women are affected by osteoporosis

(15%) and low bone mass (51%) than men (about 4% and
35%, respectively).
In 2005–2010, ~10 million (10%) adults aged 50 years and
older had osteoporosis and 43 million (44%) had low bone
mass.
Source: United States Department of Health and Human Services and United States
Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed.
December 2015. Available from:
http://health.gov/dietaryguidelines/2015/guidelines/. Accessed May 21, 2018.
 The dietary guidelines for Americans (153) make the following
five basic recommendations:

Follow a healthy eating pattern across the lifespan. All food

and beverage choices matter. Choose a healthy eating
pattern at an appropriate calorie level to help achieve and
maintain a healthy body weight, support nutrient adequacy,
and reduce the risk of chronic disease.
Focus on variety, nutrient density, and amount. To meet
nutrient needs within calorie limits, choose a variety of
nutrient-dense foods across and within all food groups in
recommended amounts.
Limit calories from added sugars and saturated fats and
reduce sodium intake. Consume an eating pattern low in
added sugars, saturated fats, and sodium. Cut back on foods
and beverages higher in these components to amounts that
are within healthy eating patterns.
Shift to healthier food and beverage choices. Choose
nutrient-dense foods and beverages across and within all
food groups in place of less healthy choices. Consider
cultural and personal preferences to make these shifts easier
to accomplish and maintain.
Support healthy eating patterns for all. Everyone has a role
in helping to create and support healthy eating patterns in
multiple settings nationwide, from home to school to work to
communities.

What follows are common disorders that have both a strong

physical activity and a nutritional component, and nutritional and
physical activity strategies that have been found to reduce the
risk of developing the disorder.

Obesity and Related Conditions

Obesity affects 78 million adults and 12.5 million children, with

the prediction that, if obesity rates continue at their current
pace, 44% of all Americans will be obese by the year 2030. In
2013, there were 112,000 obesity-related deaths in the United
States, and obese children were twice as likely as their nonobese
peers to die before reaching the age of 55. Chronic disease risks
associated with obesity include increased risk of heart disease,
respiratory disease, liver disease, hypertension, osteoarthritis,
cancer, and type II diabetes (48). Reducing obesity has a risk
reduction effect for all of these conditions (Figure 14.2, Table
14.1).

FIGURE 14.2: Obesity and related chronic disorders.

Table 14.1 Conditions Closely and Commonly Linked

to Obesity
Condition Links to Obesity
Table 14.1 Conditions Closely and Commonly Linked
to Obesity
Condition Links to Obesity
Heart disease Also referred to as cardiovascular disease, this
disease is associated with elevated blood lipids
(including cholesterol), high blood pressure (BP),
obesity, smoking, diabetes, and insufficient
physical activity (90). There is also evidence that
regular consumption of nuts lowers heart attack
risk (90). It has been estimated that most heart
disease can be prevented through obesity
reduction, cessation of smoking, and moderating
alcohol consumption (165, 166).
Type II Type II diabetes is the most common form of
diabetes diabetes, resulting from high blood sugar
(hyperglycemia), insulin resistance, and
eventually insufficient functional insulin.
Complications include heart disease, strokes,
and poor blood flow to the extremities and eyes.
Type II diabetes is commonly associated with
obesity and insufficient physical activity. The
prevalence of type II diabetes has increased in
parallel with the prevalence of obesity.
Consumption of refined carbohydrates results in
hyperglycemia, exacerbating the diabetes, and
diets with more protein/less refined
carbohydrate appear to ameliorate the
symptoms (12, 84, 106).
Table 14.1 Conditions Closely and Commonly Linked
to Obesity
Condition Links to Obesity
Metabolic Metabolic syndrome has four major
syndrome components, including visceral obesity (i.e.,
large levels of stored fat in the trunk),
dyslipidemia (i.e., high blood lipids with low
high-density lipoprotein cholesterol and elevated
very low-density lipoprotein cholesterol and
triglycerides), hyperglycemia (i.e., high blood
glucose), and hypertension (i.e., high BP), and a
proinflammatory state. There is increased risk of
type II diabetes with metabolic syndrome, and
all of these components are associated with
obesity and insufficient physical activity (1, 57).
Liver disease Obesity is associated with elevated risk of
developing nonalcoholic fatty liver disease
(NAFLD), with up to 85% of obese individuals
having NAFLD (38, 52). Overfeeding in
laboratory animals has been linked to
development of NAFLD, whereas energy intakes
that sustain energy balance, which results in
lower obesity, appear to be an effective strategy
for lowering NAFLD risk (35).
Hypertension Obesity and hypertension are closely linked and
are associated with heart muscle enlargement
(left ventricular) and kidney damage, which are
associated with high cardiac output, high plasma
volume, and peripheral tissue resistance.
Sodium (salt) retention is a common feature of
the obese-hypertensive (74). Recent evidence
suggests that elevated leptin production seen in
obesity may also contribute to hypertension
(129).
Table 14.1 Conditions Closely and Commonly Linked
to Obesity
Condition Links to Obesity
Cancer It has been estimated that obesity-related
cancer risk is high, with 20% of cancers
attributable directly to obesity. Obesity-related
cancer risk is particularly high of endometrial,
esophageal, colorectal, breast, prostate, and
renal cancers. These cancers are associated with
excess production of insulin, insulin-like growth
factor I, sex hormones (primarily testosterone,
estrogen, and progesterone), and adipokines
(the cell signaling proteins produced by fat cells)
(32).
Osteoarthritis Osteoarthritis is a joint disease that is associated
with the deterioration of joints, with symptoms
associated with pain and stiffness. It has been
found that obesity and osteoarthritis are clearly
linked, affecting both weight- and nonweight-
bearing joints (155). It has been found that
lowering weight/obesity by 10%, particularly
when coupled with a regular exercise program,
can result in significant improvement in pain
relief and physical function (19).

Metabolic Syndrome

Refers to a cluster of metabolic disorders that increase risk of

cardiovascular disease. An individual with a combination of two
or three of the following conditions is thought to have
metabolic syndrome: high abdominal obesity, high triglyceride
level, low high-density lipoprotein cholesterol, high BP, and
high fasting blood glucose. Lowering fat mass through
appropriate dietary strategies and exercise is the standard
strategy for lowering metabolic syndrome risk.
Factors That Contribute to Obesity
Obesity is the result of several factors, including (151, 154):

Excess energy consumption relative to energy expenditure.

Excess energy is stored as fat, resulting in obesity.
Inactivity. The human system has a “use it or lose it”
protocol related to survival, particularly for tissue that is
energy expensive. Inactivity lowers the need for muscle, so
the body lowers this energy-expensive tissue. As a result,
there is less tissue with which to metabolize consumed
energy, resulting in greater fat storage.
Environment. Many environments make it difficult to sustain
activity as a normal part of daily living, thereby lowering
activity and the opportunity to metabolize energy. The
environment we live in often overemphasizes unhealthy
foods with low nutrient densities, such as high sweetened
beverages and desserts, and underemphasizes healthy foods
with high nutrient densities, such as fresh fruits and
vegetables.
Genetic background. Obesity may be familial, with a greater
chance of becoming obese if one or both parents are obese.
To a certain extent, having an obese parent may also
increase obesity risk because the food environment created
by the obese parent is adapted by the children in the
household.
Preexisting disease state. Certain diseases are associated
with obesity, including hypothyroidism, Cushing’s syndrome,
and polycystic ovarian syndrome. Resolving the disease
state may help to resolve the associated obesity.
Medications. Some medications that are taken to control or
resolve a health condition may predispose an individual to
obesity. For instance, corticosteroids that are often taken for
allergies may lower lean mass and, therefore, lower the
tissues that metabolize energy. The difference in a person’s
capacity to metabolize energy is small, but over time may
predispose the person to obesity.
Smoking. The addictive substance in cigarette smoke,
nicotine, elevates the rate of energy expenditure. Stopping
 smoking without finding a means of increasing energy
expenditure (i.e., physical activity) may predispose the
person to obesity. However, the mortality risk from obesity is
far lower than the mortality risk from smoking, suggesting
that smokers should most definitely stop smoking and also
find a way to become regularly physically active.
Age. Aging is associated with a loss of lean mass and an
increase in fat mass, greatly increasing obesity risk.
Menopause in women is also associated with an increase in
fat mass. These age-related changes in body composition,
referred to as sarcopenia, are best addressed through
regular physical activity that is matched with a diet that
sustains energy balance. There are also data to show that
evenly distributing relatively small amounts of protein intake
during meals throughout the day may improve the older
person’s ability to sustain muscle mass.
Pregnancy. Weight gain is a necessary part of a normal
pregnancy, as the extra tissue helps to satisfy the energy
needs of the growing fetus and, after delivery, the energy
needs associated with lactation. However, many women find
it difficult to return to the prepregnancy weight after
pregnancy. This is likely due to multiple reasons, not the
least of which is increased difficulty to find time to be
physically active because of the increased responsibilities
associated with child rearing.
Poor sleep. Insufficient sleep is associated with higher
obesity risk across all age groups. This may be due to better
maintenance of the hormones leptin (lowers hunger) and
ghrelin (increases hunger), but may also be associated with
altered food preferences. Insufficient sleep is associated with
greater consumption of high-calorie, high-sweet foods that
are associated with obesity.

Of the factors related to activity, the ones over which most

people have direct control over, energy balance and activity,
may appear relatively simple. However, there are complexities
that must be considered when addressing these issues to
prevent or resolve an obese state.
Weight and Body Mass Index
Weight and body mass index (BMI) are often used as measures
of whether an individual is obese or whether the obesity is
getting better or worse. Obesity is defined as having excess
body fat, not excess weight (61). BMI is an appropriate
population indicator of obesity prevalence, but as it does not
differentiate between fat mass and lean mass, it is not a good
individual indicator of obesity. Weight, therefore, is a poor
measure because it fails to consider what component of weight
(muscle mass? fat mass?) is changing. Low-calorie weight loss
diets may cause a lowering of weight, but studies now show that
these diets often result in a greater loss of lean mass than fat
mass. The resultant greater proportion of fat mass (i.e., higher
body fat percent) is suggestive of greater obesity, despite a
lowering of weight.

Higher Lean Mass and Lower Fat Mass

Athletes typically have a greater proportion of lean mass and a
lower proportion of fat mass than nonathletes, and this greater
presence of lean mass often makes them appear to be obese on
a BMI index (i.e., BMI > 30), when they are not (95). Because BMI
has a low sensitivity to detect excess body fat, it fails to identify
over a quarter of children and adolescents as obese who have
normal BMI but excess body fat (68).

Energy Balance
The concept of energy-in, energy-out (i.e., energy balance) is
often assessed in 24-hour units, but data suggest that such an
assessment fails to address the expected endocrine response to
real-time deviations in energy balance that could affect obesity
(14, 15, 93). For instance, an athlete who has no energy intake
prior to the morning workout will achieve a severe negative
energy balance and low blood sugar (i.e., the body used
significantly more energy than was provided), resulting in
elevated cortisol production that breaks down both muscle and
bone tissue (i.e., lean mass goes down), and a hyperinsulinemic
response at the next eating opportunity that results in greater
fat acquisition, even if the total calories consumed later in the
day suggest that the daily energy balance appears to satisfy
energy needs (15, 34, 39). It is likely for this reason that low-
calorie fad diets have a poor record of lowering obesity and also
increasing health risks (36).

Infrequent Meals
Studies have found that decreasing meal frequency may create
problems in controlling obesity, likely because such a strategy is
likely to result in larger energy balance deviations than more
frequent eating patterns. It has been found, for instance, that
people with infrequent eating patterns are likely to have greater
total energy intakes than those with more frequent eating
patterns, likely because of an upregulation of the appetite-
stimulating hormone ghrelin (130). Insulin release following a
meal typically suppresses ghrelin, but if a long period of time
between meals leads to low blood sugar, there is a
hyperinsulinemic response at the next eating opportunity and
ghrelin is not suppressed, resulting in sustained high appetite (7,
131).

Physical Activity and Controlled Energy Consumption

Programs that increase physical activity but fail to
simultaneously address the additional energy/nutrient
requirements associated with this physical activity with
strategies that ensure good relative energy availability may not
be as beneficial as they could be in lowering obesity risk. There
is evidence that the combination of an exercise program coupled
with controlled energy consumption to sustain energy balance
rather than place the subject on a severe calorie restriction is a
more successful strategy for losing body fat and reducing obesity
than either diet alone or exercise alone (92, 121).

Basic Strategies for Reducing Obesity

Limit Foods High in Saturated Fats and Trans-Fats

A basic strategy for reducing obesity is to limit the chronic
consumption of foods that are high in saturated and trans-fats,
including processed meats, fatty cuts of red meats, and fried
foods, and that result in higher per-meal energy intakes.
Although the reduction of the total consumption of fat has been
seen as a desirable strategy for lowering obesity risk, the
evidence suggests that the type and the amount of fat
consumed per meal may be more important predictors of obesity
(123, 163). To some extent, this is because lower fat intake is
often associated with higher intake of refined carbohydrates,
such as white bread and white rice, which tend to produce
hyperinsulinemia and higher fat storage. An assessment of a
large cohort of women found that greater consumption of
unhealthy fats (i.e., saturated and trans-fats) was associated
with greater obesity risk, but that consumption of more healthy
fats (i.e., mono- and polyunsaturated fats) was not (43). The
type of meat consumed also has a direct impact on cancer risk
separate from obesity. Regular consumption of red meats and
processed meats (e.g., bacon, sausage) is associated with higher
risk of diabetes, heart disease, and colon cancer (10, 18, 106).

Limit High-Sugar Beverages

Limit the consumption of drinks that are high in sugar, including
sodas and fruit juices. Sugary beverages are clearly associated
with greater obesity risk, as they tend to result in both
hyperinsulinemia and greater fat manufacture, and also greater
total energy consumption (63, 122, 142, 156). It has also been
found that there is a significant association between artificially
sweetened soda consumption and obesity (122). When possible,
consumption of fresh whole fruit is a better option than juices
made from fruit (94). However, sports beverages when
consumed correctly (i.e., small amounts consumed at regular
intervals during physical activity), and which typically contain
sugar as the primary source of energy, are appropriate and
unlikely to contribute to obesity risk when consumed in this
fashion. Appropriate use of sugar-containing sports beverages
may help the athlete achieve better within-day energy balance,
which would lower obesity risk (34, 39, 93, 147).

Increase Daily Physical Activity

Increase regular, daily physical activity. According to the CDC,
people should accrue a minimum of 150 minutes of weekly
physical activity (150). The CDC notes that more time spent in
physical activity (even beyond 300 minutes/week) results in
greater health benefits. The CDC recommends one of the
following three guidelines for physical activity:

2 hours and 30 minutes (150 minutes) of moderate-intensity

aerobic activity (i.e., brisk walking) every week; and muscle-
strengthening activities on 2 or more days per week that
work all major muscle groups (legs, hips, back, abdomen,
chest, shoulders, and arms). A total of 1 hour and 15 minutes
(75 minutes) of vigorous-intensity aerobic activity (i.e.,
jogging or running) every week; and muscle-strengthening
activities on 2 or more days a week that work all major
muscle groups (legs, hips, back, abdomen, chest, shoulders,
and arms).
An equivalent mix of moderate- and vigorous-intensity
aerobic activity; and muscle-strengthening activities on 2 or
more days a week that work all major muscle groups (legs,
hips, back, abdomen, chest, shoulders, and arms).

Improve Sleep Duration and Quality

Insufficient sleep is associated with greater inflammation and
higher risk of obesity and cardiovascular disease (91). It has
been found that improving sleep duration and/or sleep quality
significantly improves body composition (i.e., lowers body fat)
and also positively affects other energy balance–associated
factors (22). An analysis of the first National Health and Nutrition
Examination Survey found that individuals who averaged less
than 7 hours of sleep per night were more likely to be obese that
those who averaged at least 7 hours of sleep. Insufficient sleep
was associated with sweet cravings and additional energy
intakes, but with no compensatory increase in energy
expenditure (50). Short sleep duration appears to particularly
affect younger age groups, which appear to be even more likely
to experience weight gain with sleep deprivation than older
groups (Figure 14.3) (107).
FIGURE 14.3: Proposed mechanisms causing predisposition to
obesity with sleep deprivation. (From Patel SR, Hu FB. Short
sleep duration and weight gain: a systematic review. Obesity.
2008;16:643–53.)

Participate in Activities That Lower Stress

Stress influences eating behavior, resulting in over- or
undereating, and also increases the preference for energy-dense
foods that are high in sugar and fat (146). Studies have found
that mindfulness-based stress reduction strategies, including
nonreligious meditation, significantly reduce stress and,
therefore, provide a coping strategy for lowering obesity risk
(56).

Regularly Assess Body Fat Level/Weight

Find a way to regularly assess body fat level in conjunction with
weight, to determine if weight loss is the result of primarily fat
mass or lean mass. (See Chapter 8 for information on
assessment of body composition.) It is important for people to
understand that lowering fat mass while retaining lean mass is
not something that can occur quickly and involves creating an
eating pattern that dynamically matches energy expenditure to
sustain a reasonable energy balance throughout the day (32, 93,
143).

Improve Meal Frequency and Eating Patterns

Avoid meal skipping and eat in a pattern that dynamically
matches energy expenditure to sustain a reasonable energy
balance throughout the day. Skipping breakfast, for instance, is
associated with greater obesity risk. Subjects who skipped
breakfast as adults had significantly higher waist circumference
and BMI, and those who skipped breakfast as children and as
adults had even higher waist circumference and BMI, along with
more cardiometabolic risk factors (67, 130). Findings of studies
assessing eating frequency are inconsistent, likely because
randomly increasing eating frequency will not necessarily help to
sustain a desirable energy balance. Rather, eating frequency
should be patterned in a way that will reduce large energy
balance deficits and surpluses, to limit cortisol production and
avoid losses in lean mass and increases in fat mass (14, 34, 39,
147).

Follow the Mediterranean Diet

The traditional Mediterranean diet is rich in olive oil, fruits,
vegetables, nuts, and fish. Studies of individuals consuming this
type of diet have generally found lower risk of obesity, heart
disease, and type II diabetes (21).

Improve the Microbiome

The gut microbiome (i.e., the collection of bacterial colonies
that reside in the colon) is involved in multiple metabolic
functions, including energy balance. In addition, it appears that
dietary composition and caloric intake quickly regulate the
composition of microbes in the intestines and their functions
(145). Obesity risk may be increased through microbiome-
enhanced energy extraction from foods and by contributing to
the regulation of fat storage (11, 79). The increased obesity risk
is the result of higher body fat, higher liver triglycerides, higher
fasting plasma glucose, and greater tissue insulin resistance. It
was observed in a study on mice that switching from a low-fat,
plant-based diet high in polysaccharides to a typical Western diet
high in fat and sugar altered the microbiota in a single day and
altered the metabolic pathways toward increased fat storage
(148). It has become increasingly clear that certain strains of
bacteria that are part of the gut microbiome can have a positive
impact on metabolic health and obesity risk (108). These and
other studies suggest that consumption of a Mediterranean-type
diet high in fresh fruits and vegetables and lower in meat-based
fats facilitates lower obesity risk, at least in part through
beneficial alterations in the gut microbiome (31).

Microbiome

Microorganisms in any defined area of the body. The gut

microbiome refers to the microorganisms in the intestines.
These gut microorganisms are involved in metabolism and
immune function and are highly influenced by the foods
consumed. A poor gut microbiome (referred to as a dysbiotic
state) is associated with irritable bowel syndrome (IBS),
inflammatory bowel disease, obesity, and type II diabetes.

Microbiota

Synonymous with microbiome.

Oxidative Stress

Oxidative stress is created through an accumulation of reactive

oxygen species (ROS) and is a common component of intense
physical activity, particularly when coupled with fatigue (113).
Tissue damage may occur when ROS has created damage to the
cellular structures, cellular DNA, and cellular proteins and lipids
(see Chapter 9) (59). Although it is seemingly logical to consume
more of the antioxidant vitamins, including vitamins C and E,
through supplementation, studies have not found this strategy to
be useful in reducing markers of oxidative stress (53, 103). Some
studies have found that taking commonly available supplemental
doses of these vitamins has precisely the opposite of the desired
effect by increasing oxidative stress with a resultant decrease in
performance (54). It appears that exercise-induced oxidative
stress will cause an adaptive response by promoting production
of more antioxidant defenses. However, supplementation with
antioxidant vitamins appears to blunt this natural adaptive
response, thus lowering potential adaptive benefits that the
exerciser should obtain, including promotion of endogenous
antioxidant defense capacity (116). A study assessing 1–2
months of vitamin E supplementation (800 IU) compared with a
placebo in triathletes found that vitamin E supplementation
resulted in more oxidative stress and inflammation following a
competitive triathlon (103). These data strongly suggest that
athletes wishing to achieve a normal adaptive response to the
potentially damaging effects of exercise-associated oxidative
stress should rely on a good-quality healthy diet that satisfies
energy needs (87). Consumption of antioxidant vitamin
supplements appears to be counterproductive unless there is a
known biologic deficiency to a vitamin as a result of food
allergies, intolerances, or sensitivities (87).

Phytonutrients and Health

Phytonutrients are chemicals found naturally in plants and

generally refer to nonnutrient (i.e., nonvitamin or mineral)
substances. The phytonutrients are not necessary for human
survival, so there are no recommended dietary intakes of these
chemicals. Plants produce phytonutrients as self-protection, and
there is evidence that these same phytonutrients may also be
cell protective/health enhancing, through reduction of cellular
inflammation and oxidative stress, for humans (114). The
flavonoids are receiving a great deal of attention because of
their health and performance potential (Table 14.2).

Table 14.2 Food Sources of Dietary Flavonoids

Flavonoid Food Sources
 Table 14.2 Food Sources of Dietary Flavonoids
Flavonoid Food Sources
Anthocyanidins Berries that are red, blue, and purple in color;
and red and purple grapes; red wine
anthocyanins
Flavan-3-ols Monomers: Teas, including white, green, and
oolong; cocoa-based products, grapes, berries,
and apples
Dimers and polymers: Apples, berries, cocoa-
based products, red grapes, red wine
Theaflavins: Black tea
Flavonols Onions, scallions, kale, broccoli, apples,
(including berries, teas
quercetin)
Flavones Parsley, thyme, celery, hot peppers
Flavanones Citrus fruit and juices
Isoflavones Soybeans, soy-based foods, legumes

Source: Linus Pauling Institute. Resveratrol. Available from:

http://lpi.oregonstate.edu/mic/dietary-factors/phytochemicals/resveratrol. Accessed
January 2, 2017.

Phytonutrients

Nonvitamin chemical components of plants that may have

cellular protective effects through antioxidant and other
functions. Although there are no recommended intakes of
phytonutrients, their importance in lowering disease risks is
increasingly being recognized and provides some basis for why
consumption of fresh fruits and vegetables is important.

Several companies are now including phytochemicals in

sports drinks and energy bars, but these have not yet been
investigated to determine if they benefit the athlete through
enhanced performance, improved mental acuity, reduced injury
risk, or enhanced injury recovery. Several phytochemicals have
been undergoing testing to determine their potential usefulness
with athletes, including possible performance and health
benefits, and these include anthocyanin; curcumin; green tea
extract and a chemical within this extract, epigallocatechin
gallate; flavonol; and polyphenol.

Anthocyanin
Anthocyanin flavonoids are responsible for the blue color of
blueberries and other deep blue/deep red berries. A study of wild
blueberries that are high in anthocyanins found that
consumption for 6 weeks resulted in a significant reduction in
oxidatively induced DNA damage (115). A similar finding was
observed with consumption of strawberry-based anthocyanin,
which was found to lower cardiovascular risk by improving the
plasma lipid profile and oxidative stress in humans (3). In a study
of athletes, anthocyanin supplementation was found to
significantly improve VO2max compared with a placebo, despite
no body composition difference following the 6-week
intervention (167). Other studies have found improvements in
strength or lower strength reductions following exercise in
athletes consuming fruits high in anthocyanins (i.e.,
pomegranate juice or tart cherry juice) (25, 55). A study of
endurance athletes consuming anthocyanin through blackcurrant
powder found that it increased stroke volume and cardiac output
significantly and improved lactate clearance, both of which have
implications for exercise performance (162).

Curcumin
Curcumin is a polyphenol derived from the spice turmeric and
has historically been used medicinally in different parts of the
world. Studies have suggested that curcumin lowers the risk of
oral, gastrointestinal (GI), liver, and colon cancers and may also
lower oxidative stress and inflammation associated with the
onset of type II diabetes (23, 37, 64, 117, 124, 141). In athletes,
it has been found that curcumin lowered the pain associated
with delayed-onset muscle soreness following exercise, and
there is also evidence suggesting improved muscle recovery
following exercise (102).
Green Tea Extract and Epigallocatechin Gallate
Green tea is made from the plant Camellia sinensis L., which is
rich in polyphenol catechins and caffeine that may have
anticarcinogenic, anti-inflammatory, oxidative, and cardiac
protective effects. A study of the effect of green tea extract on
healthy humans during rest and exercise found that it may
increase fat metabolism through improved oxidative stress
biomarkers (134). A similar result was found in a study of trained
and untrained males, who consumed either a cellulose placebo
or green tea prior to two exercise sessions. It was observed that
the green tea significantly improved resting and postexercise fat
oxidation (49). In a study assessing green tea on oxidative stress
and muscle damage in soccer players, it was found that it was
beneficial in reducing oxidative stress but not muscle damage in
these athletes (58).

Quercetin
Quercetin, a polyphenol (flavonoid) antioxidant, appears to have
anti-inflammatory and antioxidant properties (9). However, an
analysis of multiple studies assessing the effect of quercetin on
endurance performance found that the effect of supplementation
is likely to be small with no ergogenic benefit for both trained
and untrained people (109). A study assessing oxidative damage
and inflammation following intense exercise using laboratory
mice found that quercetin was effective in lowering both muscle
and liver inflammatory markers (139). These and other data
suggest that quercetin has the potential for lowering tissue
inflammation and improving peripheral tissue circulation that
may have a small benefit on endurance performance, suggesting
that athletes should consume quercetin and other antioxidant
polyphenols as a regular part of the diet. (See Table 14.2 for
quercetin-containing foods.) There are limited data at this time
to suggest that regular supplemental intake of quercetin would
impart additional beneficial effects in athletes (109).

Resveratrol
The flavonoid resveratrol is found in red wine, grape skins and
seeds, peanuts, blueberries, raspberries, mulberries,
lingonberries, and senna. Because it is found in red wine, red
wine consumption has for some been attributed to lowering
cardiovascular disease risk. However, studies assessing
nonalcoholic red grapes containing 8 mg/day of resveratrol found
that it lowered inflammation, atherosclerosis, and risk of
cardiovascular disease (30, 132). There is no additional evidence
suggesting that the resveratrol in red wine would have similar
benefits (81). An early animal study assessing the potential
benefits of resveratrol on endurance exercise found that it
improved aerobic capacity and fat metabolism while increasing
insulin sensitivity (75). However, a study assessing the effect on
inflammation and delayed onset muscle soreness in male
marathoners found no benefits associated with the resveratrol
consumption (76).

Food Safety, Food Allergies, Intolerances,

and Sensitivities

Food safety, allergies, intolerances, and sensitivities are

important to consider for an athlete’s health and performance.
The federal government has made headway in labeling foods for
allergenic ingredients (the Food Allergen Labeling and Consumer
Protection Act of 2004; effective January 1, 2006), but this law
does not yet have an impact on food labeling requirements on
restaurant menus. In addition, this law does not address
common food intolerances and food sensitivities. Nutritional
menu labeling legislation is currently an important area of
interest as the obesity epidemic has initiated efforts that
mandate restaurants to list calorie counts and nutritional
information on every menu offering. The current food labeling
requirements almost exclusively deal with the caloric values of
menu items and ignore other equally important factors that
could help people with food intolerances, food sensitivities, and
food allergies. To exacerbate this issue, many states require food
service employees to obtain some form of certification on food
sanitation and safety practices, but these certifications fail to
address the equally important areas of food allergies, food
intolerances, and food sensitivities (2, 110). This leaves affected
customers at risk, because those who serve the food have little
or no idea about the issues related to these other areas that can
affect health.

Food Safety
The existing food safety and sanitation laws deal with the
preparation, storage, and serving of food that is safe for
customers to consume. Depending on the statistical strategy
used to estimate the prevalence of disease and mortality, it has
been estimated that there are between 9.4 and 76 million
foodborne-related diseases in the United States every year, with
between 55,961 and 325,000 hospitalizations and between
1,251 and 5,000 fatalities (88, 125). The number of individuals
who experience foodborne illnesses and recover amounts to over
a million per year, and it is estimated that an equivalent number
of cases is never reported. The cause of these illnesses goes well
beyond commercial restaurants. Foodborne illnesses also include
private homes and social meal functions where state food safety
and sanitation regulations are not mandated by law. Given the
close proximity with which athletes live and train with each
other, the possible transfer of disease from one athlete to
another, through shared foods and drinks, is an important
consideration in avoiding the transfer of illness from one athlete
to another. The generally recommended strategies for avoiding
transfer of contaminated foods and preventing foodborne illness
are:

Athletes should avoid sharing bottled beverages (i.e., water,

sports beverages). Toward this end, athletes should have
bottles with their name clearly imprinted on it.
Pathogens (bacteria, viruses, etc.) can be transferred via
food from infected individuals. Therefore, food sharing
should be limited to avoid pathogen transfer. As an
additional caution, athletes should be encouraged to
frequently and thoroughly wash their hands to limit
 pathogenic transfer via food and other means (equipment,
etc.).

