From Problems to Solutions

January 29, 2015
A runner with anemia. A field hockey athlete with celiac disease. A swimmer with changing dietary needs. Those were the problems. These experts offer the solutions.

By Dr. Christine Rosenbloom, Caroline Mandel, & Jennifer Brunelli

Athletes may sometimes feel as if their body is working against them when it comes to nutrition. The effects of deficiencies, allergies, and aging can be great. A diet that was once helping to optimize performance may now be causing performance to suffer.

But athletes should not fear. Once recognized, anything the body throws at an athlete can be handled with careful changes to their dietary regimen. It may not be easy at first, and the athlete may need to relearn how to fuel their body, but if their diet is tweaked correctly, performance will improve.

In the following case studies, three sports dietitians share how they each helped an athlete conquer a dietary issue. In all three cases, the athletes got back on track to athletic success.


Running Low on Iron

By Dr. Christine Rosenbloom

Christine Rosenbloom, PhD, RD, CSSD, is the Sports Dietitian at Georgia State University and Owner of Chris Rosenbloom Food & Nutrition Services. She is also Professor Emerita at Georgia State and was the Editor in Chief of Sports Nutrition: A Practice Manual for Professionals, 5th edition. She can be reached through her Web site at: www.chrisrosenbloom.com.


A high school cross country and track and field athlete, Miranda became a vegetarian because she read about the health benefits associated with a plant-based diet. She also hoped it would help her lose five pounds and get her to her self-determined "ideal" body weight.

However, after successful sophomore and junior seasons, Miranda was struggling in her senior year of high school. The 5,000- and 10,000-meter specialist complained of fatigue, shortness of breath during exercise, cold intolerance, and an inability to fully recover between training runs.

Miranda's physician diagnosed her with an iron deficiency (her hemoglobin was 10.3 g/dL, hematocrit 34 percent, transferrin 371 mg/dL, and ferritin 8 ng/mL) and suggested she see a Registered Dietitian for a nutrition consultation. When I initially met with Miranda, I reviewed her complete blood count and asked her to write down everything she ate for three days.

Along with revealing a lack of iron from food choices, her food record showed she was not eating enough carbohydrate and protein to sustain her training. She did have normal menses and was taking calcium carbonate gummies (500 mg/day). I explained to her that because she was not getting enough iron, her body was not able to carry enough oxygen to her muscles (hemoglobin) or make enough oxygen reserve in muscles (myoglobin), resulting in early fatigue and lack of energy.

Iron depletion in tissues can also cause cold intolerance and reduced exercise endurance. By not eating enough carbohydrate and protein, her body was not able to provide the building blocks to make the iron-carrying proteins or replenish glycogen stores in her muscles after a workout. I recommended she do the following:

Increase calorie intake. Miranda was consuming just 1,600 calories per day, but based on her age, training volume, and frequency of competitions, a calorie range of 2,600 to 2,800 per day was much more appropriate. We started by increasing her intake to 2,100 calories a day by adding snacks between meals. After two weeks, we bumped it up to 2,350 calories by increasing the portion sizes of her meals.

Increase carbohydrate intake. Miranda was consuming 192 grams of carbohydrate per day, which equaled 3.9 grams per kilogram of her body weight. The goal was to up that to 5 g/kg, and possibly to 6 or 7 g/kg as her training increased. We added carbohydrate-rich snacks between meals to help her accomplish this goal. Her favorites were dried fruit, granola bars, yogurt, and whole grain fruit muffins.

Increase protein intake. Miranda was taking in 56 grams of protein per day, which translates to 1.1 grams per kilogram of her body weight. She needed 1.5 g/kg to provide adequate protein for endurance exercise and for hemoglobin synthesis. She added yogurt smoothies after workouts, snacked on nuts, and we identified vegetarian protein-rich options like beans, lentils, soy nuts, and veggie burgers that would fit her dietary restrictions.

Increase iron intake. This was the main area of concern for Miranda, and probably the most difficult. Her average dietary iron intake was 8.2 milligrams per day and it needed to be 15 mg/day to reach the Recommended Dietary Allowance. She was prescribed 325 milligrams of ferrous sulfate once daily for three months. But she also needed to learn how to increase iron in a vegetarian diet. One strategy was to simply eat more iron-rich plant foods. I gave her this list for ideas:

- Instant oatmeal
- Fortified breakfast cereals
- Long-grain enriched rice
- Vegetarian baked beans
- Lentils
- Soy crumbles and soy burgers
- Trail mix with raisins
- Bean burrito
- Chili with beans
- Chick peas
- Hummus
- Black beans
- Fat-free refried beans
- Clam chowder
- Lima beans.