Food Allergies
It has been estimated that 2.5% of the U.S. population has a
food allergy, with higher allergy risks found in African-
Americans, males, and children (83). Food allergies are caused
by the ingestion of a specific antigen with an ensuing
immunoglobulin E (IgE)-mediated allergic response. The
symptoms of food allergies are usually immediate, occurring
within 2 minutes to 2 hours after ingestion, and can involve the
GI tract, respiratory system, eyes, and skin (128). Symptom
severity can be unpredictable and life-threatening in the case of
anaphylaxis (96). The most common food allergies are related to
the consumption of peanuts, tree nuts, egg, milk, wheat,
soybeans, fish, and crustacean shellfish, with a food-specific
protein the usual offending substance (128). Athletes should be
completely aware of any allergen-containing food and avoid
consumption of it. If the athlete is unsure about the contents of a
food, they should err on the side of caution and avoid consuming
the food. Athletes with known food allergies should also be
extremely cautious about accepting foods and beverages from
other athletes without firm assurance that the offered foods and
beverages are free of a potential allergen. On a rare occasion, an
athlete may have a food-dependent, exercise-induced
anaphylactic reaction (118). In this condition, the allergic
reaction only occurs when food and exercise are combined, but
does not occur when the food is consumed without exercise.
With such a condition, athletes should avoid the offending food
for a minimum of 4 hours before exercise and should always
have immediately available a self-injectable EpiPen (a self-
injectable dose of adrenaline) should a reaction occur. Even with
appropriate caution, however, allergic reactions are possible.
Therefore, the following steps should be taken with any athlete
who has a known allergy:

1. The team’s health care professionals (athletic trainer, doctor)

should make an inquiry on the initial contact with an athlete
 as to whether the athlete has an allergy and, if so, the nature
and severity of the allergy.
2. If the allergy is to a commonly consumed food, food
alternatives should be made available at team meetings,
competitions, travel, etc., with the knowledge that even
passive contact with that food may result in an allergic
response.
3. There should be a plan in place should the athlete
experience an allergic reaction, including knowledge of
whether the athlete has available medications, often an
EpiPen or antihistamine, and where the medications are
kept.
4. Should an athlete experience an allergic reaction, which may
include anaphylaxis (throat tightness, tongue swelling, and
loss of consciousness), the medications should be
immediately administered and the emergency action plan
activated (call 911, etc.) On arrival, the ambulance personnel
should be notified whether a medication was already
provided.

Food Intolerance
Food intolerance typically involves insufficient or missing
digestive substances, such as enzymes or bile salts, causing an
usually rapid onset of distressing GI symptoms, such as gas,
bloating, and diarrhea. For example, symptoms of lactose
intolerance are present in about 10% of the population and occur
when the enzyme lactase is not produced in sufficient amounts
to adequately break down the lactose in dairy products. Some
athletes may experience a food intolerance from consuming
carbohydrates that are not well absorbed but are rapidly
fermentable. These carbohydrates are known as "fermentable
oligo-, di-, and monosaccharides and polyols” (FODMAP), and
limiting their intake in individuals with food intolerances may
help to manage the symptoms. Common FODMAP foods that are
typically listed on food labels include: fructose, fructans, lactose,
sorbitol, and xylitol. (See: https://www.aboutibs.org/low-fodmap-
diet/effects-of-fodmaps-on-the-gut.html for more information on
the FODMAP diet approach.)
Celiac Disease
Celiac disease is an autoimmune disease that results from
exposure to gluten, which causes an inflammation in the small
intestine and affects nutrient absorption (29). The resulting
malabsorption is associated with iron deficiency resulting in
anemia and poor calcium absorption resulting in low bone
mineral density (47). Other nutrient deficiencies may also occur,
including deficiencies of vitamins D and B12, and folate and the
mineral zinc (85). It takes an extremely small exposure to gluten
to trigger a response. In most celiac patients, only 20 parts
per million (equal to approximately two crumbs of bread on a
large dinner plate) is sufficient to create the celiac-associated GI
symptoms of abdominal pain, bloating, nausea, vomiting, and
alternating constipation and diarrhea. Other signs, including
myalgia, arthralgia, low bone density, menstrual irregularities,
and dermatitis, are also associated with celiac disease (85).
Athletes with celiac disease must totally avoid the consumption
of gluten. Because gluten is found in many carbohydrate
products commonly consumed by athletes (breads, energy bars,
etc.), it is important for athletes to find gluten-free alternatives
that can provide the necessary carbohydrate required to satisfy
energy needs, including fruits, vegetables, legumes, quinoa,
millet, potato, corn, rice, pumpkin, and squash. Many gluten-free
products are now available, making this task easier, but the
athlete with celiac disease should seek the guidance of a
dietitian to ensure that both energy and nutrient needs are being
met. It is important to note that consuming diets that are gluten-
free has become popular, even in athletes without celiac disease
or gluten sensitivity, but there is no evidence of a performance
benefit derived from adopting a gluten-free diet in athletes
without celiac disease or other nonceliac gluten intolerance
(158).

Food Sensitivities
Food sensitivities are non–IgE-mediated inflammatory
reactions involving the immune system (Figure 14.4). There has
recently been an increase in the popularity of gluten-free diets,
in large part due to an increase in nonceliac disease gluten
sensitivity which, if not properly managed, can result in IBS,
chronic fatigue, and autoimmunity issues (41, 157). There is a
fad diet component to consumption of a gluten-free diet, which
would unnecessarily limit the consumption of a wide spectrum of
carbohydrate foods if celiac disease or nonceliac gluten
sensitivity is not present (82). The prevalence of food
sensitivities has not been estimated, but is now thought to be a
major contributor to chronic GI disease in the population (77).
Symptoms occur as a result of cytokine and mediator release
from granulocytes and T-cells. These released mediators,
including prostaglandins, histamines, cytokines, and serotonin,
adversely affect gut function through tissue inflammation,
smooth muscle contraction, mucus secretion, and pain receptor
activation. The mechanisms underlying food sensitivities are
complex, requiring time and the sleuthing skills of an astute
diagnostician. There are many possible food sensitivities, and
because the inflammatory response may occur more than 24
hours following consumption (unlike an allergy or intolerance
that can have a response soon after consumption), it is difficult
to find the offending food(s). As a result, the food source of
symptoms may remain elusive without food sensitivity testing
and a personalized elimination diet under the supervision of a
registered dietitian or other appropriately credentialed health
professional.
FIGURE 14.4: Food sensitivity inflammatory reactions. GERD,
gastroesophageal reflux disease. (From Oxford Biomedical
Technologies, Inc. How Food Sensitivities Cause Inflammation.
Available from: http://nowleap.com/how-food-sensitivities-cause-
inflammation. Accessed May 21, 2018.)

Food Allergy

A reaction that occurs when the body’s immune system

overreacts to a food or a food substance. Symptoms of food
allergy may range from mild (i.e., slight skin rash) to severe
(i.e., impaired breathing, altered heart rate, sudden drop in
BP). There is a wide variation in the individual causes of food
allergies, but they often result from exposure to one of these
foods/food categories: eggs, milk, peanuts, tree nuts, fish,
shellfish, wheat, and soy.

Food Intolerance
The difficulty a person may have in consuming a particular
food, often because of a missing or inadequate level of a
specific digestive enzyme. For instance, lactose intolerance is
the result of insufficient lactase (the enzyme that digests
lactose). The undigested lactose results in bloating and
diarrhea. A food intolerance is not a food allergy.

Food Sensitivity

Refers to nonallergic (i.e., non-IgE) and nonfood intolerance

inflammatory reactions to specific foods or food components
that, over time, may result in a number of clinical outcomes
that affect the gut as well as the immune and neurologic
systems.

A healthy gut microbiome is necessary to help migrate or

metabolize potential inflammatory agents, such as gluten, out of
the gut before it can become an inflammatory agent (27, 70).
Besides GI symptoms that include bloating and diarrhea, other
common symptoms of nonceliac gluten sensitivity include
problems with attention span, lowered immunity, skin rash, joint
and muscle aches, and chronic fatigue.

Disordered Eating and Eating Disorders

Important Factors to Consider

Disordered eating and eating disorders are important

conditions that affect many athletes, particularly if they
are involved in aesthetic/appearance sports that have a
large subjective component in the scoring (i.e., how you
appear doing a skill, not just if the skill is completed) (20,
89, 93, 143). Because these are psychometric disorders, it
is important that you not try to resolve a disordered
eating/eating disorder problem by yourself. These are
complicated disorders that require a trained health
 professional (typically a psychiatrist or psychologist trained
in eating disorder treatment) to work with anyone with this
health problem.
Be careful what you say to an athlete, as there is often an
excess level of importance placed on appearance rather
than performance, which may exacerbate an eating
problem (133). For instance, imagine seeing an athlete and
as a greeting you say “You look really good today!” Sounds
innocent enough, but what if this athlete had just finished
purging (vomiting) in the bathroom? Your statement could
be viewed by the athlete as reinforcement for what was
just done in the bathroom that helped to make the athlete
look “really good.” Rather than focusing on appearance,
try sticking to more important things like: “Good to see
you!” and “I hear you’re doing really well in biology!”

Some athletes, particularly those involved in sports where

appearance or making weight is a common aspect of the sport
and are often subjectively scored (i.e., wrestling, gymnastics,
figure skating, diving), are at risk of developing disordered eating
patterns that may develop into classical eating disorders,
including anorexia nervosa (AN) and bulimia nervosa (BN) (62,
137). It has been found that the prevalence of eating disorders in
athletes is nearly four times higher than in nonathletes (18% vs.
5%) and is particularly high in athletes involved in sports where
appearance or weight is considered important (20, 136). The
route taken is often the following:

A normal eater is someone who has a flexible eating pattern,

tends to feel no guilt about eating a wide variety of foods, and
eats with little restraint when hunger occurs (46). A disordered
eating pattern is characterized by restrained eating behaviors
that tend to ignore physiologic signals of hunger, often because
of an excessive emphasis on body weight and the potential that
eating will contribute to excess weight (111). Greater difficulty in
regulating emotion and body dissatisfaction are important
predictors of disordered eating in female athletes (127). An
eating disorder is a psychological condition that is associated
with distorted body image, low self-esteem, and an excessive
emphasis on food (51). There is likely to be an energy deficiency
relationship in the progression of disordered eating patterns to
diagnosable eating disorders, as insufficient energy intake is
associated with a proportionately greater loss of lean mass than
fat mass, resulting in a larger body size because of the higher
relative fat mass. The lower density of fat mass makes the
athlete look bigger at the same weight (36). As illustrated in
Figure 14.5, the adaptation to a lower level of tissue capable of
metabolizing energy (i.e., adaptive thermogenesis) causes a
progressive lowering of energy intake that further reduces lean
tissue and, eventually, leads to an eating disorder.

Disordered Eating

Characterized by restrained eating behaviors that tend to

ignore physiologic signals of hunger, often because of an
excessive emphasis on body weight and the potential that
eating will contribute to excess weight.

Eating Disorder

One of several psychological conditions, including AN, BN, and

binge eating disorder (BED), that are associated with distorted
body image, low self-esteem, and an excessive emphasis on
food.
FIGURE 14.5: Possible relationship between energy deficits and
disordered eating. (From Benardot D, Thompson W. Energy from
food for physical activity: enough and on time. ACSM Health Fit J.
1999;3(4):14–8.)

There are also changing cultural expectations for what a

healthy person should look like, potentially encouraging athletes
in appearance sports to resort to restrained eating behaviors in
an attempt to achieve the unachievable (112, 119). The female
athlete triad, which is often seen in female athletes participating
in appearance sports, consists of the following (Figure 14.6) (4,
13):

1. Low energy availability

2. Low bone mineral density
3. Abnormal menstrual status

It has become increasingly clear that the poor energy

availability commonly seen in eating disorders may be directly
responsible for lower bone mineral density and the low estrogen
that is associated with abnormal menstrual status (45). However,
low energy availability may also be the result of a failure to
adequately consume sufficient energy to support the exercise,
separate from an eating disorder (93). It has also become
evident that male athletes also develop a series of problems
associated with low energy availability, recently reported as
relative energy deficiency in sport (RED-S). (See Chapter 8 for
additional information on RED-S.) To help determine if an athlete
may have the female athlete triad, a series of questions have
been developed as part of the preparticipation physical
examination (i.e., an examination that should occur before an
athlete is allowed to participate in sport). The recommended
screening questions for the preparticipation physical
examination are (33):

FIGURE 14.6: Athletes in “aesthetic” sports have higher rates of

pathogenic weight control practices. VLCD, Very low calorie diet.
(From Beals KA, Manore MM. Disorders of the female athlete triad
among collegiate athletes. Int J Sport Nutr Exerc Metab.
2002;12(3):281–93.)

1. Have you ever had a menstrual period?

2. How old were you when you had your first menstrual period?
3. When was your most recent menstrual period?
4. How many periods have you had in the past 12 months?
 5. Are you presently taking any female hormones (estrogen,
progesterone, birth control pills)?
6. Do you worry about your weight?
7. Are you trying to or has anyone recommended that you gain
or lose weight?
8. Are you on a special diet or do you avoid certain types of
foods or food groups?
9. Have you ever had an eating disorder?
10. Have you ever had a stress fracture?
11. Have you ever been told you have lost bone mineral density
(osteopenia or osteoporosis)?

The American Medical Society for Sports Medicine and the

ACSM have developed guidelines for a preparticipation physical
examination that include questions meant to determine the
likelihood of disordered eating or an eating disorder. These
questions relate to whether the athlete worries about weight, if
anyone has recommended weight change, if the athlete is on a
special diet that avoids certain foods, if the athlete was ever
diagnosed with an eating disorder, of if he or she is taking
supplements for the express purpose of altering weight (17).
Eating disorders have a psychological component, sometimes
associated with a coping strategy used to deal with deeper
problems that are too difficult to address directly. For instance, a
young female may find it difficult to deal with the increased
attention she is receiving as she begins developing into a
woman. An eating disorder that dramatically lowers energy
intake is also seen as a coping strategy in adolescent girls who
have experienced sexual abuse (24, 71, 112). There may also be
a genetic component to the development of eating disorders,
with certain individuals having a genetic predisposition to its
development (73).
Reasons for the development of eating disorders in athletes
have also been assessed in athletes who were diagnosed as
having an eating disorder (135):

Prolonged dieting/weight fluctuations (37%)

New coach (30%)
Injury/illness (23%)
 Casual comments about weight (19%)
Leaving home coupled with failure at school or work (10%)
Problem in a relationship (10%)
Illness or injury to family members (7%)
Death of significant other(s) (4%)
Sexual abuse (4%)

In the United States, it has been estimated that 10 million

women and 1 million men will suffer from an eating disorder
during their lifetime (65). The prevalence of eating disorders
does appear to be higher in both male and female athletes than
in the general population. Using a questionnaire and clinical
interview to determine the presence of eating disorders in 1,620
athletes and 1,696 nonathlete controls, it was found that 13.5%
of the athletes had an eating disorder, whereas significantly
fewer (4.6%) nonathletes had an eating disorder (138). Eating
disorder prevalence was higher in female than in male athletes,
and it was also found that the eating disorder prevalence in a
subsample of female athletes participating in aesthetic sports
was significantly higher than that of females in endurance sports
(42% vs. 24%), technical sports (42% vs. 17%), and ball sports
(42% vs. 16%). Involvement in early weight control behaviors
(i.e., dieting at a young age) is a predictor of disordered eating
later in life, for both men and women (80). The health risks
associated with eating disorders are high, with the risk of
premature death 6–13 times higher in females diagnosed with
AN (8).

Types and Dangers of Eating Disorders

Eating disorders are complex and potentially life-threatening
psychological conditions that require a multidisciplinary care
team of health professionals trained in working with eating
disorders, typically a physician, psychiatrist or psychologist, and
dietitian, to diagnose and/or treat the disorder (69).
 The major eating disorders seen in athletes include: AN, BN,
BED, and other specified feeding or eating disorder (OSFED).
These are potentially life-threatening conditions, with diagnostic
criteria published by the American Psychiatric Association in the
5th edition of Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) (6). When matched for age and gender,
mortality ratios for those with AN are 5.35 times higher, with BN
1.50 times higher, and with OSFED 1.70 times higher than in
those without eating disorders (42).

Anorexia Nervosa
AN is an extremely serious and potentially life-threatening eating
disorder that is characterized by self-induced starvation that is
coupled with extreme weight loss (Box 14.2) (98). The generally
accepted criteria for AN include:

Box 14.2 Common Signs and Symptoms of Anorexia

Nervosa

Following are common signs and symptoms of AN:

Dry skin
Cold intolerance and hypothermia
Blue hands and feet
Constipation
Bloating
 Delayed puberty
Primary amenorrhea (never experienced a menstrual
period) or secondary amenorrhea (experienced a
menstrual period, but without one for 3 months or longer)
Nerve compression
Fainting and orthostatic hypotension (sudden drop in BP on
changing position, as from sitting to standing)
Lanugo hair (increase in body hair in physiologic attempt
to sustain body heat)
Scalp hair loss
Early satiety
Weakness, fatigue
Short stature for age
Osteopenia (low bone mineral density)
Sexual immaturity for age (breast atrophy, etc.)
Pitting edema (typically from poor protein status and poor
electrolyte status)
Cardiac murmurs and arrhythmias
Source: Harrington BC, Haxton C, Jimerson DC. Initial evaluation, diagnosis, and
treatment of anorexia nervosa and bulimia nervosa. Am Fam Physician.
2015;91(1):46–52.

Refusal to maintain weight within a normal range for height

and age (more than 15% below ideal body weight)
Fear of weight gain, with severe restriction of energy intake
to reduce weight
Severe body image disturbance in which body image is the
predominant measure of self-worth with denial of the
seriousness of the illness
In postmenarchal females, absence of the menstrual cycle,
or amenorrhea (greater than three cycles)

Bulimia Nervosa
This eating disorder, also referred to as bulimia, is associated
with secretively binging on large amounts of food, followed with
a purging strategy (vomiting, laxative abuse, diuretics, enemas,
etc.) to eliminate the calories consumed during the binge (100).
In extreme cases, the purging may occur after consumption of
relatively small quantities of foods. It has been reported that,
during a binge, 10,000–20,000 kcal may be consumed in a single
day, typically in secret and often from forbidden foods such as
cookies, candy, chips, and ice cream (26). The typical cause is
preoccupation with body image and weight, coupled with low
self-esteem. The current diagnostic criteria (DSM-5) required for
BN is now a binge once per week over a 3-month period. The
previous diagnostic criterion was binge twice per week for 3
months, a change that has resulted in an increase in the
diagnosis of BN (164). Eating disorders are often associated with
anxiety disorders, with many also suffering from depression,
which has been associated with suicidal attempts in this
population (28, 120). In those with BN, 23% of deaths occur as a
result of suicide or cardiac arrhythmia (8, 28). Common warning
signs of BN include (100):
Those without formal training should not be involved in
attempting to resolve an eating disorder, as any well-intentioned
action may be counterproductive. What follows is a summary of
the basic criteria for each of the more commonly seen eating
disorders in athletes, with common symptoms. The purpose of
this information is to help you understand the complexity of the
condition and, if you suspect that someone you know or work
with may have an eating disorder, to bring them to the attention
of an appropriately credentialed health professional.

Evidence of binge eating, including disappearance of large

amounts of food in short periods of time or the discovery of
wrappers and containers indicating the consumption of large
amounts of food.
Evidence of purging behaviors, including frequent trips to the
bathroom after meals, signs and/or smells of vomiting,
presence of wrappers or packages of laxatives or diuretics.
Excessive, rigid exercise regimen — despite weather,
fatigue, illness, or injury, the compulsive need to “burn off”
calories taken in.
Unusual swelling of the cheeks or jaw area.
 Calluses on the back of the hands and knuckles from self-
induced vomiting (Figure 14.7). Discoloration or staining of
the teeth (see Figure 14.7).

FIGURE 14.7: Oral manifestations of purging-type eating

disorders. Signs of purging include (A) irritation and
inflammation of the pharynx as well as the esophagus from
chronic vomiting and (B) erosion of the lingual surface of the
teeth, loss of dental enamel, periodontal disease, and
extensive dental caries. (From Wilkins EM. Clinical Practice of
the Dental Hygienist. 12th ed. Philadelphia (PA): LWW (PE);
2016.)

Creation of lifestyle schedules or rituals to make time for

binge-and-purge sessions.
Withdrawal from usual friends and activities.
In general, behaviors and attitudes indicating that weight
loss, dieting, and control of food are becoming primary
concerns.
Continued exercise despite injury; overuse injuries.

Binge Eating Disorder

BED is characterized by frequent episodes of consuming large
quantities of foods, often to the point of discomfort. Unlike with
BN, there is no purging following a binging episode with BED. As
with other eating disorders, BED is life-threatening, often from
increased suicide risk. It is the most common of the diagnosable
eating disorders, affecting 3.5% of women, 2% of men, and up to
1.6% of adolescents (65, 99). The diagnostic criteria and
symptoms associated with BED include (6):

A. Recurrent episodes of binge eating. An episode of binge

eating is characterized by both of the following:
Eating, in a discrete period of time (e.g., within any 2-
hour period), an amount of food that is definitely larger
than what most people would eat in a similar period of
time under similar circumstances.
A sense of lack of control over eating during the episode
(e.g., a feeling that one cannot stop eating or control
what or how much one is eating).
B. The binge eating episodes are associated with three (or
more) of the following:
Eating much more rapidly than normal.
Eating until feeling uncomfortably full.
Eating large amounts of food when not feeling physically
hungry.
Eating alone because of feeling embarrassed by how
much one is eating.
Feeling disgusted with oneself, depressed, or very guilty
afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week
for 3 months.

The binge eating is not associated with the recurrent use of

inappropriate compensatory behaviors (e.g., purging) as in BN
and does not occur exclusively during the course of BN or AN.

Other Specified Feeding or Eating Disorder

The criteria for OSFED are similar as for AN, except that regular
menses are accepted in the diagnosis and weight is still within
the normal range. It is the most prevalent of the eating
disorders, with about 60% of those with an eating disorder
diagnosed as having OSFED (40). A major criterion for OSFED is
that the individual does not meet the criteria for AN or BN, but
does engage in inappropriate compensatory behavior after just
consuming a small quantity of food. Examples include: engaging
in self-induced vomiting after consuming two cookies or,
something commonly seen, chewing and spitting out large
amounts of foods without swallowing. This disorder is typically
observed in young females between the ages of 15 and 30 and is
present in 3%–5% of women living in Western countries. Sample
criteria for OSFED include (99):

Atypical AN (although there is restrictive eating, weight is

not below normal)
BN (tends to have gorge–purge behavior, but less often than
in BN)
BED (will exhibit binge eating, but does so less often than in
BN)
Purging disorder (may purge, but without the binge eating
typical of BN)

Night eating syndrome (exhibits excessive nighttime food

consumption)

Summary

Physical activity should and can be health promoting, and if

the right activities are matched with an appropriate
nutrient/energy intake, there is good evidence to suggest
that the activity will result in better health, lower disease
risks, and improve longevity. There is also good evidence to
suggest that the well-nourished individual who has regular
physical activity has lower risk of major chronic disorders,
including cardiovascular disease, obesity, diabetes, and
osteoporosis.
The greater the energy expenditure, the greater the
requirement for consumed energy to satisfy need. However,
the required energy cannot be provided randomly. Rather,
there should be a dynamic relationship between energy
expended and energy consumed so that a wide shift in
energy balance during the day (i.e., within-day energy
balance) does not occur.
The higher requirement for energy in physically active
people also results in a higher requirement for many
vitamins and minerals. However, consumption of insufficient
energy with vitamin and mineral supplements fails to satisfy
need, whereas consumption of good-quality foods (i.e., fresh
fruits and vegetables, whole grains, fish, and meats) helps to
satisfy both energy and vitamin/mineral needs. After all,
what good are vitamins that are involved in energy
metabolism if insufficient energy is consumed for the
vitamins to metabolize? The best way for athletes to satisfy
nutritional requirements is through consumption of foods,
not supplements.
Vitamin supplements typically contain high multiples of RDA
for any given nutrient. For instance, although the RDA for
vitamin C is ∼60 mg, vitamin C supplements often contain
1,000–2,000 mg. There is scant evidence that chronic
overconsumption of vitamins is useful in the athletic
endeavor and an increasing body of evidence that many
vitamin supplements are counterproductive. As a simple
rule, remember: More than enough is not better than
enough. (If a small amount is good for you, it does not hold
that more is better.)
There is an increasing body of evidence suggesting that
athletes who are on “weight loss diets” and fail to consume
sufficient energy to support the combined demands of age,
sex, and physical activity are likely to develop higher body
fat percent, have greater risk of eating disorders, and are at
increased health risk.
Staying well hydrated should be a high priority for physically
active people. Poor hydration inhibits physical activity,
inhibits benefiting from the desired physiologic changes the
physical activity should result in, and may result in a life-
threatening increase in heat stress risk.
With the possible exception of swimming, physical activity
place multiples of normal gravitational forces on bones,
which causes a desired adaptation: an increase in bone
mineral density and lower risk of later osteoporosis.
However, physical activity also increases the requirement for
energy, and a failure to satisfy energy needs in real time
increases cortisol production, which results in a decrease in
bone mineral density.
Lowering obesity risk is an important goal, as the obesity
rate is now of epidemic proportions in the United States and
many other industrialized nations. Nutritional factors that
can help to lower obesity risk include maintenance of a
reasonably good energy balance, limiting the consumption of
beverages that are high in sugar, increasing daily physical
activity, ensuring good-quality sleep of at least 7 hours,
regular assessment of body composition to be able to
intervene early if there is a rise in body fat level or an
lowering of lean mass, develop an eating plan with sufficient
frequency to avoid hunger, eat foods typical of the
Mediterranean diet (fresh fruits, nuts, vegetables, fish, and
olive oil), and ensure a healthy gut microbiome through
ample consumption of plant-based foods that are not heavily
processed.
Although exercise-induced oxidative stress is a normal
component of physical activity, there is good evidence to
suggest that consumption of a good-quality, healthy diet that
satisfies energy needs and is coupled with regular physical
activity results in a positive adaptive response to the
oxidative stress. There is also evidence to suggest that
consumption of antioxidant vitamins may inhibit the desired
adaptive response to exercise, with a resultant increase in
oxidative stress.
It is increasingly being recognized that phytonutrients (i.e.,
plant-based chemicals with nutrient qualities that are not
vitamins or minerals) are an important component of a
healthy diet. Phytonutrients are derived from plants (i.e.,
fruits and vegetables) and include substances such as
resveratrol, curcumin, anthocyanin, and quercetin, all of
which impart health benefits when consumed as part of a
well-balanced healthy diet.
Food allergies are important factors to consider when
planning what to eat. It is also important to consider food
intolerances, food sensitivities, and food safety as all of
 these may negatively impact health and athletic
performance if not properly planned for and dealt with.
Athletes involved in weight control and appearance sports
appear to be at particularly high risk of developing
disordered eating and/or eating disorders, which are serious
conditions that should be addressed by a medical
professional trained to work with these conditions. There are
different types of eating disorders, all of which are
considered psychological disorders. These include AN, BN,
and BED.

Practical Application Activity

Phytonutrients are increasingly being studied and it is being

found that, although they are not directly essential for
maintaining human life the way that vitamins are, they are
important for protecting cells and enhancing health in humans.
One way of categorizing phytonutrients is by color, because
many phytonutrients are related to the color of foods (e.g., the
red/purple color of blueberries is due to the phytonutrient
anthocyanin). To determine if you are exposing yourself to a
wide array of phytonutrients, do the following:

1. Write down all the fruits and vegetables and their color
that you consume over a 3-day period.
2. Find the phytonutrient(s) associated with each color.
3. Determine if there are colors missing in your diet, and see
what fruits and vegetables you could eat that have those
colors.

Chapter Questions

1. If an athlete’s daily requirement for protein is 1.5 g/kg, there is

no difference in how this protein is consumed (i.e., in a single
meal, in three meals, in six meals)
a. True
 b. False
2. For children, the combination of physical activity and good
nutrition should help them develop:
a. Healthy body weight
b. Healthy cardiovascular system
c. Healthy self-esteem with lower risk of anxiety and
depression
d. Better academic performance
e. All of the above
f. a, b, and c only
3. Worldwide, the prevalence of physical inactivity and type II
diabetes is:
a. 2%
b. 7%
c. 10%
d. 90%
4. What proportion of the U.S. adult population fails to meet the
recommendations for physical activity?
a. 10%
b. 23%
c. 56%
d. 72%
5. A high proportion of women develop osteoporosis, and this is
likely to lead to an inadequate acquisition of bone mineral
density during adolescence.
a. True
b. False
6. Of the following, which is not a recommendation of the dietary
guidelines for Americans?
a. Consume more protein, but only from low-fat sources
b. Limit the intake of sugar and salt
c. Eat a wide variety of high nutrient-dense foods
d. Limit the consumption of saturated fats
7. Of the following conditions, which are related to obesity?
a. Nonalcoholic fatty liver disease
b. Hypertension
c. Colon cancer
d. Type II diabetes
 e. All of the above
f. b, c, and d only
8. Obesity refers to:
a. High body weight
b. High body fat
c. High abdominal fat
d. High lower body fat
9. Assessment of 24-hour energy balance is a good means of
determining if body fat level will increase.
a. True
b. False
10. Examples of phytonutrients include all of the following,
except:
a. Flavonols
b. Cobalamin
c. Anthocyanins
d. Isoflavones

Answers to Chapter Questions

1. b
2. e
3. b
4. c
5. a
6. a
7. f
8. b
9. b
10. b

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CHAPTER OBJECTIVES

Discuss energy metabolic systems and how different energy demands

of different sports use each of these systems.
Identify the different muscle fiber types, how they are different, and
how different sports emphasize the usage of different types.
Recognize anabolic and catabolic hormones and how these are used
in normal metabolic reactions.
Demonstrate an understanding of different energy stores in humans
and how athletes utilize these stores in different types of physical
activity.
Determine the factors that are necessary to successfully build muscle
mass.
Identify the nutritionally relevant factors for specific power sports.
Recognize the nutritionally relevant factors for specific endurance
sports.
Explain how athletes involved in different sports require different
eating plans to satisfy their energy requirements.

Case Study

Joanne was a bright, straight A 15-year-old high school swimmer who

was showing a great deal of promise. Her high school coach
suggested to her parents that Joanne join a local (nonschool) swim
club to help her excel. They and Joanne agreed to give it a try. The
first swim practice would take place at 5:30 AM before school,
followed by a quick drive home for some food and a quick change,
and then off to school to be there from 8:30 AM to 3:00 PM. That
would be followed by school team swim practice that ended at 5:00
PM, then a quick drive to the swim club for final practice from 6:00 PM
to 7:00 PM, and a 10 minute drive home. Dinner was at 7:30 PM,
homework until 10:00 PM, and repeat 5 days/week. On weekends,
Saturday practice was from 10 AM to 2:00 PM, and there was no
Sunday practice. Sounds tough, but Joanne loved it! She loved her
coaches, and she was making some great swimming buddies at the
local swim club — girls from other schools that she would not have
met were it not for the club. After several weeks, Joanne was clearly
beginning to drag and, to make matters worse, her algebra grade
went from an A+ to a C. When her parents got the report card, they
did not say anything because they were sure it was because of
Joanne’s new algebra teacher and not Joanne. Without saying
anything to Joanne, her dad went to the school at about 10 AM to talk
to the principal about the new algebra teacher. This was the same
time that Joanne was taking her algebra class, and when he entered
the school and walked toward the principal’s office, he walked past
Joanne’s classroom. He looked in the window and saw something he
could not believe. Joanne was sitting at her desk with her head
bobbing from exhaustion while her algebra teacher was lecturing.
Joanne was trying hard to keep her eyes open, but just could not do it.
That moment struck Joanne’s dad hard, as he realized clearly what
had happened. Joanne was doing triple the physical activity she was
doing before, depleting her carbohydrate stores, but her eating
pattern had not changed to ensure adequate glycogen recovery and
stable blood sugar (important for brain function). She was still trying
to satisfy all of her needs with breakfast, lunch, and dinner, and it was
clear now that this strategy was not working.
So, Joanne’s dad continued on to the principal’s office, but now
with an entirely new discussion focus: He wanted to ask the principal
if Joanne could bring some snacks to school with her that she could
eat mid-morning and before her school swim practice. The principal
understood completely and to her credit agreed that the snacks were
a good idea. Joanne would just have to find a way to eat the snacks
between classes so as not to disturb the other students/teachers.
Joanne started having the snacks and in just a week her entire
demeanor went from exhausted to enthusiastically energetic. To make
matters even better, her 10-week report card returned to straight A’s
again, including in algebra. The human fuel tank can only receive so
much energy at a time, particularly for carbohydrate, and if you let it
get to empty and stay there, bad things happen.

CASE STUDY DISCUSSION QUESTIONS

Maintaining a reasonably good energy balance (energy availability) of
a good distribution of macronutrients throughout the day is important
for ensuring maintenance of normal blood sugar and carbohydrate
stores. Failure to sustain normal blood sugar results in
gluconeogenesis, often with muscle tissue catabolized to provide the
liver with amino acids that can be converted to glucose, resulting in
improved attention and lower mental fatigue. Mental fatigue can
result in muscular fatigue, even if the muscles have adequate energy
to continue functioning (72, 141).

1. Create a spreadsheet to assess your hourly energy balance for

each hour of the day, by predicting the energy expended for each
hour and by assessing the energy intake of the foods and
beverages you consume each hour of the day (follow the
procedure described in earlier chapters). Carry over the ending
energy balance of each hour to begin the energy balance of the
next hour. To do this, you will need the following:
a. Obtain an estimate of your basal (resting) energy expenditure
(REE) for 24 hours, divided by 24 so you have hourly energy
expenditure. Use the Harris–Benedict equation revised by
Mifflin et al. (150):
Male REE = (10 × weight in kg) + (6.25 × height in cm) − (5
× age in years) + 5
Female REE = (10 × weight in kg) + (6.25 × height in cm) −
(5 × age in years) − 161
b. Obtain an estimate of your average hourly energy
expenditure using the following MET value scale with this as
an example: If you slept from midnight to 6 AM (6 hours),
each of these hours would represent your predicted REE. If
you did an average of very light activity from 6 AM to 7 AM,
this hour would represent your REE × 2. Follow this procedure
for each hour of the day.
Factor Descriptions (157)
1 Resting, reclining: Sleeping, reclining, relaxing
1.5 Rest +: Normal, average sitting, standing daytime activity
2.0 Very light: More movement, mainly with upper body;
equivalent to tying shoes, typing, brushing teeth
2.5 Very light +: Working harder than 2.0
3.0 Light: Movement with upper and lower body; equivalent to
household chores
3.5 Light +: Working harder than 3.0; heart rate faster, but
can do this all day without difficulty
4.0 Moderate: Walking briskly, etc.; heart rate faster,
sweating lightly, etc., but comfortable
4.5 Moderate +: Working harder than 4.0; heart rate
noticeably faster, breathing faster
5.0 Vigorous: Breathing clearly faster and deeper, heart rate
faster, must take occasional deep breaths during sentence to
 carry on conversation
5.5 Vigorous +: Working harder than 5.0; breathing noticeably
faster and deeper and must breathe deeply more often to
carry on conversation
6.0 Heavy: You can still talk, but breathing is so hard and deep
you would prefer not to; sweating profusely; heart rate very
high
6.5 Heavy +: Working harder than 6.0; you can barely talk but
would prefer not to. This is about as hard as you can go, but
not for long
7.0 Exhaustive: Cannot continue this intensity long, as you
are on the verge of collapse and are gasping for air. Heart
rate is pounding
2. For those periods of the day with wide shifts in energy balance
that exceed ±400 calories, add foods and beverages at different
times of the day to see what it would take to correct the severe
energy balance deficits and surpluses (74, 216).
3. If you have control over your eating pattern and food/beverage
availability, try eating in the corrected food pattern to see how
you feel.

Introduction

Specific sporting activities place different demands on energy/metabolic

systems. Power and speed activities typically require that the athlete
have the explosive capacity to move quickly, jump high, or move a heavy
weight. The greater the athlete’s ability to perform sport-specific tasks,
the more successful they will be. The power and speed training athletes
perform must have the appropriate nutritional support. Team sport
athletes require a combination of power and endurance (stamina) to
perform well during competition. For example, soccer players must not
only have the stamina (endurance) to jog for the entire match but also
require quick bursts of speed to sprint toward a ball when necessary.
Basketball players must not only have the capacity to jog the length of
the court during the game but also have the explosive power to block a
shot, to sprint for a shot, or to jump for a rebound. Endurance athletes
must have a high level of oxidative competence to enable the capacity to
burn a fuel, fat, that humans have a large supply of and minimize the
utilization of limited carbohydrate stores. Because of the long duration of
endurance events, successful athletes have preevent strategies for
optimizing glycogen stores and hydration state, and during-event
strategies for avoiding dehydration, maintaining blood volume to ensure
continued cooling capacity, and maintaining carbohydrate stores to
enable the complete oxidation of fats and the capacity to go faster (i.e.,
when passing a competitor) when necessary (Table 15.1). This chapter
reviews the specific nutritional requirements for each type of activity,
includes a practical guide on the basic elements of assessing athlete
readiness, and provides sport-specific nutritional issues that should be
considered.

Table 15.1 Energy Metabolic Systems

System Characteristics Duration
Phosphocreatine Anaerobic Used for maximal intensity
(PCr) system production of ATP activities lasting no more than 8
from stored PCr. s.
Anaerobic Anaerobic Used for extremely high-intensity
glycolysis (lactic production of ATP activities that exceed the
acid system) from the breakdown athlete’s capacity to bring in
of glycogen. By- sufficient oxygen. Can continue
product of this producing ATP with this system
system is the no more than 30 s.
production of lactic
acid.
Table 15.1 Energy Metabolic Systems
System Characteristics Duration
Oxygen system Aerobic production Aerobic metabolism of fats (β-
(aerobic of ATP from the oxidation) used for lower
metabolism) breakdown of intensity activities of long
carbohydrates and duration that can produce a
fats. substantial volume of ATP, but
without the production of
Aerobic system-limiting by-products.
metabolism of Aerobic metabolism of
fats referred to carbohydrates (aerobic glycolysis
as “β- and glycogenolysis) used for
oxidation.” high-intensity activities that
Aerobic require a large volume of ATP,
metabolism of but that are within the athlete’s
glucose referred capacity to bring sufficient
to as “aerobic oxygen into the system. This
glycolysis.” system can produce ATP for up to
Aerobic 2 min.
metabolism of
glycogen
referred to as
“aerobic
glycogenolysis.”

Note: The common

generic term for the
aerobic metabolism
of carbohydrate is
aerobic glycolysis.

ATP, adenosine triphosphate.

Team Sport

Team sports, or stop-and-go sports, require a combination of fast bursts

of speed (sprints) interspersed with periods of slower, predominantly
aerobic motion or with temporary cessation of activity. Examples of
team sports include basketball, soccer, and hockey, but similar energy
requirements are seen in tennis and other sports with stop-and-go
activity.
 Energy Metabolic Systems

In brief, the energy systems work as follows (126, 147).

High-power/high-intensity exercise of short duration creates a high
demand for adenosine triphosphate (ATP) because of the large volume of
power required by hard-working muscles per unit of time. At the initiation
of these high-intensity activities, the phosphocreatine (PCr) metabolic
system becomes the predominant source of energy. Although the PCr
system is capable of providing the greatest production of ATP per unit of
time, there is only sufficient preformed PCr to provide energy for up to ∼9
seconds, at which time the muscles must rely on other energy sources
that cannot produce in as great a volume of ATP per unit of time. The
result is that the athlete must, at this point, slow down (lower exercise
intensity) because of the lower level of ATP production.
The PCr system is followed by the anaerobic glycolysis system as the
system with the second greatest capacity to produce ATP per unit of time.
This system relies on carbohydrate/glycogen as a fuel and can provide
energy for up to and an additional 10–30 seconds (depending on power
production) before a buildup of lactic acid that the muscle cannot
adequately clear. At the point of lactic acid buildup, the muscle
experiences a loss of power and fatigue.

Lactic Acid

Lactic acid (lactate) is produced constantly from pyruvate during normal

energy metabolism. It can be reconverted to pyruvate and used to
create ATP energy. When the energy requirement exceeds the oxidative
capacity of tissues, lactic acid builds up in the tissues and is released
into the blood to avoid excess acid buildup in the tissues. However,
blood lactate can only build up until it affects blood pH, at which point
the tissue lactic acid builds up, causing a cessation of tissue (muscle)
function.

The anaerobic glycolysis system is followed by the aerobic glycolysis

system with the third greatest capacity to produce ATP per unit of time
and is also reliant on carbohydrate/glycogen as a fuel. Although producing
less ATP per unit of time than anaerobic glycolysis, and therefore has a
lower power potential, this system has the capacity to provide energy
longer to the working muscle. Aerobic glycolysis can produce ATP for ∼1–
2 minutes, depending on muscle power production, before the muscle
experiences a loss of power and fatigue.
 The aerobic glycolysis system is followed by the aerobic energy
system (also referred to as β-oxidation, as two carbon atoms in a fatty
acid molecule are oxidatively metabolized at a time). Although this
system produces the lowest volume of ATP per unit of time (and therefore
has the lowest power potential), it has the capacity to sustain the
production of ATP for the longest period of time (typically more than 2
hours). This system relies predominantly on fats as a source of energy,
but is also capable of metabolizing other energy substrates including
blood glucose. This aerobic energy system uses Krebs cycle (citric acid
cycle) and the electron transport system for the production of ATP.
It is important to consider that, under normal circumstances, all energy
systems function simultaneously, but the amount of muscle power
required influences which energy system becomes the predominant
system in the production of ATP.

Muscle Fibers: Converting Chemical Energy Into Mechanical

Energy
Power and speed activities are highly reliant on fast-twitch, primarily
anaerobic, muscle fibers. Also referred to as type IIB fibers, these fibers
primarily store glycogen, but low levels of fat (triglycerides). Glycogen
can be quickly metabolized as a fuel without oxygen (anaerobically),
enabling these fibers to produce a high level of power so long as the
glycogen does not run out. The intermediate fast-twitch muscle fibers,
type IIA, also produce a tremendous amount of power, but these muscle
fibers can be trained to behave more like the type I slow-twitch fibers that
are characteristic of fibers used by endurance athletes (114). The type of
training that is done is important, therefore, because it can influence the
behavior of the type IIA muscle fibers (190) (Figure 15.1, Table 15.2).

FIGURE 15.1: Characteristics of different muscle fiber types. Type I fibers

are referred to as endurance fibers; type II fibers are referred to as power
fibers; and type IIA intermediate fibers (not pictured) produce more power
than type I fibers, but less power than type II fibers. ATP, adenosine
triphosphate; NADH, nicotinamide adenine dinucleotide. (From Dudek RW.
High-Yield Histopathology. 2nd ed. Philadelphia [PA]: LWW [PE]; 2011.)
 Table Muscle Fiber Types
15.2
Fiber Characteristics
Type
Type I Also referred to as slow-twitch fibers, these fibers have many
mitochondria with a high level of oxidative enzymes that
enable aerobic (i.e., oxidative) metabolism. Speed of
contraction is low. The high level of triglyceride (fat) storage in
these muscles enables muscle contraction over a long period of
time before reaching fatigue. However, the low level of
glycogen (carbohydrate) storage in these muscle fibers lowers
power potential, but the high level of blood supply enables
refueling and fatigue resistance. These are the primary fibers
used in aerobic, endurance-type activity, including events such
as marathon running, triathlons, and cycling.
Type IIA Also referred to as intermediate fast-twitch fibers, at their
genetic baseline behave like fast-twitch fibers (type IIB), with
high glycogen (carbohydrate) storage and low triglyceride (fat)
storage. Speed of contraction is fast. They can produce a high
level of power anaerobically, but achieve fatigue relatively
quickly as glycogen stores become depleted (114). An
interesting characteristic of these fibers is that endurance
training helps to make these fibers more oxidatively capable,
with increases in oxidative enzymes and triglycerides stores.
However, cessation of aerobic training causes these fibers to
revert to their genetic baseline as mainly power fibers.
Type IIB Also referred to as pure fast-twitch fibers, they produce a high
level of power anaerobically with fast muscle contraction. The
primary fuel stored in these fibers is glycogen, and when
glycogen is depleted the muscle fiber becomes fatigued. The
relatively low level of blood supply also contributes to poor
refueling and early fatigue, best suited for events such as
sprinting, weight lifting, football linemen, and high-
jumping/pole-vault.
Smooth Smooth muscle is also referred to as involuntary muscle,
because it is capable of contracting without conscious control.
Most blood vessels and the walls of internal organs, including
the heart, are composed of smooth muscle. Although the heart
controls its own activity, it is also affected by other factors,
including the hormonal and neural effects of exercise.

The characteristics listed are those that are generally observed. However, it has become
increasingly clear that exercise training can have an impact on the primary characteristics of each
of these fiber types. For instance, chronic pure power training will somewhat alter the power
potential of the type I fibers, whereas chronic pure endurance training will somewhat alter the
endurance potential of type IIB fibers.

Sources: Billeter R, Weber H, Lutz H, Howald H, Eppenberger HM, Jenny E. Myosin types in human
skeletal muscle fibers. Histochemistry. 1980;65(3):249–59; Kenney WL, Murray R. Exercise
physiology. In: Maughan R, editor. Sports Nutrition: The Encyclopaedia of Sports Medicine, an IOC
Medical Commission Publication. London: Wiley Blackwell; 2014. p. 20–58; Schiaffino S, Reggiani C.
Fiber types in mammalian skeletal muscles. Physiol Rev. 2011;91(4):1447–531; Tesch PA, Karlsson
J. Muscle fiber types and size in trained and untrained muscles of elite athletes. J Appl Physiol.
1985;59(6):1716–20.

Because muscle fibers, particularly the type IIA fibers, are adaptable to
the kinds of activities commonly practiced by individuals, the type of
training pursued should closely mimic the type of sporting activity the
athlete is involved in (114). For instance, pure power athletes require all
of the power fibers capable of producing high power to be fully engaged
as power fibers, but if the athlete undergoes significant
aerobic/endurance training, the type IIA fibers will adapt by becoming
more aerobically capable and lose some of their anaerobic power
potential (Figure 15.1). It is not uncommon for power athletes to include a
significant component of endurance exercise in the training protocol as
part of a strategy to lower the body fat level. However, because fibers
exhibit a degree of placidity in response to exercise training, doing so
may compromise the total power capacity (114).

Muscle Fibers

Muscles have different types of fibers with different energy metabolic

potentials. Type I fibers (slow-twitch) are highly aerobic with the
capacity to use oxygen well and burn fat to produce ATP and have high
endurance. Type IIA fibers are highly anaerobic at their genetic baseline,
but can be trained to improve oxidative capacity. Type IIB fibers are
primarily anaerobic fibers that can produce a great deal of ATP in a
short period, but have low endurance.

Short-duration activities, such as the 100-m sprint and the vault in

gymnastics, demand instantly available fuel that can be quickly utilized
by muscles. This fuel, PCr, can quickly supply large amounts of ATP
energy to muscles, but the available storage of PCr is limited (Figure 15.2
shows how we derive ATP energy).
FIGURE 15.2: Adenosine triphosphate energy from macronutrients and
from phosphocreatine.

Power and Strength in the Energy Metabolic

Systems

In well-nourished athletes, ATP production via PCr is limited to between 5

and 8 seconds in sudden-onset, high-intensity activities. This is not
sufficient energy availability for most activities, as even the Olympic time
for the 100 m sprint is ∼10 seconds (106, 107). As a result, muscle
obtains the additional required energy anaerobically, mainly from stored
muscle glycogen. It should be noted that children appear to have a PCr
advantage over adults performing similar activities, as a greater
proportion of oxidative ATP is formed in child versus adult muscle,
enabling children to lower total PCr utilization and, therefore, begin
subsequent activities with higher PCr concentrations (123). Anaerobic
metabolism, however, causes the buildup of lactic acid, which limits the
time an athlete can exercise intensely while in a predominantly anaerobic
state. Most scientists believe that the anaerobic threshold (i.e., the point
at which the rate of blood lactate increase exceeds the rate of blood
lactate removal) is ∼1.5 minutes for someone working at maximal
intensity (85). It is at this point that the athlete would need to reduce
exercise intensity or stop exercising altogether (Table 15.3).
Aerobic metabolism refers to the metabolism of fuel with oxygen and,
because it does not produce lactic acid, can continue much longer than
anaerobic metabolic processes, provided the fuels and nutrients needed
for metabolism are available. A lower amount of ATP energy per unit of
time can be produced aerobically than the ATP produced anaerobically,
resulting in lower power production/lower exercise intensity for
predominantly aerobic activities when compared with predominantly
anaerobic activities. However, there is far more fuel available for aerobic
metabolism than for anaerobic metabolism, allowing for longer exercise
times.

Table 15.3 Rate of Metabolism of Fat, Blood Glucose,

Aerobic and Anaerobic Glycolysis, and
Phosphocreatine
System Maximum Production of ATP Delay Time to Achieve
(mmol/kg of dry mass/s) Maximal ATP Production
Phosphocreatine 9.0 Instantaneous
(anaerobic)
Glycolysis 4.5 5–10 s
(anaerobic)
Glycolysis 2.8 More than 1 min
(aerobic)
Blood glucose 1.0 1.5 h
(aerobic)
Fat (aerobic) 1.0 More than 2 h

ATP, adenosine triphosphate.

Important Factors to Consider

Athletes who work hard and burn more fuel per unit of time require
more oxygen to burn this fuel.
When the amount of energy burned per unit of time exceeds the
athlete’s capacity to provide sufficient oxygen to metabolically
active cells, fuel is burned that does not require oxygen (i.e., burned
anaerobically).
With greater levels of anaerobic metabolism, the volume of lactic
acid that is produced increases.
If the threshold for removing cellular lactic acid is reached, the
lactic acid builds up, resulting in the necessity to either exercise
less intensely to produce less lactic acid or to stop exercising.

Well-conditioned athletes have better oxygen delivery to working

muscles, enabling them to maintain oxidative metabolism at a faster rate
and to go faster, longer before reaching fatigue. Imagine the speed of
elite-level marathon runners, who now complete the 26.2-mile marathon
distance at an average speed of ∼4 minutes, 30 seconds per mile or less,
achieved primarily through aerobic metabolism.
Having the right fuels available is critically important, because poor
fuel availability will inhibit energy metabolism. Fat storage is rarely an
issue, as even the leanest athletes have ample stores of fat that can be
used to supply energy aerobically. However, a failure to also have
sufficient carbohydrate stores results in the production of ketones
(incompletely metabolized fats) that are acidic and result in premature
muscular fatigue (176, 220, 224). Unlike fat, carbohydrate stores are
limited and, therefore, an appropriate dietary plan that ensures adequate
carbohydrate availability is required for the planned exercise. Protein is
also a potential fuel source, but as we have no storage depot for protein
to metabolize for energy, the protein metabolized for energy is derived
from the catabolism of lean mass (51). Because a primary purpose of
exercise is intended to improve lean mass, the athlete should have a
strategy that optimizes oxygen utilization and maximizes carbohydrate
stores to limit the catabolism of protein as a source of energy.

Ketones

In humans, ketones are three water-soluble molecules that include

acetoacetate, β-hydroxybutyrate, and acetone and are produced as a
result of gluconeogenesis (production of glucose from
noncarbohydrates) by the liver as a result of poor carbohydrate
availability. Elevated blood ketones, therefore, represent a good
indication of poor carbohydrate status. Most commonly, ketosis occurs
during periods of fasting/starvation, ketogenic (carbohydrate-restrictive)
diets, poor control of diabetes, and prolonged high-intensity exercise
that is carbohydrate depleting. Acetone is the most common ketone as
it is the product of the spontaneous metabolism of the other two
ketones (acetoacetate and β-hydroxybutyrate). Ketones, which smell
like nail polish remover (acetone), can be detected on a person’s
breath.

The energy stored in ATP and PCr (energy stores) provides sufficient
energy, produced anaerobically, for up to ∼8 seconds. This phosphagen
system depends on PCr to quickly provide a high-energy phosphate
molecule to form ATP. The theory behind creatine monohydrate
supplements is that greater creatine tissue availability enables more
efficient formation of PCr, which is then available to form ATP (see
Chapter 13). The greater capacity to form PCr enables more ATP, allowing
for more high-intensity anaerobic work.
A number of sports are highly dependent on the phosphagen system,
including shot put, long jump, triple jump, discus throwers, gymnastics
vault, and short sprints. In addition, other sports that have quick bursts of
activity, such as football, volleyball, and hockey, also have a dependence
on this energy pathway. In some of these sports, the capacity to perform
repeated high-intensity actions may determine the winner. The high
jumper, long jumper, and pole-vaulter all need two or three stellar efforts
with the hope that one of them will be good enough to win, and the
forward on a basketball team would like to have the capacity to jump as
high in the last quarter as in the first to capture a rebound.

Energy Stores

Body energy stores are made of PCr, muscle glycogen, liver glycogen,
blood glucose, fat, and muscle/organ tissue (protein). Of these, we store
the most potential energy as fat, followed by protein (muscle/organ,
and not intended to be burned as fuel), muscle glycogen, liver
glycogen, and blood sugar.

Minimizing the utilization of protein to satisfy the athlete’s energy

requirements and to, therefore, have less available protein for the
synthesis of creatine, consumption of both adequate protein and energy
is required to ensure satisfactory synthesis of the creatine needed for
multiple quick bursts of high-intensity activity (128, 154). To improve the
storage of ATP-PCr in the muscles, athletes must practice activities that
focus on this system (i.e., activities that are at maximal intensity for 8
seconds and that are repeated multiple times during an exercise session)
(143). This type of training, by itself, is not sufficient to improve short-
duration, high-intensity performance. Consumption of sufficient energy
and protein, by itself, also is not sufficient to improve short-duration, high-
intensity performance. However, when both proper training and
nutritional strategies are combined, athletes can experience very real
gains in short-duration, high-intensity performance.
It should be noted that, even with higher creatine storage, the
maximum preformed PCr is sufficient to last up to only 8 seconds of hard
physical work (106, 107). There is wide variability between athletes in the
regeneration of PCr, but athletes performing maximal exercise for up to 8
seconds typically allow 2–4 minutes for PCr regeneration before
undertaking another maximal bout of exercise (10, 216). It is here that
proper nutrition management is important, as athletes with both sufficient
substrates and training are capable of reforming PCr more efficiently and
also can make the transfer to anaerobic glycolysis more efficiently. A 100-
m sprinter accelerates over the first 8 seconds of the race, but during this
8 seconds when PCr runs low, anaerobic glycolysis is synthesizing a
significant proportion of the required ATP. However, because anaerobic
glycolysis does not produce as much ATP per unit of time as PCr, the
winner of the 100-m dash is typically the person who slows down the
least during the last 2 seconds of the race (Table 15.4).

Table Energy Stores in a 70 kg (154 lb) Relatively Lean

15.4 (10% Body Fat) Male Athlete
Energy Mass (kg) Energy (kJ) Theoretical Maximal Exercise
Source [lb] [kcal] Time (min)a
Liver (0.08) (1,280) [307] 16
glycogen [0.176]
Muscle (0.40) (6,400) 80
glycogen [0.88] [1,530]
Blood (0.01) (160) [38] 2
glucose [0.022]
Fat (7.0) (260,000) 3,250
[15.4] [62,142]
Proteinb (13.0) (220,000) 2,750
[28.6] [52,581]
a
Maximal exercise time is theoretical and assumes sole use of indicated energy source.
b
Protein, although available as an energy source, is not intended to be a primary source of energy.
Not more than a very small part (<1%) of the total protein is available for use during exercise.
Source: Gleeson M. Biochemistry of exercise. In: Maughan RJ, editor. Sports Nutrition — The
Encyclopedia of Sports Medicine: An IOC Medical Commission Publication. London: Wiley Blackwell;
2014.

With intense exercise, the primary fuel becomes stored muscle

glycogen (the storage form of glucose/carbohydrate). When the stored
glycogen becomes depleted, the athlete performing high-intensity activity
fatigues quickly and the exercise stops (103, 166). Although anaerobic
metabolism typically provides only a small proportion of the total energy
used by muscles, it is important because it can provide energy quickly
and helps to fill the energy gap between the initiation of exercise (PCr)
and the time it takes for aerobic energy metabolism to begin producing
sufficient ATP. Maintenance of high-intensity (i.e., anaerobic) activity is
limited by glycogen storage, which is typically depleted within 1.5
minutes of high-intensity activity. Purely high-intensity sports are often
intentionally limited to 1.5 minutes because of the realization that
humans cannot perform continuous high-intensity activity for a longer
period of time. For example, the floor routine in gymnastics is up to a 1.5-
minute routine, as are Olympic boxing rounds. Sports with a higher
aerobic/lower anaerobic component take longer to deplete muscle
glycogen. In a 75-km cycling time trial lasting ∼168 minutes, it was found
that the cyclists experienced a 77% decrease in muscle glycogen (160). It
has been found that in someone exercising at maximal intensity for 30
seconds, the rate of ATP resynthesis from PCr metabolism is highest in the
first few seconds of exercise, but falls to almost zero after 20 seconds.
The rate of ATP resynthesis from glycolysis peaks after about 5 seconds
and is maintained for 15 seconds, but falls in the last 10 seconds of
exercise (145).
Some sports are predominantly aerobic with a heavy reliance on fat
metabolism, but may also have some reliance on anaerobic glycolysis
during the competition. The long-distance runner who has managed most
of the distance while preserving some muscle glycogen still has the
glycogen energy reserves to finish the race with a strong (anaerobic)
“kick,” enabling him or her to pass runners at critical points during the
end of the race (75). For runners in short-distance races, for swimmers in
short races, and for hockey players skating at full bore at the end of a
game to go for a winning score, the anaerobic pathway is the primary
metabolic pathway, and having sufficient stored muscle glycogen is
important for the athlete to continue exercising at a high intensity.
The fact that power athletes utilize a high degree of PCr and glycogen
via anaerobic glycolysis helps to explain the types of foods that power
athletes should consume. The limited storage of fats in fast-twitch muscle
fibers is a clear indication that the metabolism of fats is relatively limited
when compared with the predominantly high-fat-storing slow-twitch fibers
used by endurance athletes. Relatively high carbohydrate intakes have
been found to enable better carbohydrate (i.e., glycogen) storage (214).
Therefore, although power athletes often focus on consumption of high-
protein diets, the energy metabolic systems they use suggests that they
would do well to consider consuming relatively high-carbohydrate diets
(108, 214). It should be made clear that power athletes are breathing and
bringing oxygen into the system, which supports the oxidative
metabolism of fat. The high-intensity activity they do, however, is
proportionately more reliant on anaerobic metabolism (Table 15.5).