A second strategy was to add more vitamin C (ascorbic acid) to her diet since it is a potent enhancer of iron absorption. It can change iron to a more absorbable form, giving the body up to three times more iron than when taken without vitamin C. Easy ways to add vitamin C include drinking orange juice with breakfast, adding peppers and salsa to a bean burrito, slicing strawberries into cereal, and eating a citrus fruit salad with a bowl of vegetarian bean chili.

We also talked about foods that can block iron absorption. Tea, coffee, and cocoa contain polyphenolic compounds that have some health benefits, but can block non-heme iron absorption. To get the most iron from her meals, I advised Miranda to choose beverages that don't fight iron absorption such as water, citrus-based sparkling waters, and fruit juices. I told her to enjoy her coffee, tea, or cocoa only between meals.

Another discussion was about an "ideal" weight for a runner. Miranda was 5-foot-3 and 108 pounds, which is at the low end of the body mass index but still a healthy weight for her height and sport. We discussed that there is no "ideal" weight for an athlete and that performance is not tied to a specific body weight or body fat level. What was most important was how she was performing. She acknowledged that she was eating too little to maintain 108 pounds and that she ran better when she weighed 112 pounds.

Miranda reversed her iron deficiency anemia through supplementation and changes to her diet. She began to feel better and reported having more energy as the weeks progressed. She remained a vegetarian, but occasionally included fish in her diet and stuck with five to six small meals a day to boost calorie and nutrient intakes. Miranda was able to regain her endurance and energy and was a valuable part of the cross country and track and field teams. She is currently a college freshman and running on her university's team.


Going Gluten-Free

By Caroline Mandel

Caroline Mandel, MS, RD, CSSD, is the Director of Sports Nutrition at the University of Michigan. She can be reached at: chmandel@umich.edu.


Bailey is a field hockey player who was experiencing stomach pain, gas, bloating, and diarrhea during her senior year of high school. She was losing weight, feeling fatigued, and not playing well. Her personal trainer suggested she eliminate gluten from her diet, and within a few weeks, Bailey's symptoms disappeared. Fast forward to the start of her freshman year here at the University of Michigan, when she asked to meet with me for help planning gluten-free (GF) meals as a college athlete.

At our initial consult, we discussed gluten intolerance and athletic performance. Gluten is a combination of two proteins (gliadin and glutenin) found in grains such as wheat, rye, and barley. Gluten issues range from a sensitivity to an intolerance to an allergy to celiac disease--which affects one to two percent of the population.

Celiac disease is a chronic inherited T-cell-mediated autoimmune intestinal disorder, which causes damage to the villi of the small intestine. Symptoms vary from person to person and include stomach pain, gas, bloating, diarrhea, weight loss, and inability to concentrate. Individuals with celiac disease are at risk for arthritis, joint pain, dermatitis herpetiformis (a chronic blistering skin condition also known as Duhring's disease), fatigue, nutrient deficiencies such as iron deficiency anemia, and osteoporosis.

Bailey had not been diagnosed with anything before she arrived here at Michigan. She only knew that she felt better when she didn't eat gluten. In order to be tested for celiac disease, a person must include gluten in their diet for four to six weeks and then undergo blood tests that detect specific antibodies (deaminated gliadin peptide, anti-endomysial, and anti-tissue transglutaminase), as well as a biopsy of the small intestine. I consulted with the team physician, and we decided that, in order to not disrupt her season, Bailey would follow a GF meal plan until the off-season, when she would eat gluten for four weeks so she could be tested for celiac disease.

The first thing Bailey and I did was contact the dining hall manager and head chef on campus. We learned that our dining halls are quite friendly to students who need to follow a GF diet. GF foods are marked with a special icon and Bailey could check menus, nutrition information, and ingredients online to identify food choices for the day. The dining halls stock GF bagels, pasta, breads, and cereals and even prepare GF meals in a separate area of the kitchen to prevent cross-contamination. Bailey also gave the dining hall staff her weekly schedule to make sure they had food ready for her when she came in to eat.