Table Percent Contribution of Different Energy Systems in

15.5 a Sample of Different Sports
Sport Phosphocreatine and Anaerobic Glycolysis Aerobic (β-
Anaerobic Glycolysis and Aerobic Oxidation of
Glycolysis Fats)
Table Percent Contribution of Different Energy Systems in
15.5 a Sample of Different Sports
Sport Phosphocreatine and Anaerobic Glycolysis Aerobic (β-
Anaerobic Glycolysis and Aerobic Oxidation of
Glycolysis Fats)
Distance 10 20 70
running
Rowing 20 30 50
Soccer 50 20 30
Basketball 60 20 20
Tennis 70 20 10
Volleyball 80 5 15
Gymnastics 80 15 5
Sprints 90 10 0

Source: Fox EL, Foss ML, Keteyian SJ. Fox’s Physiological Basis for Exercise and Sport. 6th ed.
Madison (WI): William C Brown; 1998.

In-season exercise patterns of power athletes help them metabolize

consumed energy, but maintaining these patterns off-season is difficult
and often associated with an enlargement of the body fat mass (33).
There is also evidence that the weight cycling often experienced by power
athletes increases obesity risk after they retire from the sport, and the
associated weight fluctuations are associated with more frequent illnesses
and earlier mortality (110, 206).

Building Lean (Muscle) Mass

Power athletes look for nutrition strategies to enlarge muscle mass
because more muscle per unit weight increases the potential for
improving the strength-to-weight ratio and power production. There are
many techniques employed for increasing muscle mass, including
resistance training, consumption of more energy and protein at different
points in the exercise day, and the consumption of products claiming to
enhance muscle development (56, 109, 153, 170). Some of these
strategies have been shown to work well, whereas others do not. Athletes
and those who work with them should carefully evaluate the adequacy of
their diets before embarking on a regimen of costly and unproven
supplements that are meant to enhance muscular development, muscular
strength, or both.
It is generally recommended that competitive power athletes should
consume ∼1.7 g protein/kg mass (108, 214). Surveys, however, suggest
that the protein intake of some power athletes is often greater than 3
g/kg of body weight (16, 87, 217). Protein consumption that exceeds the
individual’s anabolic maximum, particularly if not well distributed
throughout the day, is not likely to enhance the protein mass and will
merely be used to satisfy the energy requirement or stored as fat (175).
Whether this excess protein is stored or metabolized as energy, there is
an increased need to excrete the nitrogen associated with protein, forcing
greater urinary output that can result in dehydration. In fact, many
athletes claim they lose weight on a high protein intake, but this may be
due to the high level of body water that is lost rather than from the loss of
fat (31). This may also be due to an increase in ketones from insufficient
carbohydrate availability that results in incompletely burned fat, which
causes nausea and reduces appetite (167). Athletes may also distribute
the protein they consume wrongly, with the majority of protein intake
coming at dinner (i.e., the end of the day). There is increasingly clear
evidence that protein is best utilized to improve muscle protein synthesis
if it is evenly distributed throughout the day, with no more than ∼30 g
provided in any single meal (214). A simple guide for calculating protein
intake and eating frequency is shown in Example 15.1.

Example 15.1 Calculating Protein Eating Frequency

170 lb male athlete requiring 1.5 g/kg protein per daya

1. Calculate weight in kg (170/2.2 = 77.3 kg)

2. Calculate total protein requirement (77.3 × 1.5 = 116 g protein)
3. Calculate the number of protein eating opportunities: (116 g/25b =
4.64)
4. This athlete should consume ∼25 g of protein that is evenly
distributed 4–5 times per day (e.g., breakfast, lunch, mid-afternoon
snack, dinner, and evening snack).
a
The current recommended range of protein intake is 1.2–2.0 g/kg/day
b
Maximal muscle protein synthesis occurs with a protein consumption of ∼20–25 g of protein per
meal. This example is using 25 g/meal.

Nutrients That Control Muscle Development

Muscle development occurs best in conjunction with a well-planned
resistance program, a sustained energy and nutrient balance, and normal
levels of human growth hormone (HGH), insulin, testosterone, and other
anabolic hormones including insulin-like growth factor-1 (IGF-1) (34, 64,
91, 230). Catabolic hormones are hormones that are involved in tissue
breakdown and include cortisol, thyroxine, and epinephrine.
 There is every reason to believe that an athlete who is in good energy
and nutrient balance is already producing appropriate amounts of the
anabolic hormones, so arbitrarily increasing protein intake is not likely to
initiate an even greater muscle protein synthesis (175). (Remember: More
than enough is not better than enough.)
Individual amino acids have been widely tested to determine if their
intake might change the production of HGH in athletes. It is important to
note that amino acid mixtures are the largest category of supplements
used by bodybuilders (54). Studies have shown that increasing the
consumption (via supplement) of the amino acid ornithine may in some
circumstances increase HGH production, but there is even more evidence
that there is no significant increase in HGH from taking, either individually
or in various combinations, the amino acids arginine, lysine, ornithine,
and tyrosine (40, 41, 70, 71, 132, 171, 207). There is also evidence that
taking a broad-range supplement containing all 20 amino acids has no
effect on either HGH or testosterone production (80). Nutrient supplement
companies often use studies to claim that specific amino acids stimulate
HGH and increase muscle mass (18). However, they often fail to quote
other studies that have better statistical procedures and demonstrate
that supplementation with these amino acids has no significant impact on
strength or endurance (97).
There is evidence to support protein consumption that is about double
that for nonathletes (0.8 vs. 1.7 g/kg/day). The higher requirement is
because athletes have more muscle to support, experience an exercise-
associated increase in muscle damage, and have relatively small but
important protein losses in urine (16, 214). Although the protein
requirement for athletes is higher than for nonathletes, athlete total
protein intakes are often higher than the recommended intake level (175).
A possible exception to this is found in vegetarian athletes, who tend to
satisfy the protein level recommended for nonathletes, but often consume
below the recommended protein intake for athletes (82).
There are several concerns associated with excess protein
consumption when excess levels are consumed per meal or per day.
Excess protein consumption results in a portion of the protein to be used
to satisfy the energy requirement or to be stored as fat. In either case,
nitrogen must be removed from the amino acid molecules, and the
nitrogenous wastes that are created result in increased urinary output
and greater urinary calcium loss, which increases the risk of dehydration
and may be associated with lower bone mineral density (142, 172, 212).
There is also some limited evidence that chronic excess protein
consumption may increase the risk of kidney disease (79). Because
kidney disease often occurs gradually and its presence is often unknown,
Friedman (79) suggests that individuals should test for normal kidney
function before pursuing a high protein intake. However, most
recommendations for limiting protein consumption are commonly based
on the fact that individuals suffering from kidney failure benefit from
reduced protein consumption. There is little evidence, however, to
suggest that chronically high protein intakes of up to 2.8 g/kg/day are
associated with increased kidney disease in individuals with normally
functioning and healthy kidneys (36, 175).

Anabolic Hormones

Hormones that are involved in building tissues such as muscle,

including HGH, anabolic steroids such as testosterone, IGF-1, and
insulin.

Catabolic Hormones

Hormones that are involved in breaking down tissues, typically to make

energy available to tissues, such as cortisol, glucagon, thyroxine, and
epinephrine (adrenalin).

Athletes often take multivitamin and multimineral supplements with

the belief that this will enhance the athletic endeavor, but evidence is
largely lacking that these supplements enhance performance in sports
that require power (144, 198, 212). Despite the lack of scientific evidence
to support taking supplemental doses of vitamins, and some evidence
that they inhibit performance, there is a common belief among power
athletes that a number of these vitamins enhance strength (89). The
consumption of dietary supplements in a group of surveyed Olympic
athletes (N = 372) ranged from 52% to 92%, with 83% of surveyed speed
and power athletes using dietary supplements (99). The authors of this
study suggest that, because supplement purity cannot be assured,
athletes should seek professional nutrition counseling to avoid potentially
unsafe use of dietary supplements.

Power and Strength Summary

Power and strength are critical components for athletes doing quick,
short-duration, high-intensity activities. Although also important for
athletes involved in longer-duration activities, they are not the issue of
central importance. A key nutritional element in building and maintaining
muscle mass is the acquisition of sufficient energy. Although consuming
large amounts of protein can help to satisfy the energy requirement,
consumption of additional carbohydrate is less expensive and more
effective. Power athletes are even more dependent on carbohydrates
than endurance athletes because the muscle fibers they use do not have
the capacity to burn fats effectively. Power athletes often make the
mistake of thinking that protein is the key to their success, but high-
protein consumption may limit the consumption of other essential
nutrients, including carbohydrate, which is needed to optimize glycogen
storage for anaerobic high-intensity activity. Similarly, the consumption of
dietary supplements has not been found to improve the athletic endeavor
in athletes consuming adequate diets, but their consumption may lead
the athlete to believe that they need not be as diligent in the
consumption of good foods (137). This problem is compounded by the
fact that some supplements targeting athletes contain banned
substances not listed on the label (146). Supplementation of vitamins,
minerals, protein products, and fat analogues has not been found to be
successful in improving power, muscle mass, or athletic performance in
power athletes. Although the risk of taking these products is likely to be
low, there are no data to know if these products are safe when consumed
in the amounts and duration prescribed by the manufacturers of these
products. A more sensible approach is to consume a balanced and varied
diet that is high in carbohydrates (5.0–8.0 g/kg/day), moderate in protein
(1.2–1.7 g/kg/day), and sufficient fat to satisfy the energy requirement
(<30% of total energy consumed). Provided the food consumed comes
from a variety of foods, this intake has the benefit of exposing tissues to
required minerals and vitamins. As carbohydrates are metabolized cleanly
(i.e., no nitrogenous waste; only carbon dioxide and water), there is no
question about the safety of consuming a varied diet high in good-quality
carbohydrate-containing foods (Table 15.6 shows energy sources of
different power sports).

Power Sports

Power sports are considered to be those that require a great deal of

energy over a relatively short period of time and include sports such as
sprinting, gymnastics, and weight-lifting.

Table Energy Sources of Different Sports

15.6
% Energy Contribution
Event Aerobic
Time Sample VO2max Glycolysis Metabolism
(min) Event (approx) Phosphocreatine (Anaerobic) (Oxidative)
 Table Energy Sources of Different Sports
15.6
% Energy Contribution
Event Aerobic
Time Sample VO2max Glycolysis Metabolism
(min) Event (approx) Phosphocreatine (Anaerobic) (Oxidative)
0.5–1 400-m ∼150 ∼10 ∼47–60 ∼30–43
running;
individual
cycling time
trial (500 m
or 1 km);
100-m
swimming
1.5–2 800-m 113– ∼5 ∼29–45 ∼50–66
running; 130
200-m
swimming;
500-m
canoe/kayak
3–5 1,500-m 103– ∼2 ∼14–28 ∼70–84
running; 115
cycling
pursuit;
400-m
swimming;
100-m
canoe/kayak
5–8 3,000-m 98–102 <1 ∼10–12 ∼88–90
running;
2,000-m
rowing

Note that longer durations involve relatively higher aerobic metabolism; shorter durations
relatively higher anaerobic metabolism.
Source: Stellingwerff T, Maughan RJ, Burke LM. Nutrition for power sports: middle-distance running,
track cycling, rowing, canoeing/kayaking, and swimming. J Sports Sci. 2011;29(S1):S79–89.

Endurance in the Energy Metabolic Systems

Endurance athletes perform in events that have continuous movement for

20 minutes or longer, with many endurance sports requiring continuous
movement over long distances or time periods (marathon, cross-country
skiing, triathlon, etc.). There is a premium on supplying sufficient energy
and fluid to ensure that the athlete does not become exhausted from the
activity or overheated from the continuous energy metabolism. Failing to
supply sufficient energy of the right type will result in early fatigue and
poor athletic performance. Athletes taking supplements may have a false
sense that nutrient needs are satisfied, but if the supplement
consumption reduces energy intake from food, then this is
counterproductive. There is also evidence that excess intake of certain
common supplements may create difficulties in performance. In a study
assessing both rats and humans, it has been found that vitamin C
supplemental intake (1 g/day in humans; 0.24 mg/cm2/day in rats)
significantly hampered training-induced cellular adaptations to endurance
activity (89). The goal for the endurance athlete is, therefore, to establish
a workable strategy for supplying sufficient nutrients, energy, and fluids
before training/competition to begin the training session/competition with
optimal glycogen stores and in a euhydrated state so as to enable
sustained muscular work for a long duration and at the highest possible
intensity. It is also an important goal for the endurance athlete to plan for
a suitable recovery strategy that provides for easy and fast availability of
fluids, carbohydrates, and protein (214).
Aerobic metabolism is the energy system of greatest importance for
endurance athletes. In this energy pathway, oxygen is used to help
transfer phosphorus into new ATP molecules. Unlike anaerobic
metabolism, this energy pathway can use protein, fat, and carbohydrate
for fuel by converting pieces of these energy substrates into acetyl
coenzyme A (acetyl CoA ), the intermediary compound in metabolism
(52). Glucose is converted to pyruvic acid (an anaerobic, energy-releasing
process), which can be converted either into acetyl CoA with the help of
oxygen or to the energy storage product lactic acid. Excess production of
lactic acid results in muscular fatigue, causing activity to stop. However,
the lactic acid can be reconverted to pyruvic acid to be used as a fuel
aerobically. Aerobic metabolism occurs in the mitochondria of cells, where
the vast majority of all ATP is produced from the entering acetyl CoA. Fats
can be converted to acetyl CoA through a process called the β-oxidative
metabolic pathway (147). This pathway is oxygen dependent, which
means that fats can only be burned aerobically.
The ability of an athlete to achieve a steady state of oxygen uptake
into the cells is a function of how well an athlete is aerobically
conditioned. Maximal oxygen uptake in males and females involved in
different sports can be viewed in Chapter 11, Table 11.6. An athlete who
frequently trains aerobically is likely to reach a steady state faster than
one who does not train aerobically. For a well-conditioned person, it can
take 5 minutes before enough oxygen is in the system to support aerobic
metabolism at a steady state. The first 5 minutes of activity is supported
by a combination of anaerobic and aerobic metabolism. Achievement of a
fast steady state is therefore important because that diminishes the
amount of time an athlete is obtaining energy via anaerobic pathways.
This places a heavy burden on the most limited fuel — carbohydrates. In
theory, once an athlete reaches a level of oxygen uptake that matches
oxygen requirement for the given level of exertion, the exercise could go
on for as long as the body’s carbohydrate level and fluids did not reach a
critical state. For instance, a long-distance runner who is in a steady state
could continue running provided the runner replaced the carbohydrate
and fluids that are used in the activity. Therefore, endurance is enhanced
with a periodic intake of carbohydrate and fluid during the activity.

Endurance Sports

Endurance sports are considered to be those that require a relatively

low amount of energy per unit of time, but over long periods of time,
and include sports such as distance running and swimming, distance
cycling, and triathlon.

The majority of endurance activity occurs at intensities that enable

fats to contribute a high proportion of the fuel for muscular work. Because
fat is amply available in even the leanest athlete, supplying fats before
and during physical activity is not a concern and should not be a goal
(45). However, carbohydrate is involved in the complete combustion of
fats, and because the storage capacity for carbohydrates is relatively low
and easily depleted, the goal for endurance athletes is to find a way to
supply enough carbohydrates before training/competition to optimize
glycogen stores and to have a carbohydrate-containing beverage to
consume during exercise to sustain blood sugar and buffer glycogen
utilization (214). Such a carbohydrate strategy will help to minimize the
risk for premature fatigue. Ultimately, endurance athletes must consume
sufficient total energy, a significant portion of which is carbohydrate, to
enable muscular work over long time periods, and must have a strategy
for supporting carbohydrate requirements during physical activity to help
sustain the complete oxidation of fats.
Athletes in aerobic sports have an enhanced capacity to use oxygen
than do athletes in power sports. Because even the leanest athletes have
a great deal of energy stored as fat, this increased ability to burn fat
dramatically improves endurance. However, as carbohydrate is needed
for the complete combustion of fat, carbohydrate is still the limiting
energy source for endurance work because athletes have relatively low
carbohydrate stores. This is clearly demonstrated by findings that
athletes consuming high-fat, low-carbohydrate diets have lower
performance outcomes than those consuming low-fat, high-carbohydrate
diets (45, 49).
Athletes with different levels of conditioning are likely to achieve
steady state at different levels of exercise intensity. A well-conditioned
athlete may be capable of maintaining a steady state at a high enough
level of exercise intensity to easily win a race. At the 1996 Olympic
Games in Atlanta, Georgia, the winner of the marathon ran over 26 miles
at a speed that averaged just over a 5-minute-per-mile pace. In the 2012
London Olympic Games, the pace was even faster, at about 4 minutes 50
seconds per mile (Table 15.7). However, an athlete with poor aerobic
conditioning may only be able to run at a 10-minutes-per-mile pace and
maintain a steady state. Each person has his or her own pace that allows
maintenance of a steady state. Exceeding that pace causes a greater
proportion of the muscular work to rely on anaerobic metabolism, with an
associated increase in the reliance on carbohydrate fuel. Because of the
limited storage of carbohydrate fuel, glycogen is depleted more quickly
and the person becomes exhausted.

Table Winning Men’s and Women’s Marathon Times From the

15.7 First Modern Olympic Games in 1896 to the Present
Year Men’s Marathon Time Women’s Marathon Time
1896 Spiridon Lewis 2:58:50
1900 Michel Théato 2:59:45
1904 Thomas Hicks 3:28:53
1906 William Sherring 2:51:23.6
1908 John Hayes 2:55:18.4
1912 Kenneth McArthur 2:36:54.8
1920 Hannes Kolehmainen 2:32:35.8
1924 Albin Stenroos 2:41:22.6
1932 Juan Carlos Zabala 2:31:36.0
1936 Kee-Chung Sohn 2:29:19.2
1948 Delfo Cabrera 2:34:51.6
1952 Emil Zátopek 2:23:02.2
1956 Alain Mimoun 2:25:03.2
1960 Abebe Bikila 2:15:16.2
1964 Abebe Bikila 2:12:11.2
1968 Mamo Wolde 2:20:26.4
1972 Frank Shorter 2:12:19.8
Table Winning Men’s and Women’s Marathon Times From the
15.7 First Modern Olympic Games in 1896 to the Present
Year Men’s Marathon Time Women’s Marathon Time
1976 Waldemar Cierpinski 2:09:55
1980 Waldemar Cierpinski 2:11:03
1984 Carlos Lopes 2:09:21 Joan Benoit 2:24:52
1988 Gelindo Bordin 2:10:32 Rosa Mota 2:25:40
1992 Hwang Yeong-Jo 2:13:23 Valentina Yegorova 2:32:41
1996 Josia Thugwane 2:12:36 Fatuma Roba 2:26:05
2000 Gazehegne Abera 2:10:11 Naoko Takahashi 2:23:14
2004 Stefano Baldini 2:10:55 Mizuki Noguchi 2:26:20
2008 Samuel Wanjirua 2:06:32 Constantina Tomescu 2:26:44
2012 Stephen Kiprotich 2:08:01 Tiki Gelanaa 2:23:07
2016 Eliud Kipchoge 2:08:44 Jemina Sumgong 2:24:04

First Women’s Olympic Marathon was in 1984.

a
Runner (in italics) = Olympic Record

Endurance events, including marathon, triathlon, road cycling, and

distance swimming, require a high level of aerobic fitness but also require
periods of anaerobic power for bursts of speed at critical junctures in a
race. The winning times of the men’s Olympic marathon have gradually
become faster (see Table 15.8). (Note that variations in speed between
Olympic marathons may be due to differences in marathon course
difficulty.)
The primary energy system for endurance sports is oxidative (aerobic),
which represents a work intensity below maximal, allowing for sufficient
oxygen to be brought into the system and delivered to cells. Although
endurance athletes are unable to move as quickly as sprinters, they can
continue activity for much longer distances because the oxidative system
provides energy with limited production of lactate and uses a fuel (fat)
that is in high supply. Factors that affect maximal oxygen uptake include
(19):

Pulmonary diffusing capacity (i.e., the ability to “grab” oxygen from

air in the lungs and transfer it to red blood cells [RBCs])
Cardiac output (i.e., the capacity of the heart to pump blood through
the body to deliver oxygen to tissues)
Oxygen-carrying capacity (i.e., the concentration of normal, healthy
RBCs)
Skeletal muscles (i.e., the capacity of the muscle to take oxygen from
the blood and transfer the oxygen into mitochondria for oxidative
 metabolism).

Training has the effect of increasing the capacity to deliver oxygen to

cells, primarily as the result of an increase in maximal cardiac output
(68). Studies assessing blood lactate concentration have found that
trained athletes are far more capable of tolerating high levels of blood
lactate than untrained subjects doing the same intensity of work, likely
because of a larger blood volume (a common adaptation to training) that
allows for improved lactate dilution and lesser pH impact (12, 100).
(Larger blood volumes are an adaptive benefit of aerobic fitness.) Even
lean athletes have ample stored energy as fat, and improving oxygen
delivery to tissues enhances fat metabolism while lowering the need to
obtain fuel anaerobically. It is still important to consider, however, that fat
requires carbohydrate for complete fat metabolism and the avoidance of
ketone creation. Therefore, even athletes with a high capacity to
metabolize fat may be compromised if they fail to store/supply sufficient
carbohydrate during periods of predominantly oxidative metabolism. This
is clearly demonstrated by studies finding that athletes who consume
high-fat diets have maximal endurance time of ∼57 minutes; those who
consume a normal mixed diet experience an increase in endurance times
to ∼114 minutes; and those on high-carbohydrate diets have an increase
in maximal endurance times to ∼167 minutes (199).

General Nutrition Concerns and Strategies for

Athletes in All Sports

Regardless of the athletic endeavor or sport, athletes must be mindful of

some issues that could compromise their capacity to benefit from
training. These include overtraining, overuse injury, poor fluid intake, and
poor energy availability.

Overtraining
Overtraining is a stress-related condition that has a negative impact on
the normal beneficial adaptation to training, impairs normal psychological
well-being, and creates immune system problems that are manifested
with increased illness frequency (3). Some well-established warning signs
include:

increased muscle soreness

delayed muscle recovery
inability to perform at the previous training load
poor sleep
 decreased vigor
swelling of lymph nodes
high frequency of illness
loss of appetite (42)

Many of these signs are a result of working at a level harder than the
body’s capacity to recover from it. Overtraining commonly results in poor
performance because of the increased risk that the athlete will become
sick or injured. It is a problem for an estimated 10%–20% of all athletes
with intensive training and is commonly observed in endurance athletes.
Importantly, poor intake of carbohydrate and fluids is commonly observed
in athletes with overtraining syndrome (148). According to a joint
consensus statement of the European College of Sport Science and the
American College of Sports Medicine, overtraining syndrome can be
effectively eliminated through a logical training program that allows for
adequate rest and recovery with proper nutrition and hydration (148).

Overuse Injury
Overuse injuries occur when an athlete repeats the same physical task,
causing repetitive stress to bone and muscles at a rate greater than the
tissues can be repaired (131). A blister that results from the rubbing of a
running shoe, a mild form of overuse injury, and the repeated stress on a
bone from constant repeated pounding may result in a more serious form
of overuse injury such as a stress fracture. Endurance athletes spend
many hours in training involving repetitive motion, making overuse injury
a concern for this group (222). Muscle tissue breakdown occurs as a
common and natural component of physical activity, but trained athletes
who are accustomed to the duration and intensity of the activity should
have good muscle recovery without overuse injury, provided appropriate
nutritional strategies (e.g., consumption of good-quality protein,
carbohydrate, and beverages soon after the end of training) are followed
(65). Well-nourished athletes are better able to heal minor tissue damage
that occurs during normal training and competition.

Poor Fluid Intake

Physical activity results in an inevitable loss of sweat-related body water
loss to dissipate the heat associated with exercise-associated energy
metabolism. There is a wide range of sweat loss, depending on the
endurance sport, the environmental temperature, and humidity, with
observed ranges from 4.9 to 12.7 L lost and 2.1 to 10.5 L ingested (8).
There is evidence that the prevalence of poor hydration status at the
initiation of training is high in both young and adult athletes, which has
the effect of compromising the potential benefits that can and should be
derived as a result of the training (9). Despite the high rates of sweat
losses experienced by athletes, most athletes replace only a fraction of
the body water loss, even when fluids are readily available to consume
(95). The resulting dehydration, when associated with >2% lowering of
body weight, is associated with poor athletic performance (6, 218).
Importantly, using thirst as a guideline for when to consume fluids is not
appropriate, as a high level of body water has already been lost, with a
potentially negative impact on performance, before the thirst sensation
occurs (7).

Poor Energy Availability

The energy demands of endurance athletes are extremely high, with
estimates that cross-country skiers metabolize ∼4,000 calories during a
50-km race, and metabolize even more energy during intensive training
(69). It is generally recommended that endurance athletes should
consume a minimum of 45 kcal/kg/day when daily training has a duration
of 1.5 hours or more (67). It has been estimated that a 25-year-old 125 lb
female marathoner who runs 10 miles in the morning and 8 miles in the
afternoon would require ∼4,331 kcal to satisfy the combined needs of
activity and REE (156). Athletes with poor energy availability are at
increased risk for both disease and injury (154). The long duration of
endurance training places a high demand on energy stores, and without
good planning the endurance athlete is at high risk of injury that results
from insufficient energy (76). The higher risk of injury includes a wide
array of problems, including higher risk of stress fractures and poor
muscle recovery. The athlete with poor energy availability is also at high
risk of psychological, metabolic, endocrine, and immunologic problems.
Importantly, it is hard to imagine how an endurance athlete could
properly benefit from endurance training without sufficient energy to
optimally support the training. Female endurance athletes who fail to
consume sufficient energy are at high risk of menstrual dysfunction,
which is also associated with poor bone health (158, 191).

Nutrition Strategies for Pre-, During-, and

Postcompetition/Practice

Precompetition/Practice
It has become increasingly clear that when endurance athletes compete,
carbohydrate availability is the limiting energy substrate for performance
(98). Preexercise carbohydrate consumption, regardless of glycemic
index, is associated with improved performance, with a general
recommendation for 800–1,200 kcal be consumed between 2 and 3 hours
prior to practice or competition (43, 55, 194). Ideally, this preexercise
meal should also provide sufficient fluid to allow initiation of exercise in a
well-hydrated state and should be moderate in protein and relatively low
in fat and fiber to ensure efficient gastric emptying (214). There are also
beginning data to suggest that other foods or food components may be
useful in improving performance when consumed preexercise: caffeine, at
a level ∼10 mcg/mL but below 15 mcg/mL, may reduce the perception of
fatigue, potentially allowing exercise to continue longer; nitrate (as
commonly obtained from beetroot juice) increases nitric oxide availability
with the effect of lowering the oxygen cost of exercise, thereby improving
exercise performance (11, 44, 117, 165, 210).
Consumption of fluids before exercise/competition is also important to
ensure effective glycogen storage, which is stored with water, and to
begin the exercise/competition in a well-hydrated state. There is also
evidence that consumption of cold fluids or ice slurry before exercise on a
hot day may be an effective strategy of precooling core temperature,
which can improve endurance performance (205, 209). It is common for
athletes to consume fluids only when thirsty, so a planned effort should
be made to encourage fluid consumption prior to exercise/competition to
a point where urine color is clear (96). Consumption of sports beverages
prior to exercise is useful because they provide the two things athletes
require: carbohydrates and fluids. The American College of Sports
Medicine position on fluids states that (189):

the fluid consumed should be flavored and sweetened to encourage

fluid intake;
to help maintain training intensity, the fluid should contain
carbohydrate; and
to stimulate rapid and complete rehydration, the beverage should
contain sodium chloride (salt).

Sports beverages that meet these criteria are particularly useful in

helping to deliver both carbohydrates and fluids to athletes.

During Competition/Practice
Fluids are available at fixed 5 km intervals in organized 10-km races and
marathons, and athletes should be encouraged to take advantage of each
fluid station and consume fluids. However, to be ensured that the athlete
can tolerate fluid consumption at this interval, they should practice
consuming fluids at the same intervals during training sessions. This will
have the advantage of helping the athlete adapt to the fluid consumed
and will also improve tolerance to greater fluid consumption to better
offset sweat loss. The following recommendations have been suggested
(38):

Fluids should be easily and readily available.

Athletes should have their own bottle from which to drink, and this
bottle should be with them during both training and competition.
Practices should be designed in a way that enables and encourages
athletes to drink frequently, with every possible attempt to mimic the
fluid intake availability during competitions.

Athletes and coaches should know that sweat rates can far exceed
fluid consumption/absorption rates, so diminishing this difference through
frequent fluid consumption is an important strategy. There is concern that
some athletes may consume excess fluids, resulting in weight increase
(i.e., more fluids consumed than lost). Although a rare occurrence,
overconsumption of fluids is a potential cause of hyponatremia (i.e., blood
sodium below 125 mmol/L), which can result in bloating, vomiting,
confusion, respiratory distress, and possible death that may result from
brain edema (5, 104, 189). Other causes of hyponatremia include excess
sodium loss in sweat and consumption of beverages that fail to supply
sufficient sodium (214).

Postcompetition/Practice
Carbohydrate consumption immediately postexercise is useful because it
maximizes the availability of glycogen synthetase to optimize glycogen
resynthesis and storage (21). Even delaying carbohydrate consumption
for as little as 2 hours reduces glycogen synthesis (115). There is also
strong evidence suggesting that skeletal muscle breakdown increases
with endurance training and/or with a single endurance exercise bout,
and athletes who consume foods immediately following endurance
activity have improved muscle protein synthesis and recovery (184).
Providing a combination of good-quality protein and carbohydrate 1 hour
postexercise resulted in three times greater muscle protein synthesis than
when the same foods are provided 3 hours postexercise (134).

Nutrition Issues for Selected Sports With a High

Power Component

The following sports provide examples of how nutrition influences power

and speed activities. The list of sports is not intended to be
comprehensive. Rather, the sports provide the reader with ideas for how
to apply the science to athletes involved in different activities.
Baseball
Because baseball is often played in a hot and humid environment, it
should be a high priority for baseball players to sustain a good hydration
state. Poor hydration will increase injury risk, reduce attention span and
reaction time, result in early fatigue, and diminish coordination (102,
155). Fitness is also a factor, as it was found that, at exercise intensities
normal for baseball, players with greater fitness sustained body
temperature better than less fit players because of improved capacity to
sustain sweat rates and cooling capacity (231). The capacity to sustain
blood flow to the pitching arm is a factor in performance that is also
related to hydration state. It has been found that blood flow increased
with up to 40 pitches but steadily declined after that, and by the 100th
pitch blood flow to the pitching arm was 30% below baseline (20). It is
likely that the reduction in pitching arm blood flow is associated with
hydration state. Taken together, these studies suggest that baseball
players should make efforts to sustain hydration state using strategies
described in Chapter 7.
Baseball players play many games over the course of any in-season
week or month, predisposing them to overuse injuries if they fail to get
adequate rest, fluids, and energy. Pitchers, in particular, may be at high
risk of overuse injury (225, 229 The reduced throwing power observed
over the course of the season may be due to a combination of overuse
injury and reduced leg strength, both of which would affect the throwing
motion (138). Catchers work hard and carry more equipment weight, so
they are likely to need more sports beverages than other players. They
should take every advantage of dugout time when on offense to consume
fluids that help to satisfy both carbohydrate and hydration requirements.
Both reduced muscular strength and lower muscular strength could be
associated with poor hydration and poor energy availability (102, 154).
Baseball requires power and speed with a high reliance on PCr and
carbohydrate for muscular fuel. Although PCr is synthesized from three
amino acids, requiring an adequate protein consumption, humans have
an energy-first system mandating that energy consumption is also
adequate to ensure the consumed protein can be used to manufacture
needed substances (including PCr) rather than contributing to the
requirement for energy. Put simply, baseball players who focus
excessively on protein consumption but who fail to meet total energy
needs are at risk of poor performance. Because normal blood sugar is
typically maintained for only a short period of 1 to less than 3 hours, and
baseball games typically last for ∼3 hours, baseball players should
consume a carbohydrate-containing sports beverage between innings.
The amounts consumed should be related to sweat rates, with the goal of
maintaining postgame weights that are within 2% of pregame weights
(214). Failure to maintain blood sugar will result in a loss of concentration,
poor reaction time, and mental and muscular fatigue.

Bodybuilding
To achieve a high level of muscle mass, bodybuilders place a high level of
repetitive stress (typically via free weights and muscle resistance
equipment) on each muscle group with high-intensity repetitions that
rarely last longer than 30 seconds per muscle group and never last longer
than 1.5 minutes (202). In preparation for competition, bodybuilders
combine this hard muscle training with the consumption of extra energy,
often composed of high-protein foods coupled with nutrient supplements,
to enlarge the muscle mass. Because a single training session may result
in an up to 40% drop in muscle glycogen stores, it is possible that
glycogen depletion may result in impaired training (129). Although
bodybuilders have protein requirements at the upper end of the
recommended range (∼1.7 g/kg/day), typical protein consumption is well
above this level at the expense of carbohydrate, which should be in the
range of 4–7 g/kg/day (202). Note also that it was found that there was no
scientific evidence for 42% of the products for which beneficial nutritional
claims were made in bodybuilding magazines, with 32% of the products
having misleading information (18). Bodybuilders may restrict fluids and
salt to enhance the appearance of being “cut” but fluid restriction has
been found to be dangerous, particularly in younger bodybuilders, who
are predisposed to developing hypokalemia (low potassium that
predisposes the athlete to fatigue, weakness, and cramping),
hypophosphatemia (low phosphorus that predisposes the athlete to
muscle dysfunction and weakness, and irritability), rhabdomyolysis (refers
to damaged muscle that is associated with muscle pain and weakness),
and flaccid tetraparesis (refers to muscle weakness affecting all four
limbs) with fluid restriction (37). It has been reported that the majority of
bodybuilders follow regimens that result in severe dehydration associated
with glycogen depletion (127, 201). There is also evidence that the
energy (calorie) restriction common in the period immediately prior to
competition results in a loss of lean mass, suggesting that the energy
restriction is excessive (105).
Bodybuilders have repetitive patterns of weight gain and weight loss to
try to enlarge muscle while reducing body fat. Typical weight loss during
the competitive season alternatingly decreases (∼6.8 kg; 15 lb) and
increases (∼6.2 kg; 14 lb). This dieting pattern results in food
preoccupation that leads to both binge eating and psychological stress
following competitions (2). Importantly, bodybuilders should be made
aware of the increased risk of developing eating disorders that may result
from the repetitive pattern of weight adjustments (101). A more
appropriate strategy is to follow a pattern that sustains energy balance by
dynamically matching intake with energy expenditure and provides
sufficient carbohydrate and protein to satisfy both glycogen and muscle
protein needs. This would simultaneously optimize musculature while
minimizing fat tissue acquisition (24).

Diving
Diving requires a combination of power, body control, and flexibility,
which all require sustaining good energy and hydration needs (28). The
training regimen for divers is similar to that of gymnastics that
emphasizes dry-land fitness and focuses on tumbling and water entry.
Dietary restriction is often used as a strategy to achieve the desirable
muscular and lean physique in divers (136). There is strong evidence that
the common strategy of dietary restriction has a negative impact on both
health and performance, with greater disease risk from an impaired
immune system, dizziness and weakness, and low bone mineral density
(17, 63, 73, 161). In addition, there is evidence that restrictive eating
results in higher body fat percent and greater risk of menstrual disorder
(63, 208). For the pretraining or precompetition period divers should have
a planned meal and/or snack ∼1–4 hours prior to exercise that is
relatively high in carbohydrate and low in fats (214). This intake should
help the diver practice/perform with both normal muscle/liver glycogen
and blood sugar, thereby diminishing the risk of mental disorientation and
premature muscular fatigue. Training far exceeds energy and hydration
needs than divers experience during competition (28). As a result, divers
should plan to have multiple opportunities during training to consume
small quantities of carbohydrate so as to ensure normal blood sugar and
muscle carbohydrate availability (47). During the postcompetition and
posttraining period, divers should consume sufficient fluids, electrolytes,
and energy to recover glycogen stores and to enhance muscle recovery
and muscle protein synthesis (151). Ideally, divers should consume foods
and beverages soon after training/competition to optimize the benefit
(28). There is evidence that, particularly postcompetition, alcohol is
commonly consumed (232). However, alcohol consumption interferes with
nutrient and hydration recovery and also has a negative multiday effect
that can interfere with both training and competition (195). As a result,
alcohol should be avoided.

Football (United States)

American football is highly anaerobic, with plays rarely exceeding 15
seconds, followed by a period of rest/recovery after each play. Football
players are getting bigger and stronger each year and have a relatively
positive body image when compared with other male athletes (169).
Players carry the extra burden of heavy equipment, which adds to the
energy requirement. Because the primary fuels used in this activity are
PCr and muscle glycogen, it is doubtful that the traditional “steak and
potatoes” pregame meal, which overemphasizes protein and
underemphasizes carbohydrate, will optimize glycogen storage. Studies
of athletes, including football players, have found that a wide range of
dietary supplement consumption is common and, although there is no
firm indication that this supplementation negatively influences health,
there are also no data confirming that such supplementation improves
performance (198). Studies of collegiate football players have found that
the rate of vitamin and mineral supplements ranges from 23% to 50%
(119, 196).
The stop-and-go nature of football is also associated with a high level
of body water loss, which can affect the ability to concentrate and
perform (46). Maintenance of plasma volume is strongly associated with
athletic performance, which should encourage football players to
consume a well-designed sports beverage to maintain endurance and
performance (60). A recent assessment of National Collegiate Athletic
Association Division 1 football players suggested that there should be
significant efforts made to improve hydration awareness among football
teams to avoid serious health consequences (including possible
hydration-associated fatalities) that could occur, especially among higher
weight players (i.e., linemen) (120).
The higher weight of current football players compared with the weight
of past players is, by itself, not necessarily a good thing. It was found that
football linemen with higher body fat percentages and higher body mass
indexes had higher rates of lower extremity injuries, and players with
higher body fat levels had a 2.5 times greater relative risk of injury than
those with lower body fat (90, 122). These findings strongly imply that
weight per se is the wrong metric for football players. Instead, any
increase in weight should be accompanied with relative enlargement of
the lean mass to minimize injury risk. This can only be accomplished with
a dynamic interplay between appropriate training and eating, with well-
distributed energy and protein and avoidance of relative energy
deficiency (154). A recent study found that players who ingest protein in a
relatively good energy-balanced state had higher lean mass and lower fat
mass, and those consuming an appropriate level of protein (1.2–2.0
g/kg/day) while not in a state of negative energy balance had even higher
lean mass and lower fat mass (81).

Gymnastics
Artistic gymnasts are small, and there is a high level of pressure to keep
both stature and weight low (83). As a result, gymnasts are considered to
be at high risk of eating disorders and disordered eating, which can
increase risks for poor health and also lower athletic performance (26, 63,
118). Even in men’s gymnastics, it is suggested that controlling energy
intake to achieve lower weight is an appropriate and desired approach if a
gymnast is to achieve success (139). Although lowering mass may lower
the risk of traumatic injuries to joints in gymnastics, achieving lower mass
through inappropriate means places the gymnast at higher skeletal injury
risk (113, 154).
As with other predominantly anaerobic athletes, gymnasts have a
heavy reliance on type IIB (pure fast-twitch) and type IIA (intermediate
fast-twitch) muscle fibers (35). As a result, gymnastic activity is heavily
dependent on PCr and carbohydrate (both blood glucose and muscle and
liver glycogen) to fuel activity. This reliance suggests that gymnasts
should consume a diet that provides ample carbohydrate to optimize
glycogen storage, with a distribution of energy and protein to ensure
optimal muscle protein synthesis and muscle recovery. A number of
studies have evaluated the nutrient intake of elite gymnasts. In general,
these studies demonstrate an inadequacy in the intake of total energy,
iron, and calcium (25, 26, 27). Inadequate calcium, coupled with the fact
that virtually all gymnastic training is indoors, increasing risk for poor
vitamin D status, suggests that gymnasts may be at high risk for stress
fracture. Poor iron intake is associated with anemia, which is a risk factor
in the development of amenorrhea (135). Gymnasts have delayed
menarche, often past the age of 15, which may play a role in bone health
(83). The possible cause of either primary (never having experienced a
period; delayed menarche) or secondary (no period for the past 3
months) amenorrhea includes (154):

relative energy deficiency

poor iron status
high physical stress
high psychological stress

high cortisol level, which interferes with the production of estrogen

(often the result of relative energy deficiency; low blood sugar).
Competitive gymnasts often reach their competitive peak between the
ages of 16 and 18 (83). As adolescents, they have the combined
nutritional requirements to satisfy growth and development and the
physical demands of sport. Satisfying these high nutritional needs is
difficult without appropriate planning. Ideally, this should be done in
cooperation with the training facility to ensure availability of foods and
beverages.

Hockey
For both men and women, hockey is a high-speed, full-effort sport. With
frequent substitutions that allow hockey skaters to perform continuously
at high intensity, it is rare for a skater to be on the ice for more than 1.5
minutes before being replaced. This high-intensity effort focuses on PCr
and carbohydrate (glycogen and glucose). Although nutrition knowledge
of hockey players appears to be poor, there is good indication that hockey
players and team management are open to making appropriate
nutritional changes (50, 179).
A study of elite Swedish hockey players found that skating
performance (speed, distance skated, number of shifts, amount of time
per shift) improved with carbohydrate loading (1). It was also found that
∼60% of quadriceps glycogen is metabolized during a single game (112).
It is conceivable that successive game days and/or successive days of
practice (both common in hockey) could contribute to glycogen depletion
and performance reduction. Although data suggest that players
commonly consume a high-protein diet, the heavy reliance on glycogen
suggests that hockey players should consume a diet relatively high in
carbohydrate (112). Because high-protein diets are also often higher fat
diets, players appropriately changing to a high-carbohydrate diet should
be aware that the lower energy concentration may result in an
inadequate total energy consumption (211). Switching to foods that are
lower in fat and higher in carbohydrate, while maintaining the same
eating frequency, may result in a negative energy balance that is likely to
increase health risks and also be detrimental to performance (23, 111).
The high-intensity activity common in hockey results in high sweat
rates, suggesting that players should strategize for how to sustain
hydration state during a game and should arrive at the game in a well-
hydrated state. It has been found that 1% body weight loss is common in
hockey players, suggesting that a conscious strategy of frequent sports
beverage consumption is necessary (168).

Power/Speed Track and Field Events

Track and field competition includes a number of high-intensity, short-
duration events that are primarily anaerobic. These include sprints, short
distance hurdles, jumping (long jump, high jump, and pole-vault), and
throwing (javelin, shot put, and discus). All of these events are highly
reliant on PCr and glycogen (carbohydrate) to satisfy energy needs (130).
A study assessing different levels of carbohydrate consumption found that
high carbohydrate intakes (∼75% of total calories) produced better sprint
performance than lower intakes (<45% of total calories) of carbohydrate
(159). It is now well established that sprint performance is regulated by
the content of skeletal muscle glycogen, which is largely influenced by
carbohydrate ingestion. Higher carbohydrate intakes of ∼70% of total
calories result in higher glycogen storage levels (14, 58, 200, 214).
The combination of carbohydrate (25 g) and caffeine (100 mg) has
been found to improve intermittent sprint performance when ingested 1
hour before exercise (57). This study found higher glucose levels during
the final states of exercise, a finding that could be important for
competitive field events where several tries/rounds (i.e., long-jump, pole-
vault) are necessary to determine the winner.
Pure sprinters should consider carefully whether carbohydrate
supercompensation (i.e., maximizing glycogen storage through reduced
glycogen utilization through avoidance of higher intensity activity, and
higher glycogen formation through high carbohydrate intake) is
necessary, because glycogen is stored with water (1 g glycogen to 3–4 g
water) (162). Having a level of glycogen storage that exceeds the
requirement of a single competitive performance may add unnecessary
(water) weight, thereby putting the sprinter at a disadvantage. Sprinters
should sustain relatively high carbohydrate intakes but make a
performance-related self-determination regarding whether following a
carbohydrate supercompensation strategy is warranted.

Swimming (100–400 m)
Swimmers spend a great deal of time in water training to practice
techniques that help to overcome drag. Typical energy expenditures of
swimmers range between 3,600 and 4,800 kcal/day for males and 1,900
and 2,600 kcal/day for females (192). During competitions, the shorter
(sprint) distances derive most of the required energy anaerobically from
PCr and glycogen (see Table 15.5). Studies have found a large between-
swimmer variation in energy intakes, with male swimmers more likely to
satisfy energy needs than female swimmers (30, 121). This finding
suggests that a large proportion of swimmers have dietary habits that fail
to optimally support training and competition needs.
The need for carbohydrate is estimated to be in the range of 3–10
g/kg, depending on training demands (193). Protein requirements, which
are in the range of 1.2–1.6 g/kg/day, appear to be met, but many
swimmers often fail to optimally time protein consumption to optimize
muscle recovery and muscle protein synthesis (4, 48). Ideally, high-
quality protein should be consumed in 20–25 g amounts evenly
distributed over 4–5 meals/snacks during the day (48).
Competitive training for swimmers often begins at a young age, with
many of them in junior high school and high school. Training often occurs
before school begins in the early morning and often continues
immediately after school. This schedule, particularly for adolescent
swimmers experiencing a growth spurt, requires a high-energy intake that
must be planned for to ensure normal growth and development and no
additional health risks. Relative energy deficiency in this young group of
athletes could have both negative performance effects (i.e., reduced
performance, increased injury risk, decreased coordination) and long-term
health implications (i.e., poor bone health, poor growth and development,
poor menstrual function in female athletes) (154, 192).
Sprinting times that exceed 2 minutes should be followed with a
recovery time of at least 4 minutes to regenerate PCr. Without an
appropriate recovery period, swimmers will be forced to train shorter
durations at lower intensities, which could negatively affect competition
(120, 177, 192).
It may appear odd that swimmers may suffer from poor hydration
because they train in a water environment, but it has been found that
poor hydration is prevalent in swimmers (182). Although the level of
dehydration is mild, swimmers should take steps to sustain normal
hydration by having readily available sports beverages during training
and competition.

Wrestling
Surveys of wrestling coaches assessing nutrition knowledge suggest that
a high proportion of the coaches have a less-than-adequate knowledge
base to be guiding young athletes in these areas (203). The American
College of Sports Medicine position on weight loss in wrestlers states
(163):

Despite a growing body of evidence admonishing the behavior,

weight cutting (rapid weight reduction) remains prevalent among
wrestlers. Weight cutting has significant adverse consequences that
may affect competitive performance, physical health, and normal
growth and development. To enhance the education experience and
reduce the health risks for the participants, the ACSM recommends
measures to educate coaches and wrestlers toward sound nutrition
and weight control behaviors, to curtail “weight cutting,” and to enact
rules that limit weight loss.

The general goal of this weight-loss strategy is to qualify for a weight

class during a weigh-in on the night before a match, and to gain as much
weight as possible between the weigh-in and the match on the next day.
Sadly, there is evidence that wrestling at a weight below the predicted
minimum wrestling weight appears to be associated with greater
wrestling success (228). There is also good evidence that successful
weight gain during this short period is important for success. In one study
evaluating the relative weight gains of wrestlers, the heavier wrestler was
successful 57% of the time (227).
There is concern on many levels about the weight-loss techniques
commonly practiced by wrestlers. There is some evidence that
undernutrition may lead to altered growth hormone production in
wrestlers that, if present over several seasons, could lead to growth
impairment (185). In another study, it was determined that dietary
restriction reduced protein nutrition to an average of 0.9 g/kg/day, which
is below recommended levels, and also lowered muscular performance
(186). These data are confirmed by findings indicating that weight loss by
energy restriction significantly reduced anaerobic performance of
wrestlers. Those on a high-carbohydrate refeeding diet tended to recover
their performance, whereas those with lower intakes of carbohydrate did
not (178). Besides the obvious physiologic changes that occur from rapid
weight loss, there is good evidence that rapid weight loss in collegiate
wrestlers causes an impairment of short-term memory, a fact that could
have an impact on scholastic achievement in these student athletes (53).
“Making weight” is a hazard to both performance and health. There is
ample evidence to suggest that the weight cycling associated with
making weight (i.e., weight loss to make weight followed by weight
recovery for performance) is dangerous and can lead to glycogen
depletion, a lower muscle mass, a lower REE, and an increase in body fat
(110). Should this occur with frequency, it is likely that the reduction in
REE could make it more difficult for dietary restriction to achieve the
desired weight, leading the wrestler to take more draconian (and more
dangerous) measures to achieve the desired weight outcome. Wrestlers
and coaches should follow a reasonable model for achieving desired
weight, such as that offered by the Wisconsin Interscholastic Athletic
Association, to avoid health and performance difficulties (164). This
program develops reasonable goals for weight and provides nutrition
education information to help wrestlers achieve desired weight
reasonably and to understand the implications of improper weight-loss
methods. The basic message of these weight-achievement guidelines is
that a cap is placed on the maximum amount of weight change that can
occur during the course of a season, and a monitoring system has been
added to ensure that sudden and dramatic weight change does not occur
at any point in the season.

Nutrition Issues for Selected Sports With a High

Endurance Component
The following sports provide examples of how nutrition influences
endurance activities. The list of sports is not intended to be
comprehensive. Rather, the sports provide the reader with ideas for how
to apply the science to athletes involved in different activities.

Distance Running
Distance running involving distances of 10,000 m (6.2 miles) or longer
places a high reliance on aerobic metabolism, with only 2%–7% of the
total energy obtained derived anaerobically (202). Despite this relatively
low reliance on glycogen, the fact that distance runners have continuous
activity far longer than power athletes places a high demand for
glycogen. Put simply, although the proportion of glycogen utilized is
relatively low, the volume of glycogen used is high because of the long
time spent in the activity (116). As a result, high muscle and liver
glycogen stores prior to the run and carbohydrate delivery during the run
are important factors for runners to consider.
Gastrointestinal (GI) issues occur with high frequency in long-distance
runners, often the result of the consumption of fluids that are
hyperosmolar, with excessive concentrations of carbohydrate (>8%
carbohydrate solution), electrolytes (>200 mg sodium/250 mL), or both
(174). It is important for individual runners to know their tolerance for the
beverages they consume during the run, as higher carbohydrate
concentrations are typically associated with improved performance, but
may also be associated with higher levels of GI distress. These symptoms
include nausea, abdominal cramping, vomiting, and diarrhea (181).
More serious problems can include blood loss in the feces as a result of
damage to the intestines (116). Distance runners train for long hours with
repeated motion, which may increase the risk of stress fractures (173).
Stress fractures occur more frequently in women runners than in male
runners, particularly if the female runner is amenorrheic (219). There is a
clear relationship between amenorrhea and lower bone density, so
amenorrheic runners should seek the advice of a physician to determine if
there are reasonable steps that can be taken, including running “softer"
through stride modifications and runner surface changes, to reduce the
risk of stress fractures (154, 180, 219). A review of stress fractures in
runners found that being female and a prior history of stress fractures
were predictive of future fractures (226). Sufficient energy and
consumption of calcium and vitamin D are important to ensure normal
bone development. Although vitamin D is likely to be adequate,
particularly for runners who train during the day and have ample sun
exposure, runners must be purposeful in consuming diets that provide
sufficient energy and calcium (223). Inadequate energy intake is a red
flag that nutrient intake may also be low (food is the carrier of both
nutrients and energy) and that the runner is at high risk for both disease
and reduced performance (154). The nonmenstruating female runners
had lower intakes of fat, and higher fat intakes were associated with more
adequate total energy consumption (62). These findings suggest that
high-carbohydrate diets, which are preferred for optimal performance,
may make it more difficult to consume the high level of needed energy
because carbohydrates have a lower caloric density than high-fat foods.
Surveys of distance runners confirm that total energy intake is below
recommended levels, suggesting that runners must make a concerted
effort to consume the recommended amounts before, during, and after
exercise (22). Runners should learn to manage hydration state by taking
pre- and posttraining weight in different environmental conditions. This
strategy will help them understand the degree to which they are
satisfying body fluid needs (214). Studies of distance runners suggest a
range of weight loss averaging ∼3%, with individual ranges from 0.8% to
5.0% (61). Surveys of runners have found that, despite knowing that
hydration is important, a large proportion of runners (41%–54.4%) have
poor hydration habits, particularly during training, and that 35.4% of
runners consumed sports drinks, whereas nearly 4% never consumed
fluids of any kind in training (84). Studies strongly suggest that 7%
carbohydrate solutions with electrolytes are effective as both fluid and
energy replacement beverages (152, 214). Long-distance runners should
develop the habit of frequent fluid consumption to maintain body water
status, whether they are thirsty or not. See Box 15.1 for the calculation of
the percent of carbohydrate in a sports drink.

Box 15.1 How to Calculate the Percent of Carbohydrate in a

Sports Drink

1. Convert the serving size from fluid ounces (oz) or milliliters (mL) to
grams (g).
a. Fluid ounces (oz): Divide the total ounces by 0.03527 for grams
i. Example: 16 oz/0.03526 = 453.77 g
b. Milliliters (mL): Divide the amount in mL by 1
i. Example: 500 mL/1 = 500 g
2. Calculate the carbohydrate percent in a serving size by dividing the
carbohydrate amount in 100 g and then multiply by 100.
a. A drink containing 6 g of carbohydrate per 100 mL (or 100 g) =
6/100 = 0.06
b. 0.06 × 100 = 6% carbohydrate solution
Triathlon
The Olympic-Distance Triathlon consists of a 1.5-km swim, a 40-km cycle,
and a 10-km run. The most well-known IRONMAN competition in Hawaii
(Kona) includes a 2.4-mile swim, a 112-mile bike run, and a 26-mile, 385-
yard run. A survey of triathletes found that the average weekly training
distances were: swimming 8.8 km (5.47 miles); cycling 270 km (167.77
miles), and running 58.2 km (36.16 miles) (93). Interestingly, there
appears to be a high level of overtraining, as a study found statistically
significant performance improvements when triathletes reduced the total
time spent during training prior to a competition (15). The improvement is
likely due to improvement in net glycogen storage associated with a
reduction in intense activity that is coupled with a relatively high
carbohydrate intake (214).
Different sporting activities may influence athletes to consume
different foods and to consume different supplements, resulting in
different nutrient exposure (86). In an athlete survey it was found that
calcium intake was lower in triathletes than in athletes participating in
team sports, including volleyball and basketball, with more pronounced
lower intakes in female triathletes (92). Consumption of sufficient calcium
is an important component of reducing stress fracture risk.
Maintenance of normal hydration is important to sustain sweat rates
and blood volume. There are indications that triathletes may not consume
sufficient fluids, which would affect performance and increase risk for
heat stress. One study found that pre- and postevent weight declined
significantly, whereas urine osmolarity increased significantly, both signs
of underhydration (13). Triathletes appear to have difficulty sustaining
good hydration during a competition, with body weight loss that
commonly exceeds 4% (187). Particularly when competing in warm
climates, triathletes should develop well-practiced fluid consumption
behaviors to minimize dehydration risk. It is important to note that
consumption of ice slurry is useful for cooling core temperature in
triathletes when they compete or train in hot environments, resulting in
improved performance (205, 209).
The majority of Olympic-distance triathletes appear to consume
sufficient carbohydrate to satisfy prerace guidelines, but carbohydrate
consumption during the race varies widely between athletes, with a large
proportion of them failing to satisfy recommended carbohydrate intake
levels (59). This is significant, as the carbohydrate demands in the
triathlete are greater than the capacity of the athlete to store it (183).
Therefore, it is important for triathletes to have a strategy for adequate
carbohydrate intake during competition, which should be in the range of
1.0–1.5 g/kg/hour (214). Nutrition interventions encouraging the
consumption of more fluid and carbohydrates by triathletes have been
successful, with triathletes consuming a level of energy closer to the
requirement than before the intervention, which was associated with
improved performance (78).

Long-Distance Swimming
Distance swimmers must spend a great deal of time training in water to
achieve incrementally small improvements in time and performance
(192). Swimming performance is based on a swimmer’s ability to create
forward propulsion while minimizing the drag created as he or she moves
through water, a task that is better enabled with a relatively lean
physique (177). Achieving this level of endurance and body composition
requires avoidance of relative energy deficiency, which could compromise
lean mass and diminish necessary glycogen stores (149). Ideally, needed
energy should be provided before, during, and after training to optimize
the training benefit. Male and female swimmers report energy intakes of
up to 4,800 kcal/day and 2,600 kcal/day, respectively (192).
When compared with other athletes, swimmers often have higher
upper body strength but lower bone mineral densities (29, 133). There are
likely to be three reasons for this, including inadequate energy
availability, poor vitamin D status associated with many hours training in
an indoor pool without exposure to sunlight, and less physiologic stress
being placed on bone because swimmers train in water, which is
essentially a gravity-free environment (140). This latter reason suggests
that at least a portion of the training by swimmers, particularly young
adolescent swimmers who are undergoing the adolescent growth spurt
and large changes in bone development, should place resistance on both
the upper and lower body.
The volume of training by distance swimmers will deplete muscle
glycogen stores, indicating a high need for carbohydrate replacement
strategies (193). Consuming fluids during training that are carbohydrate
containing would serve to satisfy both carbohydrate and fluid
requirements (48).

Cycling
The Tour de France cycle race has extreme endurance demands on
participating athletes, with a distance of 4,000 km traveled in just over 3
weeks with only a single day of rest. The energy expended is the highest
values ever reported for athletes over a period longer than 7 days (188).
Consumption patterns indicate a high carbohydrate diet (62%
carbohydrate; 15% protein; 23% fat), with ∼50% of total consumed
energy between standard meals, and about 30% of energy is consumed
as a carbohydrate-containing sports beverage (39).
 Asthma prevalence in elite cyclists appears to be approximately twice
that of the general population (221). As a result, it may be prudent to
make careful allergy inquiries before making recommendations on food
and beverage consumption so as to avoid triggering an allergic response.
Cyclists can easily carry fluids and foods on the bike frame or in jersey
pockets, and because there is less jarring motion in cycling than in
running, cyclists can consume some solid foods without experiencing GI
distress. Cyclists should take advantage of this on long rides by bringing
along sport beverages to drink and some crackers, bananas,
carbohydrate gel, or bread to consume, but whatever is consumed should
be known to be well tolerated. Although the need for carbohydrate is
highest, many cyclists believe that higher protein foods are beneficial for
performance. However, there is no indication that protein foods
consumed during cycling enhance performance, and because these foods
detract from the consumption of carbohydrate foods they may be
performance reducing (94).

General Athlete Assessment Strategies to Ensure

Nutritional Readiness

The assessment and status of an athlete’s health typically include

health/medical history, body composition, and food intake and energy
balance.