From there, I helped her plan meals that would meet calorie, macronutrient, and micronutrient requirements for her sport based on nutrient-dense choices of starches, lean proteins, colorful vegetables and fruits, and healthy fats. At 5-foot-5 and 140 pounds, Bailey required approximately 2,400 calories per day: 318 to 445 grams of carbohydrate (2.3-3.2 grams per pound of body weight), 76 to 108 grams of protein (0.54-0.77 g/lb), and 64 grams of fat (0.45 g/lb).

Bailey aimed to include starch from GF oatmeal or other GF cereals and breads, lean protein (milk, yogurt, eggs), and fruit at breakfast. At lunch and dinner, she included starch, lean protein (often a meat alternative such as beans), fruits, and vegetables. She used snacks such as fruits, vegetables, additional servings of dairy, and healthy fats from nuts and seeds to fill nutrition gaps. Bailey's favorite meals included:

Breakfast: A vegetable omelet for protein with hash browns and fresh fruit for carbohydrates and fiber

Lunch: A GF wrap for carbohydrates containing GF lunchmeats for protein and vegetables for nutrients and fiber

Dinner: Stir-fry with chicken for protein and vegetables for nutrients and fiber over brown rice

Snacks: Homemade trail mix made with dried fruit, almonds and GF cereal or GF pretzels and a cheese stick.

Before her season started, I contacted the field hockey team's director of operations to plan Bailey's meals when the team was on the road. We arranged with hotels to provide GF meals made up of items like a baked potato without seasoning, grilled chicken with garlic and lemon, salad with a GF salad dressing or olive oil and vinegar, and steamed vegetables. I also searched online for restaurants with GF options.

I designed a card for when the team went to restaurants. The front had a definition of celiac disease and a description of Bailey's nutritional needs, and the back had a list of gluten-containing foods and ingredients and a request to prepare her meal separately with clean pans and utensils to avoid cross-contamination. All Bailey had to do was hand the card to the server and ask that he or she give it to the chef.

Bailey had a great freshman year, appearing throughout all 22 games in both the regular and postseason. After the season, Bailey ate gluten for four weeks so she could be tested for celiac disease. Unfortunately, she had to withstand severe digestive symptoms, but we knew this was a possibility. We were not surprised when her blood tests came back positive for the antibodies associated with celiac disease. Her intestinal biopsy was positive for celiac disease as well, meaning Bailey would need to follow a GF diet for life.

Bailey moved off-campus to an apartment with a teammate her sophomore year. We worked on menu planning, grocery shopping, and label reading, and found a variety of GF foods in local grocery stores. Her roommate came to one of our nutrition meetings so we could educate her on how to avoid cross-contamination in their kitchen by keeping food preparation, pots, pans, utensils, sponges, dishtowels, and even toaster ovens separate. Bailey stored most of her food, silverware, plates, and cups in plastic bins with lids to prevent contamination.

As with any drastic diet change, there can be roadblocks. Bailey hit one during her sophomore season when she started experiencing constipation. Without consulting me or a doctor, she decided to eat small amounts of gluten-containing food because she knew they usually caused her diarrhea and would therefore solve her constipation problem. She also purchased a fiber supplement without reading the label and realizing that it contained gluten.

When Bailey told me about her "solutions," I realized she did not fully understand the disease. We had a long talk. I explained how these strategies are dangerous for patients with celiac disease because the ingestion of gluten damages and inflames the intestines, decreasing absorption of nutrients, and possibly leading to long-term complications. Even if she wasn't experiencing symptoms, the gluten was wreaking havoc on her body.

But we still needed to solve the constipation problem. We checked her dietary intake, which revealed that she was relying on many low fiber GF foods in her meal plan such as bagels, cereals, bars, breads, and pasta, and was not consuming enough fruits, vegetables, GF whole grains, and beans. Her dietary fiber intake was only 15 to 18 grams per day--inadequate compared to the Institute of Medicine's recommendation of 25 grams per day for women under 50. We revamped her meal plan to include eight to 10 servings of fruits and vegetables per day plus beans, potatoes, quinoa, wild or brown rice, and snacks that included fewer processed GF products. I also recommended she take a GF fiber supplement daily and increase her fluid intake. Her constipation resolved within a few days.

Bailey and I continue to follow up at the beginning of each semester to plan eating strategies around her class and training schedule. Following a GF meal plan that is nutrient-dense will help Bailey heal intestinal damage, keep her healthy, support her athletic performance, and prevent future complications of celiac disease.