Health/Medical History
Health/medical history is typically obtained via an in-depth athlete
interview and includes a discussion of:

medical history that provides information on prescribed and

nonprescribed (over-the-counter) drug usage;
alcohol consumption;
typical eating environment (i.e., university cafeteria; cooks for self in
apartment);
chronic disease state (e.g., diabetes, amenorrhea);
relevant acute conditions (e.g., broken bones, muscle strains);
allergies (food and nonfood), food intolerances, and food sensitivities;
understanding of changes that may have occurred in appetite;
if athlete has self-initiated or been placed on a special diet that may
put the athlete at nutritional risk;
family history of disease states (e.g., cardiovascular disease; kidney
disease)
 results of any past blood tests indicating normal or abnormal values
(e.g., serum iron test for diagnosis of anemia); and
recommendations for biologic tests (e.g., blood tests, urine tests)
where risk of disease/condition is suggested by health history results
(e.g., athlete is considered to be at risk of anemia because of food
avoidance pattern).

Body Composition Assessment

Body composition assessment is a multicomponent analysis, involving:

measurement of height, weight, body fat percent, lean mass percent;

comparison of these values with sport-specific norms;
trend analysis to assess how body composition values have changed.
Note: it is important to use the same validated measurement
strategies for this purpose; and
Z-score analysis to assess how athlete body composition values differ
from position-specific team values.

Food Intake and Energy Balance Assessment

Food intake and energy balance assessment involves the following:

computerized food intake analysis to include assessment of

micronutrient and macronutrient intakes compared with age/gender-
specific dietary reference intakes;
understanding of food avoidance/food preference patterns;
review of any possible disease states and clinical conditions with
associated drug intake that could affect nutrient needs;
prediction of energy balance values to assess within-day relative
energy availability and 24-hour energy balance, for typical training
and nontraining days;
gain an understanding of possible cultural, religious, and/or cultural-
associated food intake patterns that may influence macro- and
micronutrient intake; and
under some circumstances, measuring hydration state via
assessment of urine-specific gravity.

See Appendix A for sample athlete health history, nutritional status,

and body composition questionnaire and Appendix B for three examples
of dietary intake analysis and eating plans. Please note that NutriTiming,
which accesses the United States Department of Agriculture nutrient
database and the Harris–Benedict equation for predicting REE, was used
to create the food plans in Appendix B.
 Summary

The type of activity performed impacts the type of energy

metabolized, but this difference does not necessarily have an impact
on the types and frequency of foods/beverages that should be
consumed. Although high-intensity power activities (e.g., sprinting)
are highly reliant on glycogen as a source of fuel and low-intensity
endurance activities (e.g., marathon) are highly reliant on fat as a
source of fuel, glycogen storage is the limiting substrate for both
types of activities because of the high duration of endurance
activities. Therefore, regular dietary sources of carbohydrates should
be consumed by all types of athletes to ensure optimal glycogen
storage (214).
Because power athletes are heavily reliant on glycogen stores to fuel
the activity, a practice lasting several hours will require regular
consumption of carbohydrate to avoid glycogen depletion and a
reduction in performance.
Although endurance athletes are heavily reliant on fat stores to fuel
the activity, glycogen is still being used over the long duration of
training and competition. Therefore, a regular intake of carbohydrate
during training and competition is needed to avoid glycogen depletion
and a reduction in performance.
Different types of muscle fibers have different power potential, with
type II fibers producing more power than type I fibers. The type IIA
intermediate fibers behave more like power fibers than endurance
fibers, but the type of chronic activity that is performed can change
the behavior of these fibers. For instance, an athlete who does more
endurance activity will modify their type IIA fibers to develop more
mitochondria and oxidative capacity, so they begin to look more like
type I fibers.
Well-conditioned athletes have a better capacity to deliver and use
oxygen in working muscles, enabling better performance and a longer
time before reaching fatigue. Because even the leanest of athletes
have ample body fat stores that can be called upon for fuel but
glycogen storage is relatively limited in all athletes, a greater capacity
to use fat as a fuel (the result of better oxygen utilization), the less
likely that glycogen will become depleted.
Carbohydrate insufficiency during exercise will increase ketone
production from gluconeogenesis (i.e., the creation of carbohydrate
from noncarbohydrate sources).
PCr, a source of instantaneous ATP, storage is limited to ∼8 seconds
of high-intensity activity. Assuming sufficient availability of creatine
(likely with sufficient intake of energy/protein), depleted PCr stores
can be regenerated with 2–4 minutes of rest.
Consumption of more protein, by itself, will not result in an increased
muscle mass. Increasing muscle mass is multifactorial, requiring a
reasonably good sustained energy and nutritional balance, resistance
training, and a timing and quality of food intake that can take
advantage of muscle protein synthesis potential.
Although the recommended protein intake for athletes is
approximately double that of nonathletes, most athletes appear to
consume sufficient amounts of protein from foods alone. A possible
exception is vegetarian athletes who do not as consistently obtain
sufficient protein.
Anabolic hormones are involved in tissue building and include
testosterone, insulin, HGH, and IGF-1.
Catabolic hormones are involved in tissue breakdown and include
cortisol, thyroxine, and epinephrine.
There is limited evidence that dietary supplements are useful in
improving athletic performance. Ideally, athletes should take a “food-
first” approach to meeting nutritional needs.
Sustaining a good hydration state is important for all athletes,
regardless of the sport. One of the adaptations to physical activity is
to enlarge the blood volume, enabling a better sustained state of
hydration if the athletes follow a hydration protocol that maintains
both blood volume and fluid balance between the extracellular (blood)
and intracellular (tissues) environments. As little as a 2% drop in body
weight, resulting from more body water lost than replaced, can have
a significant impact on athletic performance.
Overtraining is associated with multiple problems that is likely to
reduce athletic performance, including high muscle soreness and
delayed muscle recovery. Athletes should have a training play that
incorporates an adequate diet to meet energy/nutrient needs and
sufficient rest to recover from training.
Optimal nutritional/hydration preparation for practice/competition
cannot occur in the meal just before physical activity. Athletes require
a consistent daily plan for ensuring adequate energy, protein,
carbohydrate, fluids, and nutrients to ensure that nutrition is positive
factor in athletic performance.
Excess fluid consumption resulting in weight gain increases the risk of
hyponatremia, which can result in bloating, respiratory distress, and
brain edema with a potentially fatal outcome.
Blood sugar typically remains in the normal range for ∼3 hours when
performing normal daily activity. However, physical activity increases
the rate at which brain and muscle tissues utilize blood sugar,
dramatically reducing the length of time that blood sugar stays in the
normal range. As a result, athletes should have a strategy of
carbohydrate consumption, typically by consuming a carbohydrate-
containing beverage, during physical activity that helps to sustain
normal blood sugar.
Much of the information that athletes receive about nutrition comes
from false nutritional claims in magazine advertisements and stories
that target athletes. A significant proportion of the “evidence”
presented in these magazines is false.
Alcohol consumption can negatively impact athletic performance,
with even a single serving (i.e., 1 beer, 1 glass of wine) affecting
reaction time for multiple days. If an athlete consumes alcohol, they
should be aware of the performance sequelae of doing so.
Athletes are at high risk of iron deficiency for multiple reasons,
including faster breakdown of RBCs, poor dietary intake, and
increased urinary and fecal loses of iron. It is not possible for an
athlete with iron deficiency or iron deficiency anemia to perform up to
their conditioned capacity.
Athletes in sports where “making weight” (e.g., wrestling) or sports
where appearance (e.g., figure skating, gymnastics) is a factor in
scoring are at risk for following dietary patterns that will hinder
performance. Relative energy deficiency in sport is now documented
to cause numerous performance and health problems that may
prematurely cause an athlete to fail athletically and leave the sport
prematurely.
Athletes who train indoors (i.e., basketball, gymnastics, figure skating)
are at risk of vitamin D deficiency because of a failure to receive
adequate ultraviolet B radiation from the sun. Vitamin D deficiency
has multiple negative health and performance outcomes, including
low bone density, increased illness frequency, and poor muscle
recovery.
Preparticipation evaluations that include a health/medical history are
important and should be performed annually in all athletes to identify
health and nutritional risks.
Body composition assessment is an important component of the
nutritional assessment to ensure that the athlete is eating in a way to
achieve body composition goals. However, care must be taken to use
body composition results in a way that will result in positive
outcomes. As an example, the risk that an athlete will follow a low-
calorie diet that fails to provide sufficient energy is greater if told that
their body fat percent is too high, than if they are told that lean body
mass percent is too low.
 Practical Application Activity

Imagine 2 young adults, age 23, of the same sex, height, weight, and
body composition. Person A has spent the last 5 years running long
distances of ∼ 5 miles (8 kilometers) every other day, and he has
participated in several half-marathon races. Person B is a talented
tennis player who has been playing competitive tennis for the past 5
years. Both are healthy and fit. Now imagine that Persons A and B have
met at a party, and Person A invites Person B to go for a long morning
run. They agree, and go for a morning run. After about 1 mile, Person A
is carrying on a conversation with Person B, but Person B is starting to
get short of breath and cannot participate in the conversation without
taking frequent gasps for air. In addition, Person A is running faster but
with greater ease than Person B, who is now struggling to keep up.
Explain what is happening:

1. Is there a difference in the trained metabolic systems that could be

the cause of this difference in comfort level while running?
2. How do training differences impact muscle fibers, and could this
difference help to explain why Person A and Person B are
responding differently to this morning run?
3. Who (Person A or B) is likely to more efficiently burn fat as an
energy substrate, and how would this difference impact time to
fatigue?
4. If the tables were turned, and Person B asked Person A to
participate in stop-and-go activity such as tennis, would Person A
now become fatigued more quickly? If so, what is the metabolic
explanation for this?
5. If you were making dietary recommendations to both Person A and
Person B, would these recommendations differ? If so, in what ways
would they be different?

Chapter Questions

1. Of the following, which energy metabolic system is used for high-

intensity activities that require a large volume of ATP, but that are
within the athlete’s capacity to bring sufficient oxygen into the system?
a. PCr system
b. Anaerobic glycolysis
c. Aerobic glycolysis
d. Aerobic metabolism
e. b and c
 f. c and d
2. Of the following muscle fibers, which store a high level of glycogen and
remain primarily anaerobic regardless of conditioning protocol?
a. Type I
b. Type IIA
c. Type IIB
d. Type III
3. Preformed PCr has sufficient energy to supply an athlete with up to
________ seconds of sudden-onset, high-intensity activity.
a. 3
b. 8
c. 20
d. 60
4. The delay time to achieve maximal ATP production with aerobic
glycolysis is approximately:
a. 0–1 seconds (instantaneous)
b. 5–10 seconds
c. More than 60 seconds
d. More than 20 minutes
5. Well-conditioned athletes have better oxygen delivery to working
muscles, enabling them to maintain oxidative metabolism at a faster
rate and to go faster longer before reaching fatigue.
a. True
b. False
6. A relatively lean male athlete weighing 154 lb will store ∼_______
calories as fat?
a. 500
b. 1,000
c. 50,000
d. 90,000
7. The percent contribution of aerobic β-oxidation to total energy needs in
distance running is approximately:
a. 30%
b. 50%
c. 70%
d. 90%
8. The percent contribution of aerobic β-oxidation to total energy needs in
gymnastics is approximately:
a. 5%
b. 20%
c. 40%
d. 60%
9. Of the following hormones, which is not anabolic to muscle mass
development?
a. Insulin
b. Creatine
c. Growth hormone
d. Testosterone
10. The eating pattern of bodybuilders leading in weight loss and weight
gain over a competitive season increases preoccupation with food that
may result in both binge eating and psychological stress following
competitions.
a. True
b. False

Answers to Chapter Questions

1. c
2. c
3. b
4. c
5. a
6. d
7. c
8. a
9. b
10. a

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Type of Use For an Individual For a Group
Planning RDA: Aim for this EAR: Use in
intake. conjunction with a
measure of
variability of the
group’s intake to set
goals for the mean
intake of a specific
population.
AI: Aim for this intake.
UL: Use as a guide to
limit intake; chronic
intake of higher
amounts may increase
risk of adverse effects.
 Type of Use For an Individual For a Group
Assessmenta EAR: Use to examine EAR: Use in the
the possibility of assessment of the
inadequacy: prevalence of
evaluation of true inadequate intakes
status requires clinical, within a group.
biochemical, and/or
anthropometric data.
UL: Use to examine
the possibility of
overconsumption;
evaluation of true
status requires clinical,
biochemical, and/or
anthropometric data.

RDA, the average daily dietary intake level that is sufficient to meet the nutrient
requirement of nearly all (97%–98%) healthy individuals in a group;
EAR, a nutrient intake value that is estimated to meet the requirement of half the
healthy individuals in a group;
AI, a value based on observed or experimentally determined approximations of
nutrient intake by a group (or groups) of healthy people — used when an RDA
cannot be determined;
UL, the highest level of daily nutrient intake that is likely to pose no risk of
adverse health effects to almost all individuals in the general population. As
intake increases above the UL, the risk of adverse effects increases.
a
Requires statistically valid approximation of usual intake.

AI, adequate intake;

EAR, estimated average requirement;

RDA, recommended dietary allowance; UL, tolerate upper intake level.

Source: Institute of Medicine, Food and Nutrition Board. Washington, DC: National
Academy Press; 1998.

Barr SI. Introduction to Dietary Reference Intakes. Applied Physiology Nutrition

and Metabolism. 2006; 31: 61–65. doi:10.1139/H05–019

The Institute of Medicine full reference:

Institute of Medicine (US) Food and Nutrition Board. Dietary Reference Intakes: A
Risk Assessment Model for Establishing Upper Intake Levels for Nutrients.
Washington (DC): National Academies Press (US); 1998. What are Dietary
Reference Intakes? Available from:
https://www.ncbi.nlm.nih.gov/books/NBK45182/
This table (taken from the DRI reports, see www.nap.edu) presents RDAs in bold
type and AIs in ordinary type followed by an asterisk (*). An RDA is the average
daily dietary intake level, sufficient to meet the nutrient requirements of nearly
all (97%–98%) healthy individuals in a group. It is calculated from an EAR. If
sufficient scientific evidence is not available to establish an EAR, and thus
calculate an RDA, an AI is usually developed. For healthy breastfed infants, an AI
is the mean intake. The AI for other life stage and gender groups is believed to
cover the needs of all healthy individuals in the groups, but lack of data or
uncertainty in the data prevent being able to specify with confidence the
percentage of individuals covered by this intake.
AIs, adequate intakes; EAR, estimated average requirement; RDAs,
recommended dietary allowances.

Sources: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium,

Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin,
Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline
(1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and
Carotenoids (2000); and Dietary Reference Intakes for Vitamin A, Vitamin K,
Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel,
Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water,
Potassium, Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes
for Calcium and Vitamin D (2011). These reports may be accessed via
www.nap.edu.
Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus,
Magnesium, Vitamin D, and Fluoride. 1997. Washington DC: The National
Academies Press.
(This report may be accessed from the National Academies Press via
www.nap.edu)
Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin,
Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. 1998.
Washington, DC: The National Academies Press. (This report may be accessed
from the National Academies Press via www.nap.edu)
Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E,
Selenium, and Carotenoids. 2000. Washington, DC: The National Academies
Press. (This report may be accessed from the National Academies Press via
www.nap.edu)
Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic,
Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon,
Vanadium, and Zinc. 2001. Washington, DC: The National Academies Press. (This
report may be accessed from the National Academies Press via www.nap.edu)
Institute of Medicine, Dietary Reference Intakes for Water, Potassium, Sodium,
Chloride, and Sulfate. 2005. Washington, DC: The National Academies Press. (This
report may be accessed from the National Academies Press via www.nap.edu)
Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. 2011.
National Academies Press. (This report may be accessed from the National
Academies Press via www.nap.edu)
An UL is the highest level of daily nutrient intake that is likely to pose no risk of
adverse health effects to almost all individuals in the general population. Unless
otherwise specified, the UL represents total intake from food, water, and
supplements. Due to a lack of suitable data, ULs could not be established for
vitamin K, thiamin, riboflavin, vitamin B12, pantothenic acid, biotin, and
carotenoids. In the absence of a UL, extra caution may be warranted in
consuming levels above recommended intakes. Members of the general
population should be advised not to routinely exceed the UL. The UL is not meant
to apply to individuals who are treated with the nutrient under medical
supervision or to individuals with predisposing conditions that modify their
sensitivity to the nutrient.
a
Although the UL was not determined for arsenic, there is no justification for
adding arsenic to food or supplements.
b
The ULs for magnesium represent intake from a pharmacological agent only and
do not include intake from food and water.
c
Although silicon has not been shown to cause adverse effects in humans, there
is no justification for adding silicon to supplements.
d
Although vanadium in food has not been shown to cause adverse effects in
humans, there is no justification for adding vanadium to food and vanadium
supplements should be used with caution. The UL is based on adverse effects in
laboratory animals and this data could be used to set a UL for adults but not
children and adolescents.
e
ND = Not determinable due to lack of data of adverse effects in this age group
and concern with regard to lack of ability to handle excess amounts. Source of
intake should be from food only to prevent high levels of intake.

Sources: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium,

Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin,
Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline
(1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and
Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic,
Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon,
Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium,
Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes for Calcium
and Vitamin D (2011). These reports may be accessed via www.nap.edu.
Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus,
Magnesium, Vitamin D, and Fluoride. 1997. Washington DC: The National
Academies Press. (This report may be accessed from the National Academies
Press via www.nap.edu)

Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin,

Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. 1998.
Washington, DC: The National Academies Press. (This report may be accessed
from the National Academies Press via www.nap.edu)

Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E,

Selenium, and Carotenoids. 2000. Washington, DC: The National Academies
Press. (This report may be accessed from the National Academies Press via
www.nap.edu)

Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic,

Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon,
Vanadium, and Zinc. 2001. Washington, DC: The National Academies Press. (This
report may be accessed from the National Academies Press via www.nap.edu)

Institute of Medicine, Dietary Reference Intakes for Water, Potassium, Sodium,

Chloride, and Sulfate. 2005. Washington, DC: The National Academies Press. (This
report may be accessed from the National Academies Press via www.nap.edu)

Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. 2011.
National Academies Press. (This report may be accessed from the National
Academies Press via www.nap.edu)
This table (taken from the DRI reports, see www.nap.edu) presents RDAs in bold
type and AIs in ordinary type followed by an asterisk (*). An RDA is the average
daily dietary intake level, sufficient to meet the nutrient requirements of nearly
all (97%–98%) healthy individuals in a group. It is calculated from an EAR. If
sufficient scientific evidence is not available to establish an EAR, and thus
calculate an RDA, an AI is usually developed. For healthy breastfed infants, an AI
is the mean intake. The AI for other life stage and gender groups is believed to
cover the needs of all healthy individuals in the groups, but lack of data or
uncertainty in the data prevent being able to specify with confidence the
percentage of individuals covered by this intake.

a
As RAEs. 1 RAE = 1 mcg retinol, 12 mcg β-carotene, 24 mcg α-carotene, or 24
mcg β-cryptoxanthin. The RAE for dietary provitamin A carotenoids is two-fold
greater than RE, whereas the RAE for preformed vitamin A is the same as RE.
b
As cholecalciferol. 1 mcg cholecalciferol = 40 IU vitamin D.
c
Under the assumption of minimal sunlight.
d
As α-tocopherol. α-Tocopherol includes RRR-α-tocopherol, the only form of α-
tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of α-
tocopherol (RRR-, RSR-, RRS-, and RSS-α-tocopherol) that occur in fortified foods
and supplements. It does not include the 2S-stereoisomeric forms of α-tocopherol
(SRR-, SSR-, SRS-, and SSS-α-tocopherol), also found in fortified foods and
supplements.
e
As NE. 1 mg of niacin = 60 mg of tryptophan; 0–6 months = preformed niacin
(not NE).
f
As DFE. 1 DFE = 1 mcg food folate = 0.6 mcg of folic acid from fortified food or
as a supplement consumed with food = 0.5 mcg of a supplement taken on an
empty stomach.
g
Although AIs have been set for choline, there are few data to assess whether a
dietary supply of choline is needed at all stages of the life cycle, and it may be
that the choline requirement can be met by endogenous synthesis at some of
these stages.

h
Because 10%–30% of older people may malabsorb food-bound B12, it is
advisable for those older than 50 years to meet their RDA mainly by consuming
foods fortified with B12 or a supplement containing B12.

i
In view of evidence linking folate intake with neural tube defects in the fetus, it is
recommended that all women capable of becoming pregnant consume 400 mcg
from supplements or fortified foods in addition to intake of food folate from a
varied diet.

j
It is assumed that women will continue consuming 400 mcg from supplements or
fortified food until their pregnancy is confirmed and they enter prenatal care,
which ordinarily occurs after the end of the periconceptional period — the critical
time for formation of the neural tube.

AIs, adequate intakes; DFE, dietary folate equivalents; EAR, estimated average
requirement; NE, niacin equivalents; RAEs, retinol activity equivalents; RDA,
recommended dietary allowances; RE, retinol equivalents.
Sources: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium,
Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin,
Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline
(1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and
Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic,
Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon,
Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium,
Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes for Calcium
and Vitamin D (2011). These reports may be accessed via www.nap.edu.

Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic,

Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon,
Vanadium, and Zinc. 2001. Washington DC, The National Academies Press. (This
report may be accessed from the National Academies Press via www.nap.edu)

Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. 2001.
Washington DC, The National Academies Press. (This report may be accessed
from the National Academies Press via www.nap.edu)

Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin,

Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. 1998.
Washington DC, The National Academies Press. (This report may be accessed
from the National Academies Press via www.nap.edu)

Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E,

Selenium, and Carotenoids. 2000. Washington DC, The National Academies Press.
(This report may be accessed from the National Academies Press via
www.nap.edu)
A UL is the highest level of daily nutrient intake that is likely to pose no risk of
adverse health effects to almost all individuals in the general population. Unless
otherwise specified, the UL represents total intake from food, water, and
supplements. Due to a lack of suitable data, ULs could not be established for
vitamin K, thiamin, riboflavin, vitamin B12, pantothenic acid, biotin, and
carotenoids. In the absence of a UL, extra caution may be warranted in
consuming levels above recommended intakes. Members of the general
population should be advised not to routinely exceed the UL. The UL is not meant
to apply to individuals who are treated with the nutrient under medical
supervision or to individuals with predisposing conditions that modify their
sensitivity to the nutrient.

a
As preformed vitamin A only.
b
As α-tocopherol; applies to any form of supplemental α-tocopherol.
c
The ULs for vitamin E, niacin, and folate apply to synthetic forms obtained from
supplements, fortified foods, or a combination of the two.
d
β-Carotene supplements are advised only to serve as a provitamin A source for
individuals at risk of vitamin A deficiency.

e
ND = Not determinable due to lack of data of adverse effects in this age group
and concern with regard to lack of ability to handle excess amounts. Source of
intake should be from food only to prevent high levels of intake.

Sources: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium,

Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin,
Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline
(1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and
Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic,
Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon,
Vanadium, and Zinc (2001); and Dietary Reference Intakes for Calcium and
Vitamin D (2011). These reports may be accessed via www.nap.edu.

Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic,

Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon,
Vanadium, and Zinc. 2001. Washington DC, The National Academies Press. (This
report may be accessed from the National Academies Press via www.nap.edu)

Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. 2001.
Washington DC, The National Academies Press. (This report may be accessed
from the National Academies Press via www.nap.edu)

Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin,

Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. 1998.
Washington DC, The National Academies Press. (This report may be accessed
from the National Academies Press via www.nap.edu)

Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E,

Selenium, and Carotenoids. 2000. Washington DC, The National Academies Press.
(This report may be accessed from the National Academies Press via
www.nap.edu)
This table (take from the DRI reports, see www.nap.edu) presents RDA in bold
type and AI in ordinary type followed by an asterisk (*). An RDA is the average
daily dietary intake level, sufficient to meet the nutrient requirements of nearly
all (97%–98%) healthy individuals in a group. It is calculated from an EAR. If
sufficient scientific evidence is not available to establish an EAR, and thus
calculate an RDA, an AI is usually developed. For healthy breastfed infants, an AI
is the mean intake. The AI for other life stage and gender groups is believed to
cover the needs of all healthy individuals in the groups, but lack of data or
uncertainty in the data prevent being able to specify with confidence the
percentage of individuals covered by this intake.
a
Total water includes all water contained in food, beverages, and drinking water.

b
Based on g protein per kg of body weight for the reference body weight, e.g., for
adults 0.8 g/kg body weight for the reference body weight.

AI, adequate intakes; EAR, estimated average requirement; ND, not determined;
RDA, recommended dietary allowances.

Source: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty
Acids, Cholesterol, Protein, and Amino Acids (2002/2005) and Dietary Reference
Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005). The report
may be accessed via www.nap.edu.

Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber,

Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. 2005. Washington, DC:
The National Academies Press. (This report may be accessed from the National
Academies Press via www.nap.edu)

Institute of Medicine. 2005. Dietary Reference Intakes for Water, Potassium,

Sodium, Chloride, and Sulfate. Washington, DC: The National Academies Press.
(This report may be accessed from the National Academies Press via
www.nap.edu)
Food and Nutrition Board, Institute of Medicine, National Academies

RANGE (PERCENT OF ENERGY)

CHILDREN, CHILDREN,
MACRONUTRIENT 1–3 YR 4–18 YR ADULTS
Fat 30–40 25–35 20–35
n-6 polyunsaturated 5–10 5–10 5–10
fatty acidsa (linoleic
acid)
n-3 polyunsaturated 0.6–1.2 0.6–1.2 0.6–1.2
fatty acidsa (α-linolenic
acid)
Carbohydrate 45–65 45–65 45–65
Protein 5–20 10–30 10–35
a
Approximately 10% of the total can come from longer-chain n-3 or n-6 fatty
acids.

Source: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty
Acids, Cholesterol, Protein, and Amino Acids (2002/2005). The report may be
accessed via www.nap.edu.

Dietary Reference Intakes (DRIs): Acceptable

Macronutrient Distribution Ranges
Food and Nutrition Board, Institute of Medicine, National Academies
 Macronutrient Recommendation
Dietary As low as possible while consuming a
cholesterol nutritionally adequate diet
Trans fatty As low as possible while consuming a
acids nutritionally adequate diet
Saturated fatty As low as possible while consuming a
acids nutritionally adequate diet
Added sugarsa Limit to no more than 25% of total energy
a
Not a recommended intake. A daily intake of added sugars that individuals
should aim for to achieve a healthful diet was not set.

Source: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty
Acids, Cholesterol, Protein, and Amino Acids (2002/2005). The report may be
accessed via www.nap.edu.

Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber,

Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. 2005. Washington, DC:
The National Academies Press. (This report may be accessed from the National
Academies Press via www.nap.edu)
This table represents the calcium content of foods commonly consumed, with
values from the United States Department of Agriculture nutrient database. It
does not represent a comprehensive list, but is provided as a way of better
understanding the foods that will best help to satisfy the calcium requirement.
The Nutrient/Calorie Ratio is provided to enable a better understanding of the
concentration of calcium relative to the Calories provided by the food serving
indicated. A higher ratio is an indication that, for the Calories provided, there is a
higher concentration of calcium.

Please note that the bioavailability of calcium may vary between foods,
depending on factors that may either enhance or diminish calcium absorption.
This table represents the iron content of foods commonly consumed, with values
from the United States Department of Agriculture nutrient database. It does not
represent a comprehensive list, but is provided as a way of better understanding
the foods that will best help to satisfy the iron requirement. The nutrient/calorie
ratio is provided to enable a better understanding of the concentration of iron
relative to the calories provided by the food serving indicated. A higher ratio is an
indication that, for the calories provided, there is a higher concentration of iron.

Please note that the bioavailability of iron may vary between foods, depending on
factors that may either enhance or diminish iron absorption.
Background Female marathon runner (5′ 2″, 26-yr
old, 120 lb) is training to establish a
qualifying time for an upcoming race in 5
mo. She was a 10K runner on her college
track and field team, and for the past 3
yr has been training to reach the elite
rank of marathon runners to qualify for
the Olympic trials. She works full time,
Monday through Friday. While she
experienced improvements in her
marathon times in her first year
following her move to go from 10K to
marathon, the past 2 yr have been
frustrating, with no improvements in
time. She is within 5 min of making the
qualifying time for breaking into the elite
group of major marathon runners, but
has not been able to find a way to make
that time. Importantly, she is now
seeking help because she feels her
ability to recover is diminished, and she
is plagued with minor injuries that
prevent her from training the way she
would like.
ASSESSMENT Procedure Findings/Results
Health History Standard procedure Trains every
inquiring about day except
past health, Sunday, and
injuries, indicates she
hospitalizations, spends most of
special diets, sense Sunday on the
of self (i.e., good couch resting
weight, good body and watching
composition), and television. Too
subjective tired to do
symptoms (i.e., much else.
normal bowel urine High level of
habits, sense of muscle
energy/exhaustion). soreness
following
training.
Irregular
menstrual
period
frequency
(every 3–5 mo);
otherwise
normal period.
Stable weight
(views her
weight as too
high).
Occasional (1–2
× weekly at
end of training
week) use of
nonsteroidal
anti-
inflammatory
drugs to
alleviate
training-
associated
pain/soreness
(potential
hyponatremia
risk).
No
hospitalizations,
but has been
experiencing
occasional (with
increasing
frequency) joint
pain in right
knee. Visit with
orthopedist last
month did not
find any serious
medical
problem; was
told it was due
to overtraining.
States that she
has normal,
regular bowel
habits with
normally
formed stool.
Rarely has
diarrhea.
Cannot
remember ever
vomiting.
Using urine
color chart,
indicates that
her urine is
typically
moderately
dark,
suggesting mild
dehydration.
Experiences
bloating (belly,
and fingers) on
days 5 and 6 of
training week
(potential
hyponatremia
risk).
Clear skin, good
teeth,
frequently
smiles.
Not on any
prescribed or
self-selected
special diet.
No family or
personal history
of disease state
(cardiovascular,
diabetes, etc.).
Not consuming
dietary
supplements,
with the
exception of
whey protein
isolate (25 g) in
8 oz orange
juice consumed
30 min prior to
training runs.
 No foods
avoided
because of
perceived
problem, and
no eaten
frequently
because of
perceived
benefit.

Body Composition Available system:

8-mode 6-current Body fat
bioelectrical percent =
impedance 25.3%
analysis. (surprisingly
high for a
distance
runner)
Trunk fat is
higher than
predicted for
runner’s
weight, height,
age, while leg
and arm fat
levels appear to
be in the
normal range.
Total body
skeletal muscle
mass is slightly
below the 100th
percentile for
runner’s
weight, height,
age.
 Right and left
arm
musculature
nearly identical.
Large difference
between right
and left leg
musculature,
with right leg
having 2.2 lb
more muscle
than the left
leg. (Note to
discuss with
orthopedist if
higher right leg
muscle mass
may result in
excessive
reliance on
right leg for
power
production,
resulting in
reported right
knee soreness.)
Total body
water,
intracellular
and
extracellular
fluid all in the
normal range.

Diet Analysis Four-sequential

days (including a See following
minimum of 2 for actual
analysis results,
training days and 2 which include
weekend days) the following:
using a within-day List of foods
energy balance consumed and
data acquisition activities for
and analysis each day
procedure. analyzed
(Figure A.1).
The list includes
the energy
(caloric) value
of each food
and the
subtotal of
energy
consumed at
each meal; the
daily total of
energy
consumed; and
the predicted
energy
expenditure for
the activities
above normal
daily activity
and sleep.
Analysis of
energy balance
using two
methods of
viewing the
data:
continuous
(Figure A.2) and
discreet (Figure
A.3). Included is
an analysis of
the number of
hours spent in
an anabolic
state (i.e.,
above 0
calories energy
balance), in a
catabolic state
(i.e., below 0
calories energy
balance), and
hours spent in a
severe energy
balance surplus
or deficit, but of
which have
been
associated with
undesirable
endocrine
and/or body
composition
changes.
The continuous
method takes
the ending
energy balance
of one day and
makes it the
beginning
energy balance
of the
subsequent
day. Since
energy balance
is continuous
(i.e., it does not
end at
midnight), this
is a more
realistic means
of assessing
energy balance
over a multiday
assessment
period.
The discreet
method
assesses each
day as if it is an
independent
assessment
period. This
form of
assessment is
useful to see if
any particular
day in the
assessment
period is better
or worse than
the other days
to help
determine what
went right or
wrong. A
particularly
good day can
be used as a
model for how
to manage
eating and
exercise to help
ensure good
within-day
energy balance.
List of energy
substrates,
vitamins, and
minerals with
recommended
dietary
allowances
where they
exist (Figure
A.4). The
assessment
also flags
nutrient intakes
that are
considered high
(H) or low (L).
As there are
typically large
daily
differences in
nutrient
consumption,
this assessment
averages the
nutrient intakes
over the 4-day
assessment
period.
The average
protein intake
distribution
over the 4
analysis days
(Figure A.5).
 This analysis is
useful to
determine if the
protein is well-
distributed
throughout the
day and is
consumed in
amounts that
are well
tolerated. The
analysis can
also be used to
determine if the
protein is being
consumed at a
time when the
athlete is in a
severe energy
balance deficit,
the result of
which would be
a more likely
usage of the
protein to
satisfy the
energy
requirement
rather than to
be used
anabolically for
tissue repair,
tissue building,
hormone
formation, etc.

Referral(s)
Dual-energy X- Total body BMD
ray is -0.6 standard
absorptiometry deviations
scan for total below the
body bone young-adult
mineral density standard. This
(BMD) does not reach
assessment. the threshold
Blood test for for osteopenia
iron status (< -1.0), but is
assessment a concern
(hemoglobin, because
hematocrit, runners placing
ferritin). high
Blood test for gravitational
serum vitamin forces on the
D skeleton should
have BMD
values above
the standard.
A regional
analysis
indicates no
portion of the
skeleton (i.e.,
lumbar spine,
legs, arms, ribs,
femoral neck)
reaches the
threshold for
osteopenia.
Blood test for
iron indicates
normal
hemoglobin (16
g/dL), normal
hematocrit
(48%), but
 below normal
ferritin (21
ng/mL),
suggesting
runner may
have an
inadequate iron
status.
As adequate
vitamin D is
associated with
improved
muscle
recovery,
reduced muscle
soreness, and
normal BMD,
this test was
performed
despite the
runner’s
frequent
exposure to
sunlight during
training. Her
serum vitamin
D status was in
the normal
range (52
ng/mL).

Recommendations
Based on Findings The average energy balance over 4
days demonstrates a persistent
deficiency of intake resulting in
many hours spent in an energy-
deficient state and a significant end-
of-day energy balance deficiency.
These results are consistent with
high cortisol, which is associated
with catabolism of bone mass and
lean mass; low estrogen, which is
associated with menstrual
irregularity and low BMD; and high
body fat percent, which is the result
of poor muscle protein synthesis and
high lean mass catabolism. This
runner has relatively high body fat
percent, irregular menstrual status,
and below predicted BMD.
Assessing energy balance over the 4
assessment days as discreet days
indicates that weekend (nonwork)
days places the runner in a better
energy balance state, suggesting
that these days can be used as a
model for the runner to try to
emulate during the work week. This
will require dietary planning to
ensure that she can continue to train
while planning for better food
availability.
It appears from these data that the
most likely time for significant
energy balance deficits is before
lunch and before dinner, suggesting
that a more significant planned
snack in midmorning and one in
early evening are appropriate. It is
recommended that she consume a
200 calorie snack consisting of a
combination of protein and
carbohydrate (e.g., cheese and
crackers; yogurt and fruit) at these
times.
Nutrient intake assessments suggest
the runner has insufficient intake of:
Fiber: This can be resolved through
the consumption of more whole
grains, fresh fruits, and vegetables.
The workweek habit of consuming
only coffee for breakfast suggests a
good opportunity to add a whole
grain cereal, and fresh fruit as a
means of obtaining both more fiber
and energy.
Vitamin D: Dietary intake is low, but
the blood test revealed a satisfactory
serum vitamin D, suggesting that no
dietary changes to enhance vitamin
D are necessary.
Vitamin E: Vitamin E deficiency
symptoms are rare in humans, but
for an athlete who is undergoing
heavy oxidative metabolism in her
runs suggest that there should be
sufficient dietary vitamin E available.
This could easily be achieved
through the consumption of more
vegetables that have a good quality
vegetable oil added, such as olive
oil. This would also help to better
satisfy her energy needs and her
fiber intake.
Iron: Dietary iron intake is not
satisfactory, and this is
demonstrated by her low serum
ferritin. She is encouraged to more
regularly consume foods that are
good sources of iron (e.g., legumes,
fortified breakfast cereals, cooked
dark green vegetables, red meat).
Iron status should be reassessed
within 30 to 60 days to determine if
iron status has stabilized, is getting
better, or is getting worse. Any
indication that iron status is
worsening warrants a referral to a
physician for consideration of iron
supplementation.
Potassium: This mineral is the main
intracellular electrolyte, with
important implications for fluid
balance. While her body composition
test suggested good intracellular and
extracellular fluid balance, low
potassium intake remains a concern.
Earlier recommendations for greater
consumption of fresh fruits and
vegetables should help to resolve
the low potassium consumption.
Dark urine, suggestive of
dehydration is a concern for both
health and performance. The athlete
should take pre- and postexercise
weight to determine the proportion
of weight that is loss. Any amount of
weight exceeding 2% of body weight
is strongly suggestive that the
volume of fluid consumed is not
sufficient to satisfy sweat loss and
should be increased. The increase in
fluid consumption is most easily
achieved by increasing slightly the
volume and frequency of intake
during training.
Muscle mass difference between left
and right legs is an injury concern,
and should be referred to an athletic
 trainer and/or strength and
conditioning coach to provide runner
with strategies for increasing muscle
in the weaker leg.

Follow-up This athlete should be reassessed in 3 to

4 weeks to determine if she is able to
incorporate the recommended changes
and to begin establishing a trend line on
body fat percent and skeletal muscle
mass. Iron status should also be
reassessed at this time, along with a re-
evaluation of dietary intake. Dietary
monitoring should continue to see if the
athlete has incorporated recommended
changes to improve nutrient intake and
correct energy balance deficiencies. A
conference with the runner’s orthopedist
should take place before the follow-up,
so that there is agreement on how to
satisfy any possible drug-nutrient
interactions and/or any other possible
nutritional factors associated with care of
current injuries.
FIGURE A-L.1: List of foods consumed and analysis of
activities for each day.
FIGURE A-L.2: Energy balance assessment using continuous
analysis (i.e., ending energy balance of one day is beginning
energy balance of next day).
FIGURE A-L.3: Energy balance assessment using each day as
a discreet day rather than continuous assessment period of 4
days.
FIGURE A-L.4: Four-day average nutrient intake analysis.

FIGURE A-L.5: Four-day average protein consumption.

Note: Page numbers followed by f and t indicate figures and
tables, respectively.

Absorption, 41, 68
carbohydrates, 41
digestion and, 89–90, 90t, 456–457
inadequate, 24
intestinal, 187
lipid digestion and, 89–90, 90t, 456–457t
of nutrients, 166, 456–457t
protein, 68
sodium, 171
Accelerometry, 265
Acclimatization, 327, 332–334
Acetone, 38
Acetyl coenzyme A (acetyl CoA), 300
Acetyltransferases, 93
Acid-base balance, 62
Acid production rate, 35t
Activity energy expenditure (AEE), 265
Activity intensity, 177
Acute dietary intake, 353
Acute mountain sickness, 327
Adaptive thermogenesis, 208
Adenosine triphosphate (ATP), 46, 135, 293, 294, 300, 352,
398f, 399
molecules, 46
production of, 396
Adequate diets, 402
Adequate intake (AI), 14, 131
ADH (antidiuretic hormone), 171f
Adolescents, children and, 16
Adrenocorticotropic hormone, 302
Adults, 16
with chronic medical conditions, 17
with disabilities, 17
AEE (activity energy expenditure), 265
Aerobic activity, 16
Aerobic/endurance training, 396
Aerobic energy system, 396
Aerobic glycolysis system, 46, 395t, 396, 398t
Aerobic metabolism (oxygen system), 46, 294, 295, 300,
398, 404
Aerobic/oxidative metabolic processes, 295
Aerobic sports, 297t, 298
Age and sex, nutrition strategies for, 178, 261–262
energy needs, 273–275
body image and eating disorders, 275
female athlete triad, 275–280
female athlete, 273
older athlete, 280–281
bone mineral density, 281–282
energy needs, 281
fluids and heat stress, 281
immune function, 282
organ function, 282
young athlete, 262
energy needs, 263–264
total energy expenditure, 264–272
Age-related drop in triathlon completion, 280f
Aging, 75, 372–373
AI (adequate intake), 14, 131
Air, contents of, 242
Air displacement plethysmography, 216
Alanine, 59t
Alcohol, 10, 13, 24, 108, 111, 116, 349, 357–358
Aldosterone, production of, 171f
Allergenic ingredients, 378
α-linolenic acid (ALA), 84
Altitudes
nutritional requirements for, 327f
sickness, 327
Ambient humidity, 168, 177
Ambient temperature, 168, 177
Amenorrhea, 277
American College of Sports Medicine, 408
Amino acids, 58, 61f
basic structure of, 58
deaminated, 69
distributions of, 63
essential and nonessential, 59–61t
individual, 402
ratio of, 64
requirements, 71t
structure of, 58, 58f
AN. See Anorexia nervosa
Anabolic hormones, 402
Anabolic steroid, 349
Anaerobic events, 326
Anaerobic glycolysis, 46, 395t, 396, 398t, 401
Anaerobic metabolism, 298, 404
Anaerobic sports, 293
Anaerobic threshold, 294, 295, 398
Anemia, 128, 243
development of, 247
Anion, 138–139, 166
Anorexia nervosa (AN), 384
signs and symptoms of, 385, 385t
Anovulation, 277
Anthocyanidins, 254
Anthocyanin, 378
Antidiuretic hormone (ADH), 171f
Antioxidants, 249
intake, 254
nutrients, 251t
Apparent temperature, 176
Appearance sports, 267
Appetite, 325t
Arginine, 60t, 63
Arginine vasopressin (AVP), 317t
Ascorbic acid (Vitamin C, Ascorbate), 115–116
Asparagine, 60t
Aspartic acid, 60t
Asthma prevalence in cyclists, 415
Atherosclerosis, 90
Atherosclerotic artery, 91f
Athletes, 20, 200
in aerobic sports, 301, 405
in “aesthetic” sports, 383f
conditioning and adaptation, 187
conditions affecting nutritional status, 24–25
dietary reference intakes, 14–15
adults, 16–17
children and adolescents, 16
older adults, 16
for planning, 15–16
safe physical activity for all groups, 17
women during pregnancy and postpartum period, 16–17
ergogenic aids commonly consumed by, 350–359
essential and nonessential nutrients, 11–12
exercise patterns of, 401
food labels, 17–19
 food restriction from allergies, intolerances, and
sensitivities, 8–11
guides for, 12
consume nutrient-dense foods and beverages, 13
maintain calorie balance, 12–13
interactions between nutrition and physical activity, 3–5
introduction to sports nutrition, 2–3
knowledge, 6–7
and nonathletes, guides for, 12–13
consume nutrient-dense foods and beverages, 13
nutrient balance, 11
nutrition myths and misinformation, 22–23
nutrition science, 23–24
professional organization position statements, 19–21
sports organizations and supplement use, 5–6
tradition, 7–8
water loss in, 241
weight and body composition in, 198–200, 201t
Athlete vitamin supplementation, 103, 106, 108, 110, 112–
114, 116, 118, 120–121, 346–347
Atkins Diet, 76
Attenuation, 178
AVP (arginine vasopressin), 317t

Balanced diet, 346

Banned substances, 339, 344t, 348, 358
Basal metabolic rate (BMR), 264
equations for predicting, 264
Baseball, 408–409
BCAAs (branched-chain amino acids), 57, 75–76, 355
BED (binge eating disorder), 385–386
Beriberi, 108
β-cryptoxanthin, 253
β-oxidation, 92
Beverages
consumption of, 76
high-sugar, 375
palatability of, 187
Bicarbonate (sodium bicarbonate), 353–354
Bifidobacteria, 42
Binge eating disorder (BED), 385–386
Bioelectrical impedance, 216
analysis, 225–227
Biologic value, 65
Biomechanical ergogenic aid, 342
Blood glucose, 38f, 398t
Blood lipids, reference ranges for, 95, 95f
Blood pressure, 134
Blood sugar, 43f, 211
control, 43–44
Blood urea nitrogen (BUN), 58
BMD. See Bone mineral density
BMR. See Basal metabolic rate
Bodybuilders, 409
Bodybuilding, 409–410
Body composition, 204–205, 328
age, 227–229
amount of activity, 229
assessment of, 214–220, 220f
change, 229–230
energy balance, 205–214, 205f
hormonal response to, 208–211
negative and hormonal changes, 212t
real-time view of, 211–213
relative energy availability in sport, 213–215
traditional view of, 206–208, 206f
estimation of, 219–220
excessive frequency of, 230
gender, 229
genetic predisposition, 227
 gut microbiome, 229
information private, 230
level of, 415
methods for predicting
air displacement plethysmography, 224–225
bioelectrical impedance analysis, 225–227
dual-energy x-ray absorptiometry, 227
hydrostatic weighing (hydrodensitometry), 223–224,
224f
skinfold, 220–222, 221f, 222t
ultrasound, 222–223
nutrition, 229
to performance, 219
results using different methods, 230
terms commonly associated with, 204t
type of activity, 229
Body fat, 210f, 217, 299, 374
levels, 214, 375
___location of, 220
percent and body water, 165t
Body image, 275
Body mass index (BMI), 8, 202, 203
categories, 202t
Body surface area (BSA), 177, 272
Body temperature, systems for regulating, 178
Body water, 165t
Body weight, 19
Bone density, 132–133, 132f
Bone health, 277–278, 371
Bone-loading activities, 369
Bone mineral density (BMD), 262, 264, 274, 274f, 281–282
internal and external factors, 267t
Bone-strengthening, 16
Brain ischemia, 167
Branched-chain amino acids (BCAAs), 57, 75–76, 355
BSA (body surface area), 177, 272
Building lean (muscle) mass, 300
Bulimia nervosa, 384–385
warning signs of, 385
BUN (blood urea nitrogen), 58

Caffeine, effects of ingesting, 351f

Calcium, 130–131, 131t
blood pressure, 134
bone density, 132–133, 132f
deficiency, 134
food sources of, 131, 131t
inadequacy of, 411
nerve transmission, 134
obesity, 133–134
sources of, 279
toxicity, 134
Caloric restriction, 22
Calorie, 4
balance, 12–13
Cancer, 371, 373t
Carbohydrates, 10t, 23, 32–34, 33, 270, 278, 300, 325t,
330t, 332t, 405
acid production rate, 35t
combination of, 412
composition of, 302
concentration of solution, 186
consumption of, 48, 50–51, 50f, 352, 367, 408, 411
disaccharides, 35–36
endurance sports, 50
food sources, 34
functions of
complete oxidation of fats for energy, 39
compounds, 39–40
conversion to fats, 40
 normal gastrointestinal function, 39
source of energy for cellular function and energy
storage, 38
sparing protein, 38–39
high-intensity sports, 50
and human performance, 48–49
human storage capacity for, 32
intake, 47, 50f
limited storage of, 4
loading, 351
maximizing glycogen storage, 49–50
metabolism of, 40, 46, 47f
absorption, 41, 42
blood sugar control, 43–44
digestion, 41
glycemic index, 44–46
glycemic load, 44–46
intake recommendations, 47–48
from noncarbohydrate sources, 46–47
osmolarity and osmolality, 41–42
unabsorbed carbohydrate, 42
monosaccharides, 34–35
from photosynthesis, 34
polysaccharides, 37–38
recommendations for, 303
for athletes, 19
power/strength/speed athletes, 299
relative sweetness of, 36t
requirements, 34, 48
in sports drink, 414
storage systems, 40f
stores, 48t
team sports, 50
type of, 186, 352
Carbonation of solution, 186
Carbon dioxide, 241, 243
Cardiac arrhythmia, 385
Cardiac output, 406
Cardiovascular health, 167
Carnitine, 63
Carnosine, 352
Carotenoids, 253
Catabolic hormones, 402
Catabolism, 399
Cation, 138–139, 166
Celiac disease, 380
Central nervous system function, 167
Cerebral edema, high-altitude, 327–328
Certification, 24
Ceruloplasmin, 244
Chemoreceptors, 242
Children
and adolescents, 16
growth charts for, 268–269f
Chloride, 141–142
basic information of, 141
deficiency, 142
Cholesterol, 83
Chromium, 156–157
athletes and, 157
basic information of, 156
deficiency, 157
food sources of, 156
requirements of, 157
toxicity, 157
Chylomicrons, 90–91
Circadian rhythms, 316
impact of, 320
Cis- and trans-fatty acids, 89f
Cleanliness, 321
Clinical trial research, 23
Clothing/equipment, 169, 177
Coaches, 408
Coenzyme, 107
Cold environments, 329
nutritional requirements for, 327f
nutrition considerations for exercise in, 330t
Cold fluids, 408
Cold-induced vasodilation, 326
Cold stress, 326
Combination aerobic/anaerobic sports, 307
Common probiotic foods, 355
Complementary proteins, 63–64
Complete protein, 64
Complex carbohydrates, 41
Compounds, 39–40
Concentrated source of energy, 84
Conditioned athletes, 180
Conditioned state, 169
Conditioning, 177
Contaminated foods, 379
Controlled energy consumption, 374
Cooling capacity, 409
Cooling system, 302
Copper, 154–155, 240
athletes and, 154–155
basic information of, 154
content of commonly consumed foods, 154t
deficiency, 155
food sources of, 154
requirements, 154
toxicity, 155
Cori cycle, 47
Corticotropin, 317t
Cortisol, 32, 277
Creatinine excretion, 217
Curcumin, 378
Cushion against jarring, 84
Cycling, 415
Cysteines, 60t
Cytokines, 380

Daily energy expenditure, 264f

Daily nutritional goals, 94t
Daily water loss, 166, 166t
Dairy, 321
Dark green vegetables, 145
Defective utilization, 24
Deficiency
calcium, 134
chloride, 142
magnesium, 137–138
phosphorus, 136
potassium, 143
sodium, 140–141
Dehydration, 20, 167, 181–182, 182f, 331, 368, 395
risk of, 402
Dehydration-related disorders, 261
Delayed puberty, 264
Densitometry, 216
DXA (dual-energy x-ray absorptiometer), 132, 217, 228f
DIAAS (digestible indispensable amino acid score), 66–67
Diabetes, 371
Diagnostic Criteria (DSM-5) for subclinical eating disorders,
275t
Diet, 247
adequate, 402
Dietary Approaches to Stop Hypertension (DASH) diet, 134,
172
Dietary fiber, 37, 38
consumption, 47
Dietary flavonoids, food sources of, 377t
Dietary guidelines, 12
Dietary Guidelines for Americans, 2015-2020, 370–372
Dietary lipids, 83
Dietary reference intakes (DRIs), 12, 14–15, 14f, 94t, 130,
273, 426, 428, 430–431, 433–434, 436–437, 439
acceptable macronutrient distribution ranges, 440
adults, 16
with chronic medical conditions, 17
with disabilities, 17
children and adolescents, 16
older adults, 16
for planning, 15–16, 15f
safe physical activity for all groups, 17
women during pregnancy and postpartum period, 16–17
Dietary Supplement Health and Education Act (DSHEA), 341,
342
Dietary supplements, 105t
consumption of, 402
definition of, 341
potential risks of, 348–350
weight-loss, 343–345t
Diet planning for optimal performance, 395
energy metabolic systems, 395–396, 395t
adenosine triphosphate, 398f
endurance in, 403–406
muscle fibers, 396–398, 397f, 397t
power and strength in, 398–403
nutritional readiness
body composition assessment, 416
food intake and energy balance assessment, 416
health/medical history, 415–416
nutrition strategies
during competition/practice, 408
postcompetition/practice, 408
precompetition/practice, 407–408
overtraining, 406–407
 overuse injury, 407
poor energy availability, 407
poor fluid intake, 407
sports with high endurance component
cycling, 415
distance running, 413–414
long-distance swimming, 415
triathlon, 414–415
sports with high power component
baseball, 408–409
bodybuilding, 409–410
diving, 410
football (United States), 410
gymnastics, 410–411
hockey, 411
power/speed track and field events, 411–412
swimming, 412
wrestling, 412–413
Digestibility, 66
Digestible indispensable amino acid score (DIAAS), 66–67
Digestion, 41, 68, 166
and absorption, 89–90, 90t, 456–457
Digestive enzymes, 69t
Diglycerides, 87
Disaccharides, 33, 35–36
Disordered eating pattern, 382, 382f
Distance runners/running, 413–414
surveys of, 414
Distance swimmers, volume of training by, 415
Diving, 410
DLW (doubly labeled water), 264, 265
DNA
oxidation products, 254
synthesis, 144
Dose-response relationship, 207
Doubly labeled water (DLW), 264, 265
DRIs. See Dietary reference intakes
Drug-drug interactions, 342
Drug-nutrient/food interactions, 342
Dual-energy x-ray absorptiometer (DXA), 132, 217, 228f

EAR (estimated average requirement), 14

Eating disorders, 216, 275, 382, 383
development of, 383
prevalence of, 384
types and dangers of, 384
Eating frequency, 205
ECF (extracellular fluid), 164, 165
Electrolytes, 139, 166, 332t
loss of, 177–178
potassium, 173–175
sodium and chloride (salt), 170–173, 170t
in sweat, plasma, and intracellular water, 166t
Elevated dietary intake, 172
Endogenous opioids, 317t
Endurance
activity, 301
athletes, 98, 395, 403
level of, 415
macronutrient distribution ranges for, 72t
performance, 247
sports, 50, 308–309, 403, 404
primary energy system for, 406
training, 49f
Energy
availability, 263, 273, 407
in average man, 297t
burning fats for, 96
deficiency, 213
deficits, 382f
 delivery, 33
expenditures, 266, 329
metabolism of, 175
producing capacity, 57–58
protein and, 240
requirement, 368
sources of sports, 404t
systems, percent contribution of, 401t
Energy balance, 205, 209f, 374
macroeconomic view of, 212
maintaining, 211f
model for, 214f
traditional view of, 208
Energy consumption, 413–414
in ultramarathon, 302
Energy demands, 293–295, 302
anaerobic metabolism (glycolysis), 297–298
phosphagen system (creatine phosphate), 295–297
Energy-efficient weight lifting, 62
Energy imbalances, 207
understanding of, 214
Energy-in, energy-out, concept of, 374
Energy metabolic systems, 296t, 298t, 395–396, 395t
adenosine triphosphate, 398f
endurance in, 403–406
muscle fibers, 396–398, 397f, 397t
power and strength in, 398–403
Energy metabolism, 129, 403
electron transfer for, 243
relative change in, 302f
Energy needs, 263–264, 273–275, 281
body image and eating disorders, 275
female athlete triad, 275–280
Energy stores, 399, 400t
Energy substrates, 4, 33, 278, 367, 368
distribution
 carbohydrate, 270
fat, 271
protein, 270–271
Energy utilization, 301t
characteristics, 294t
Environmental temperature, 321
Enzymes, 62, 144, 243
antioxidants, 251
Epicatechins, 350
Epidemiological research, 23
Epigallocatechin gallate, 378
Epinephrine (adrenaline), 44f
Ergogenic aids, 342
composition of, 348–349
potential risks of, 348–350
Ergogenic effect, 342
Ergolytic, 342
Essential amino acids, 59–60t, 63–64
Essential fatty acids, 84–85
Estimated average requirement (EAR), 14
Estrogen, 277
Euhydration, 165, 368
Eumenorrhea, 277
Excess energy, consumption of, 317
Excessive training, 219
Excess protein consumption, 402
Excretion of fluids, 178
Exercise, 4–5
body acclimatizes to, 180
in cold environments, 330t
duration, 352
health-enhancing impact of, 355
in hot/humid environments, 332t
lipids and, 96–98
Exercise-induced asthma, 248
causes of, 248
 recommended treatment for, 248–249
Exercise-induced oxidative stress, 377
Exercise intensities, 44f, 97f
fuel burned at, 97f
Exertional heat illnesses, 183f
Exertional hemolysis, 246–247
Experimental research, 23
Extracellular fluid (ECF), 164, 165

Fast-twitch muscle fibers, 298

Fat, 83, 271, 278, 398t
conversion to, 40
diet, high, 301
for energy, 39
intake, 20
mass, 199, 218, 374
proportion of, 97t
recommendations, 300, 304
tissue, densities of, 207f
utilization, 98
Fat-free mass, 199
Fatigue, premature, 300
Fat-soluble vitamins, 104
vitamin A, 117–119
vitamin D, 119–120
vitamin E, 120
vitamin K, 121
Fatty acids, 85–87, 93
monounsaturated, 85, 86f, 87t
polyunsaturated, 85, 86f, 87t
synthase, 93
Female athletes, 248, 273
endurance, 407
nutritional considerations for, 261
Female athlete triad, 216, 261, 276, 382
components of, 274
prevalence of, 276
Ferritin, 144, 240, 247, 250
Fiber cereals, high, 145
Fitness, 409
Flavan-3-ols, 254
Flavanons, 254
Flavones, 254
Flavonoids, 254
Flavonols, 254
Fluids, 5, 272, 325t, 330t, 331, 332t
balance, 62, 170, 177, 326
and exercise, 179–180
during training, 180–181
consumption of, 408, 414
excretion of, 178
during exercise, 181
and heat stress, 281
intake, 407
loss of, 177–178, 305
recommendations, 302–303
requirements, 368
Folate, 244–245
Folic acid, 240, 369
intake, 11
Follicle-stimulating hormone, 277
Food
allergy, 8, 379–380, 381
symptoms of, 379
calcium content of, 447–450
consumption of, 83
containing carbohydrates, 303
cravings, 22–23
energy per serving, 19
flavor and palatability of, 84
 intolerance, 9, 380, 381
iron content of, 451–454
restriction from allergies, intolerances, and sensitivities, 8–
11
safe minimum internal temperatures, 323t
storage, 323
water content of, 167t
Foodborne illnesses, 322t, 379
Food labels, 17–19, 18f
sodium on, 139t
Food safety, 379
considerations, 321–323
Food sensitivities, 9, 380–381, 381f
inflammatory reactions, 381f
prevalence of, 380
Football (United States), 410
Foot-strike hemolysis, 246–247
Free radicals, 88
superoxide, 249
Frequent eating, 329
Fructose, 35
Fruits, 321

Galactose, 35
Gastric cancer, 172–173
Gastric emptying, 185
Gastrointestinal function, 39
Gastrointestinal (GI) issues, 413
Gastrointestinal (fecal) loss, 168
Gender, 178, 248
Ghrelin, 206, 207
energy balance feedback mechanisms of, 206f
Giardia lamblia, 331
Global positioning system (GPS), 265f
Glucagon, 42
Glucogenic amino acids, 297
Gluconeogenesis, 38, 43, 291
Glucose, 300, 404
polymer products, 352
Glutamic acid, 60t, 62
Glutamine, 60t
Glutathione, 251–252
Gluten-free products, 380
Glycemic index, 44–46, 45f, 45t
Glycemic load, 44–46, 45t
Glycerol, 97
Glycine, 60t, 62
Glycogen, 302
availability of, 98
loading, 351
storage, 412
stores, 305
synthesis, 49
Glycolipids, 40
Goiter, 150–152
GPS (global positioning system), 265f
Gravity-free environment, 415
Green tea extract, 378
Growth charts for children, 268–269f
Growth impairment, 150
Gymnastics/gymnasts, 200–201, 410–411, 411

Harris-Benedict equation, 416

HDLs (high-density lipoproteins), 91
Health care providers, 12
Health risk, 105
Heart
disease, 83, 373t
 rate monitoring, 265
Heat
adding and removing, 175f
balance equation, 176f
cramps, 182–183, 333t
exhaustion, 183, 333t
and humidity environments, high, 331–334
nutrition considerations for exercise in, 332t
risks of exercise in, 332f
loss in cold environments, 326
Heat illness, 333
exertional, 183f
warning signs and symptoms of, 333t
Heat index, 177, 177f
Heat stress, fluids and, 281
Heatstroke (sunstroke), 184, 333t
extrinsic and intrinsic risk factors, 184t
Heat syncope, 184
Hematocrit, 147, 250
Hematuria, 247
prevalence of, 247
Hemochromatosis, 240, 250
Hemoglobin, 129, 240, 243, 250
concentrations, 241t, 246
in RBCs, 241
Hemolysis, 246
Hemosiderosis, 250
Herbal products, 23
HGH (human growth hormone), 402
High-altitude and cold environments, 325–326
energy and nutrient needs in, 331–332
training, 326–330
High-altitude/cold-weather competition, 334–335
High-altitude eating, foods and considerations for, 328–329
High-density lipoproteins (HDLs), 91
High-intensity activity, 175
High-intensity exercise, 179, 242
High-speed activity, 294
Histamines, 380
Hockey, 411
Hormone replacement therapy (HRT), 282
Hormones, 62
affected by circadian rhythms, 317t
Hot/humid environments, exercise in, 332t
HRT (hormone replacement therapy), 282
Human body, water distribution in, 168f
Human diet, types in, 91–92
Human growth hormone (HGH), 402
Human performance, 48–49
Hydration/dehydration, 305, 331
habits, 179
issues related to, 179
maintenance of, 414
requirements, 409
state of, 186
Hydration issues in athletic performance, 164–166
body fat percent and body water, 165t
cardiovascular health, 167
central nervous system function, 167
daily water loss, 166, 166t
effectiveness of sports beverage
amount of solution consumed, 186
athlete’s conditioning and adaptation, 187
carbohydrate concentration of solution, 186
carbonation of solution, 186
degree of mental stress, 186–187
gastric emptying, 185
intestinal absorption, 187
palatability of beverage, 187
state of hydration/dehydration, 186
type of activity, 187
type of carbohydrate in, 186
 electrolytes
potassium, 173–175
sodium and chloride (salt), 170–173, 170t
in sweat, plasma, and intracellular water, 166t
exercise and balance of fluids and electrolytes
body acclimatizes to exercise, 180
dehydration, 181–182, 182f
fluid balance and exercise, 179–180
heat index, 177
issues related to, 179
loss of fluids and electrolytes, 177–178
monitoring fluid balance during training, 180–181
systems for adding and removing heat, 175–177
systems for regulating body temperature, 178
wet bulb globe temperature (WBGT), 177
fluid balance, 170
fluid intake recommendations, 189–190
heat cramps, 182–183
heat exhaustion, 183
heatstroke (sunstroke), 184
heat syncope, 184
hyponatremia, 184–185
optimal sports beverage composition and drinking
strategy, 187–189
sustaining water balance, 167–169
sweat rates, 169f
water balance, 170
systems for regulating, 169
water content, 167t
water distribution in human body, 168f
water functions, 166
Hydrogenation, 89
Hydrostatic weighing (hydrodensitometry), 223–224, 224f
Hypercalcemia, 134
Hyperglycemia, 43
Hyperinsulinemia, 208, 212, 375
 causes of, 208
Hyperkalemia, 174
Hypertension, 172, 174, 373t
Hypoglycemia, 43
Hypohydration, 164, 165
Hypokalemia, 409
Hyponatremia, 140–141, 164, 165, 184–185, 300
risk, 185
signs and symptoms of, 185
sodium, 140–141
Hypotension (low BP), 171
Hypovolemia (low blood volume), 171

ICF (intracellular fluid), 165

Ideal weight, 201
predicting, 202
Illness, high-altitude, 325
syndromes, 327
Immune function, 282
Immune system, inadequate functioning of, 150
Immunity, 166
Immunoglobulin E (IgE), 8
Inadequate absorption, 24
Inadequate energy
consumption, 199, 276
intake, 413
Inadequate intake, 24
Indirect calorimetry, 265
Infrared interactance, 217
Infrequent meals, 374
Insoluble dietary fiber, 37
Insufficient sleep, 374
Insulation from environmental temperature, 84
Insulin, 32, 42, 207, 208, 211, 317t, 402
International governing bodies, 20
Interstitial fluid (ISF), 164
Intestinal absorption, 187
Intracellular fluid (ICF), 165
Iodination, 89
Iodine, 150–152
athletes and, 152
basic information of, 151
content of commonly consumed foods, 152t
deficiency, 152
food sources of, 151–152
requirements, 152
thyroid function, 151f
toxicity, 152
values of selected lipids, 89t
Iron, 143–148, 240, 243, 325t
associated terminology, 250
athletes and, 145–146
basic information of, 144
consumption of foods with, 145
deficiency, 128, 146–148, 146t, 147t, 148f, 243
anemia, 129, 146f, 146t, 148
signs of, 148f
stages of, 147t
ferritin, 144, 147
food sources of, 144–145
inadequacy of, 411
increased iron losses, 145
intake in vegetarian diet, 145
loss of, 145, 247
low dietary intake of, 145
requirements, 145
toxicity, 148
transferrin, 144
ISF (interstitial fluid), 164
Isoflavones, 254
J

Jet lag, minimizing, 316, 319–320

Joint lubrication, 166

Ketoacidosis, 38, 93
Ketones, 38, 92, 399
levels of, 93
Kidney stones, 141, 172, 174
Kilocalorie, 4
Knowledge, 6–7
Krebs cycle, 396

LA (linoleic acid), 84–85, 93

Lactate, 47
Lactic acid, 47, 396, 404
Lactobacillus casei, 355
Lactose, 35–36
LDLs (low-density lipoproteins), 91
Lean mass, 199
Leptin, 206, 207, 211
energy balance feedback mechanisms of, 206f
Leucine
dietary intake of, 73t
supplementation, 73–74t
Licensure, 24
Linoleic acid (LA), 84–85, 93
Lipids, 10t, 83–85, 377
blood lipids, reference ranges for, 95f
chylomicrons, 90–91
common terminology for, 88t
digestion and absorption, 89–90, 90t
lipoproteins, 90
 effective manufacturers of, 93
and exercise, 96–98
and health, monounsaturated and polyunsaturated fatty
acids, 93–95
high-density lipoproteins, 91
iodine values of, 89t
selected lipids, 89t
low-density lipoproteins, 91
making new lipids, 93
metabolism, 92–93
omega-3 fatty acids, 95–96
oxidation of, 92f, 254
of plant and animal origin, 87t
reactions
hydrogenation, 89
iodination, 89
peroxidation, 87–88
recommendations and food sources, 93
reference ranges for blood lipids, 95f
trans fats, 95
types of, 85
fatty acids, 85–87
in human diet, 91–92
utilization of, 97t
very-low-density lipoproteins, 91
Lipoproteins, 90
Lipoprotein lipase (LPL), 90t
Liver disease, 373t
Long-chain fatty acids, 87
Long-distance swimming, 415
Low-calorie diets, 208, 219
Low-density lipoproteins (LDLs), 91
Lung alveoli, 241, 241f
Lutein, 253
Luteinizing hormone, 277
Lycopene, 253
M

Macrocytic hypochromic anemia, 145

Macrominerals, 129–130
Macular degeneration, 150
Magic bullet, 349
Magnesium
athletes and, 137
deficiency, 137–138, 247
food sources of, 136–137
toxicity, 138
Magnetic resonance imaging, 217
Malnutrition, 3
Maltodextrins, 352
Maltose, 36
Manganese, 155–156
athletes and, 155
basic information of, 155
deficiency, 156
food sources of, 155
requirements, 155
toxicity, 156
Marathon, records, 405t
Maximal oxygen uptake, 302t
Meats, 321
Medications, 372
Mediterranean diet, 95, 376
Medium-chain fatty acids, 87
Medulla oblongata, 242
Melatonin, 317t
Menstrual cycle, 277
Menstrual dysfunction, 264, 276–277
Menstrual function terms, 277
Mental stress, degree of, 186–187
Metabolic health biomarkers, 369
Metabolic syndrome, 199, 372, 373t
Metabolic waste removal, 166
Metabolism, 69, 69t, 92–93
of carbohydrates, 40, 46, 47f
absorption, 41, 42
blood sugar control, 43–44
digestion, 41
glycemic index, 44–46
glycemic load, 44–46
intake recommendations, 47–48
from noncarbohydrate sources, 46–47
osmolarity and osmolality, 41–42
unabsorbed carbohydrate, 42
of energy, 5, 175
lipids, 92–93
of phosphorus, 135
Microbiome, 355, 376
Microbiota, 355, 376
Microcytic hypochromic anemia, 145, 243
Microminerals, 130
chromium, 156–157
copper, 154–155
iodine, 150–152
iron, 143–148
manganese, 155–156
selenium, 152–154
zinc, 148–150
Minerals, 10t, 129, 278, 304, 331, 348t
calcium, 130–131, 131t
blood pressure, 134
bone density, 132–133, 132f
deficiency, 134
food sources of, 131, 131t
nerve transmission, 134
obesity, 133–134
toxicity, 134
chloride, 141–142
 basic information of, 141
deficiency, 142
established roles of, 129
functions of, 129
macrominerals, 129–130
magnesium
athletes and, 137
deficiency, 137–138
food sources of, 136–137
toxicity, 138
microminerals
chromium, 156–157
copper, 154–155
iodine, 150–152
iron, 143–148
manganese, 155–156
selenium, 152–154
zinc, 148–150
phosphorus, 135
athletes and, 135–136
deficiency, 136
food sources of, 135
metabolism of, 135
toxicity, 136
potassium
athletes and, 143
basic information, 142
commonly consumed foods, 143t
deficiency, 143
food sources of, 142
requirements, 143
toxicity, 143
requirements, 368
sodium, 138
athletes and, 140
basic information of, 138
 deficiency, 140–141
food sources of, 139–140
hyponatremia, 140–141
requirements, 140
toxicity, 141
supplementation of, 369
Monoglycerides, 87
Monosaccharides, 33, 34–35
Monounsaturated fatty acids (MUFAs), 85, 86f, 87t, 91, 93–95
Mortality rate, 105t
Mortality risk, 105
MPS (muscle protein synthesis), 367–368
Mucin, 40
MUFAs (monounsaturated fatty acids), 85, 86f, 87t, 91, 93–
95
Multiple skinfolds, 216
Muscle carnosine loading effect, 353
Muscle fibers, 396–398, 397t
characteristics of, 397f
types of, 294t, 397t
Muscle hypertrophy, 75
Muscle mass, 409
Muscle protein, 74
Muscle protein synthesis (MPS), 367–368
potential of improving, 76
Muscle-strengthening, 16
Muscle tissue, densities of, 207f
Muscular performance, 254
Musculoskeletal tissues, 370
Myoglobin, 240, 243

Negative energy balance, 331

Nerve transmission, 134
Neurologic development, 150
Neuromuscular disorder, 370
Niacin (niacinamide, nicotinic acid, nicotinamide, vitamin
b3), 109–110
Nitrate in foods, 353
Nitric oxide synthase (NOS), 353
Nitrogen
balance, 65
compound synthesis, 62
excretion, 59f
quality, 67t
Nonathletes, 58
Nonenzyme antioxidants (nutrients), 251–254
Nonsteroidal anti-inflammatory drugs (NSAIDs), 174
Normal eater, 382
Normohydration, 165
Norway, 319
NSAIDs (nonsteroidal anti-inflammatory drugs), 174
Nutrients, 278, 369f
balance, 11
calcium, 271–272, 279
dense foods, 13
essential and nonessential, 11–12
imbalances, 250
intake, 24f
iron, 271, 279
transport, 166
type of, 4
vitamin D, 272, 279
Nutrition, 2
basic guidelines of, 3
belief-based vs. science-based, 104f
myths and misinformation, 22–23
science, 23–24
Nutrition interventions, 414–415
Nutrition issues
muscular performance and antioxidant intake, 254
 oxidative stress, 249–251
oxygen uptake, 240–242
nutrients associated with, 243–245
oxygen-nutrient performance relationship, causes of
anemia, and related disorders, 245–249
reactive oxygen species in cells
enzyme antioxidants, 251
measures of reactive oxygen species and oxidative
damage, 254
nonenzyme antioxidants (nutrients), 251–254
Nutrition strategies, 291–293, 302
for combined power/endurance sports, 307
after training/competition, 308
before training/competition, 307
during training/competition, 307–308
during competition/practice, 408
endurance sports, 308–309
energy demands, 293–295
anaerobic metabolism (glycolysis), 297–298
phosphagen system (creatine phosphate), 295–297
for improving endurance, 300–302
after training/competition, 306
building energy and fluid reserves to support endurance
activities, 304–307
carbohydrate recommendations, 303
energy demands, 302
fat recommendations, 304
fluid recommendations, 302–303
general daily considerations, 306–307
minerals, 304
protein recommendations, 303–304
before training/competition, 304–305
during training/competition, 305–306
vitamin recommendations, 304
for improving power and speed, 298–299
building lean (muscle) mass, 300
 carbohydrate recommendations for
power/strength/speed athletes, 299
fat recommendations, 300
protein recommendations, 299
postcompetition/practice, 408
power/speed sports, 308
precompetition/practice, 407–408
team sports, 309
Nutritional ergogenic aid, 342
Nutritional goals for age-sex groups, 94f
Nutritional issues, 367–370
celiac disease, 380
Dietary Guidelines for Americans, 2015-2020, 370–372
disordered eating and eating disorders, 381–384
anorexia nervosa, 384
bulimia nervosa, 384–385
types and dangers of, 384–386
food
allergies, 379–380
intolerance, 380
safety, 379
sensitivities, 380–381, 381f
sources of dietary flavonoids, 377t
obesity and related conditions, 372, 372f, 373t
factors that contribute to, 372–374
strategies for reducing, 374–376
oxidative stress, 377
phytonutrients and health, 377–378
anthocyanin, 378
curcumin, 378
green tea extract and epigallocatechin gallate, 378
quercetin, 378
resveratrol, 378
Nutritional readiness
body composition assessment, 416
food intake and energy balance assessment, 416
 health/medical history, 415–416
Nutritional status, 2
conditions affecting, 24–25
Nutritional supplements, 341–343
athletes taking, 343–346
dietary supplements, 346–348
to enhance immune system
bovine colostrum, 357–358
echinacea, 358
energy drinks, 358–359
glutamine, 358
omega-3 fatty acids, 358
vitamin C, 357
vitamin E, 357
zinc, 357
and ergogenic aids, 350–359
α-alanine, 352–353
branched-chain amino acids, 355
caffeine, 350–351, 351f
carbohydrates, 351–352
creatine, 354
green tea, 357
nitrate and other nitric oxide stimulators, 353
prebiotics/probiotics, 355
sodium bicarbonate/sodium citrate, 354–355
vitamin D, 355–357, 356t
review of, 350
with strong evidence of performance effect, 359
Nutriture, 2

Obesity, 13, 133–134, 200f, 202, 203, 371, 372, 372f, 373t
factors that contribute to, 372–374
meal frequency and eating patterns, 376
population, 202
 predisposition to, 376f
strategies for reducing, 374–376
Older adults, 16
Older athlete, 280–281
bone mineral density, 281–282
energy needs, 281
fluids and heat stress, 281
immune function, 282
nutritional considerations for, 261
organ function, 282
Oligomenorrhea, 277
Olympic-distance triathletes, 414
Olympic-Distance Triathlon, 414
Omega-3 fatty acids, 95–96
Optimal muscle protein synthesis, 411
Organ function, 282
Osmolality, 41–42
plasma, 179
Osmolarity, 41–42, 171
Osteoarthritis, 373t
Osteomalacia, 134
Osteopenia, 132–133
Osteoporosis, 132–133, 173, 174
Overtraining, 406–407
Overuse injury, 407
Overweight, 13, 200f, 371
Oxalic acid, 37–38
Oxidation of lipids, 92f
Oxidative damage, measures of, 254
Oxidative phosphorylation, 243
Oxidative stress, 249–251, 331, 377
Oxygen-carrying capacity, 406
Oxygen content of air, 241
Oxygen uptake, 240–242, 404
nutrients associated with, 243–245
 oxygen-nutrient performance relationship, causes of
anemia, and related disorders, 245–249
Oxygen using capacity, 242f

Palatability of beverage, 187

Pasteurization, 322
International Radura symbol of, 324f
Pathogens, 379
Pedometry, 265f
PER (protein efficiency ratio), 66
Performance enhancing, 340, 342
Performance readiness, 200
Periodic fasting, 23
Peroxidation, 87–88
Personal hygiene, 323
Pharmacologic ergogenic aid, 342
Phosphocreatine system (PCr), 46, 294, 352, 398t, 399, 400,
409
metabolic system, 395, 395t
regeneration, 400
Phosphorus, 135
athletes and, 135–136
deficiency, 136
food sources of, 135
metabolism of, 135
toxicity, 136
Physical activity, 3, 5, 33, 240, 349f, 374, 407
increase daily, 375
levels of, 207
and nutrition, 4f
type of, 293
Physical Activity Guidelines for Americans, 16
Physiologic ergogenic aid, 342
Phytic acid, 38
Phytonutrients and health, 9, 11t, 377–378
anthocyanin, 378
curcumin, 378
green tea extract and epigallocatechin gallate, 378
quercetin, 378
resveratrol, 378
Placebo effect, 349
Plasma nitrite levels, 353
Plasma osmolality, 179
Polycose, 352
Polypeptides, 58
Polysaccharides, 34, 37–38
Polyunsaturated fatty acids (PUFAs), 85, 86f, 87t, 92, 93–95
Population obesity, 202
Postcompetition/practice, 408
Postexercise period, 98
Potassium
athletes and, 143
basic information, 142
commonly consumed foods, 143t
concentrations of, 173
deficiency, 143
food sources of, 142
requirements, 143
sampling of, 174t
toxicity, 143
Poultry, 321
Power activities, 293
Power athletes, 298
Power/endurance sports, 307
after training/competition, 308
before training/competition, 307
during training/competition, 307–308
Power/speed
athletes, carbohydrate recommendations for, 299
sports, 308, 403
 track and field events, 411–412
Prebiotics, 42, 356t
Precompetition/practice, 407–408
Predominant energy systems, 295f
Preexercise carbohydrate consumption, 407
Pregnancy, 373
women during, 16–17
Premature fatigue, 300
Preoptic anterior hypothalamus, 178
Probiotics, 42, 356t
Professional organization position statements, 19–21
Progesterone, 277
Proline, 60t
Prolong satiety, 84
Prostaglandins, 380
Protein efficiency ratio (PER), 66
Proteins, 10t, 57–58, 270–271, 278, 408
absorption, 68
acid-base balance, 62
and amino acid requirements, 71t
appropriate level of, 410
biologic value, 65
breakdown and nitrogen excretion, 59f
building block of, 58
complete protein worksheet, 65t
consumption, 58, 75, 169, 402
content of commonly consumed foods, 72t
diets, high, 76f
dietary intake of leucine/supplementation, 73t
digestibility-corrected amino acid score, 66
digestible indispensable amino acid score (DIAAS), 66–67
digestion, 68
digestive enzymes, 69t
distribution, 75f
endurance, 20
and energy, 240
 enzymes and hormones, 62
factors influence, 67
fluid balance, 62
formed by connecting individual amino acids, 61f
functions, 62–63
individual amino acids via peptide bonds, 61f
intake, 402
intake recommendations, 70
and athletic performance, 73–74
branched-chain amino acids, 75–76
macronutrient distribution ranges for endurance and
strength athletes, 72t
measuring and evaluating, 63–64
messenger, 62
metabolism, 69, 69f, 69t
nitrogen compound synthesis, 62
oxidation, 254
per serving in grams, 19
protective, 62
protein efficiency ratio, 66
quality, 63, 64t, 67t
recommendations for, 299, 303–304
requirements, 67–68
risks of, 76, 76f
selected food sources of, 63t
sources of, 63
sparing, 38–39
structural components of, 62
structure of, 58–62
tissue structure, 62
transport, 62
utilization rates, 213, 400
worksheet, 65t
Protein-sparing effect, 70
Pseudoanemia, 246
Psychological ergogenic aid, 342
Public health agencies, 12
PUFAs (polyunsaturated fatty acids), 85, 86f, 87t, 92, 93–95
Pulmonary diffusing capacity, 406
Pulmonary edema, high-altitude, 328
Pyruvic acid, 404

Quercetin, 378
Questionnaires, 265f
Quetelet’s Index, 202

Rate of energy, 4
Reactive oxygen species (ROS), 243, 377
enzyme antioxidants, 251
internal and external cellular antioxidant defenses against,
252t
measures of, 254
reactive oxygen species and oxidative damage, 254
nonenzyme antioxidants (nutrients), 251–254
production, 249
Recommended dietary allowance (RDA), 14, 131
Recommended nutrient intake, 13
Red blood cell (RBC), 240
hemoglobin in, 241
REDOX reactions, 246f, 249
Registered dietitian (RD), 24
Registration, 24
Regular endurance training, 98
Regulation of body temperature, 166
Relative change in energy metabolism, 302f
Relative energy deficiency (RED), 17
potential performance effects of, 21f
Relative energy deficiency in sport (RED-S), 213, 213f, 216,
383
Relative sweetness of different, 36t
Research, 23
Restaurants in transportation centers, 324
Resting energy expenditure (REE), 264, 265f, 266
Resting metabolic rate, 208
Restrictive food intakes, 247
Resveratrol, 378
Ribose, 35
Rickets, 134
ROS. See Reactive oxygen species

Safe physical activity for all groups, 17

Salivary amylase, 41
Salt consumption, 169
Sample nutrition assessment, principles and components of,
441–446
Sarcopenia, 281, 372–373
Saturated fats, 374–375
Saturated fatty acids, 13, 85, 92
Scope of practice, 25–26
Seafood, 321
Sea-level/hot and humid competition, 335
Selenium, 152–153, 152–154, 240
athletes and, 153
basic information of, 153
from commonly consumed foods, 153t
deficiency, 153–154
food sources of, 153
requirements, 153
toxicity, 154
Serine, 60t
Serotonin, 317t, 355, 380
Serum ionized calcium, 133
Serum iron, 250
Serving or portion size, 17
Sharing foods, 323
Shelf-stable foods, 321t
Sherman/Costill method, 351
Short-chain fatty acids, 87
Simple carbohydrates, 38
Skeletal fragility, 134
Skeletal muscles, 406
glycogen, 411–412
Skinfold, 220–222, 221f, 222t
equations for predicting body density, 223
sites and measurement procedures, 222t
Sleep, 374
duration and quality, 375
impact of, 320
Smoking, 372
Social meal functions, 379
Sodium, 138
absorption, 171
adequate intake for, 172t
athletes and, 140
basic information of, 138
concentrations of, 173
content of commonly consumed foods, 140t
deficiency, 140–141
on food labels, 139t
food sources of, 139–140
hyponatremia, 140–141
requirements, 140
sensitivity risk, 172
toxicity, 141
Soluble dietary fiber, 37
Somatotropin, 317t
Sorbitol, 34, 35t
Sports
anemia/dilutional pseudoanemia, 145, 245f, 246
 energy sources of, 404t
issues in, 5
nutrition, historical evolution of, 341t
organizations and supplement use, 5–6
Sports beverages, 375
amount of solution consumed, 186
carbohydrate concentration of solution, 186
carbonation of solution, 186
consumption of, 408
gastric emptying, 185
state of hydration/dehydration, 186
type of carbohydrate in, 186
Sprinting, 293, 298, 307–309
“Steak and potatoes” pregame meal, 410
Stop-and-go nature of football, 410
Storage systems, 40f
Stored glycogen, availability of, 98
Strength, 293
Stress, 375
fractures, 262, 263f, 413
risk of, 407
Subcutaneous fat, 215
Sucrose, 35
Sugar beverages, high, 375
Suicide, 385
Supplement use, prevalence of, 342f
Sweat loss, 329
Sweat rates, 169f, 409
Swimmers, competitive training for, 412
Swimming, 412
performance, 415
Synbiotics, 42, 356t

Team sport athletes, 50, 309, 395

TEE (total energy expenditure), 264–272
TEF (thermic effect of food), 264, 266
Testosterone, 402
Thermic effect of food (TEF), 264, 266
Thiamin
adequate intake of, 108
deficiency of, 108
Thiamine pyrophosphate (TPP), 107
Thyroid function, 151f
Thyrotropin-releasing hormone, 317t
Tissue glucose utilization, 33t
Tissue structure, 62
Tolerable upper intake level (UL), 14, 131
Total body
electrical conductivity, 217
mass, theoretical contributors to, 218t
potassium, 217
water, 217
Total daily energy expenditure, 278–280
Total energy expenditure (TEE), 264–272
Tour de France cycle race, 415
Toxicity
calcium, 134
magnesium, 138
phosphorus, 136
potassium, 143
sodium, 141
TPP (thiamine pyrophosphate), 107
Tradition, 7–8
Transamination, 69
Trans fats, 95, 374–375
Trans fatty acids, 13, 89, 89f, 92
Transferrin, 240, 243–244, 250
Travel, 315–317
common foodborne illnesses, 322t
drinks when, 324t
 food, safe minimum internal temperatures, 323t
food safety considerations, 321–323
general rules for, 317–319
jet lag, minimizing, 319–320
___location, 320–321
to Norway, 319
planning for trip, 316f
shelf-stable foods available for, 321t, 323t
tips for, 318
Trehalose, 36
Triathlon, 414–415
Triglyceride molecule, 86f
Triglycerides, 46, 86
Tryptophan, 62
24-hour energy balance, 208
Type IIB fibers, 396
Type II diabetes, 199, 373t
Tyrosine, 61t

Ubiquinone (Coenzyme Q10), 253

Ultraendurance cyclists, 164
Ultrasound, 216
Unabsorbed carbohydrate, 42
Underhydration, 368, 414
Unenriched polished rice, 107
Upper intake levels (ULs), 430–431
Urea, 58–59f, 76–77
Uric acid functions, 252–253
Urinary loss, 168
Urine, 58, 247
Ursolic acid, 350

Vasoactive intestinal peptide, 317t

Vasopressin, 171
Vegetables, 321
Vegetarian diet, 145
Very-low-density lipoproteins (VLDS), 91
Vigorous-intensity activities, 369
Visceral fat, 202, 203
Vitamin A, 117–119
Vitamin B12, 240, 244
Vitamin C, 240, 253
Vitamin D, 119–120
supplements, 356t
Vitamin E, 120, 240, 253
Vitamin K (phylloquinone, menaquinone), 121
Vitamins, 10t, 103–106, 278, 331, 348t
belief-based vs. science-based nutrition, 104f
consumption of, 106
deficiency, 106
dietary supplements and mortality rate in older women,
105t
enrichment and fortification, 106–107
fat-soluble vitamins
vitamin A, 117–119
vitamin D, 119–120
vitamin E, 120
vitamin K, 121
recommendations, 304
requirements, 368
supplementation of, 369
toxicity, 105, 369
water-soluble
biotin, 114
choline, 116–117
folic acid, 113–114
niacin, 109–110
pantothenic acid, 114–115
vitamin B1, 107–108
 vitamin B2, 108–109
vitamin B6, 110–112
vitamin B12, 112–113
vitamin C, 115–116
VLDS (very-low-density lipoproteins), 91

Waist circumference, 202–203, 203

Water, 11t, 23, 322–323
balance, 170, 170t
sustaining, 167–169
content of foods, 167t
distribution in human body, 168f
functions, 166
loss in athletes, 241
Water, electrolytes, and carbohydrate (WEC), 179–180
Water-soluble vitamins, 104, 369
biotin, 114
choline, 116–117
folic acid, 113–114
niacin, 109–110
pantothenic acid, 114–115
vitamin B1 (Thiamin), 107–108
vitamin B2, 108–109
vitamin B6, 110–112
vitamin B12, 112–113
vitamin C, 115–116
WBGT (wet bulb globe temperature), 177
WEC (water, electrolytes, and carbohydrate), 179–180
Weight, 200
anthropometric ratios
height/age, 203
weight/age, 203
weight/height, 203
 weight/height/age, 203–204
body mass index, 202, 374
change, 207
circumferences, 202–203
cycling, 208f, 400
gain, patterns of, 409
ideal weight, 201
Weight loss
dietary supplements, 343–345t
levels of, 207
methods, 413
patterns of, 409
strategy, 412
techniques, 412–413
Well-hydrated athletes, 178
Wet bulb globe temperature (WBGT), 177
Wisconsin Interscholastic Athletic Association, 413
Wrestlers, anaerobic performance of, 413
Wrestling, 412–413

Xylitol, 35
Xylose, 35

Young athletes, 262

energy balance in, 266
energy needs, 263–264
nutritional considerations for, 261
total energy expenditure, 264–272

Zeaxanthin, 253
Zinc, 148–150
athletes and, 150
basic information of, 149
content of commonly consumed foods, 149t
deficiency, 150
food sources of, 149
requirements, 150
toxicity, 150