Changes with Age

By Jennifer Brunelli

Jennifer Brunelli, RD, LDN, is the Owner of RDpro and former Director of Sports Nutrition at North Carolina State University. She can be reached at: SportsRDpro@gmail.com.


It is possible for athletes today to be high level competitors well into their 30s and even 40s. This fact has become increasingly obvious in the sport of swimming over the past decade.

However, if these athletes want to remain competitive with their younger counterparts as they age, they often need to restructure their diet. This can include examining overall calorie intake, ratio of carbohydrate to protein to fat, hydration, recovery nutrition, and supplements. James, a swimmer who chose to compete professionally after college, knew this and sought me out for help with his nutrition plan.

James had a great track record when it came to the pool, but not such a stellar one when it came to his diet. At 14, he qualified as a senior national sprinter, and at 17 was an Olympic trials qualifier. But his diet during his high school years lacked in overall calories and carbohydrates.

James's high school coach valued high volume training--10,000-plus yards daily--that required a lot of calories. I think it would be reasonable to say that he should have been eating upwards of 6,000 calories per day. Had James and I been working together at the time, I would have suggested that he get so many calories from quality sources such as whole grains, fruits, and vegetables. His meals should have been well balanced at 55 to 60 percent carbohydrate, 15 to 20 percent protein, and 20 to 25 percent fat.

Unfortunately, he instead ate whatever he wanted to, including a lot of high fat, high sugar choices, like fast food. On the days that he hit the drive-through, his calorie count approached 5,000, but his intake looked more like 40 to 45 percent carbohydrate, 10 to 15 percent protein, and 30 to 40 percent fat. Regardless of his insufficient diet, James continued to improve his times in the pool.

Not much changed when he went to college. Consistency in nutrition is something I push for with my college-age clients. This was James's biggest hurdle at the time. Some days he was too tired between classes and practice to get to the dining hall, so he resorted to low calorie options such as cereals and prepackaged noodles.

As in high school, James saw continued success throughout his college career. He was an NCAA finalist and Olympic trials finalist in 2004. Because of his success, he was offered funding from several sponsors and decided to continue competing professionally. Only then did he begin to focus on what he was fueling his body with. James came to see me in 2005 and made some changes to his diet, focusing on consistency and the timing of his meals.

One of the things we changed was making sure he had breakfast every morning before he went to practice and a recovery meal within 30 minutes of completing his workouts. Eating breakfast allowed him to have fuel available for immediate delivery to his muscles for a 6 a.m. workout after he had been fasting through the night while sleeping.

Post-workout, I like to think of the body as an open door. The fuel and nutrients needed to benefit from the exercise are more easily absorbed and utilized within 30 minutes after a workout. After 30 minutes, the door starts to close and athletes don't get the full benefit from any carbohydrate or protein consumed.

James was also able to break one of his bad habits formed in high school: He decreased his fast food consumption. After maintaining these changes for about six months, James remarked that he was stronger than he had ever been in the weightroom and swimming faster than ever in the pool.

Unfortunately, James suffered a shoulder injury in 2006. He was told his career would be over after surgery, but was determined to recover and come back stronger. While James was injured, I helped him understand that he needed to alter his diet because of the circumstances.

We agreed that he would decrease his calorie intake while his workout schedule was lighter than normal, but keep protein intake up to help with the healing process. He also supplemented with omega-3 fatty acids to help decrease inflammation for accelerated recovery. After 10 months of rehab, his hard work showed in competition when he broke an American record.

In 2008, he was an Olympic trials finalist again at 26 years old, but missed making the Olympic team by a tenth of a second. Determined to continue training for one more chance to make the team, James moved to the Southeast and saw the combination of his age and different environment affect his training in new ways. He was now in a humid climate, training indoors only, and working a full-time job while competing--and approaching 30.

His work schedule meant that he was often only able to train once a day, and he found it harder to time his meals for optimum recovery. Our solution was to prep his meals the night before and prepare large amounts of food over the weekend so he would have fuel available quickly when he needed it during the week.

When James began feeling increasingly tired and started having trouble recovering despite his decreased training load, it was determined he was iron and vitamin D deficient. To increase his iron stores, I had him start consuming iron-rich foods such as red meat, eggs, dark green leafy vegetables like spinach, dried fruit mixed in with trail mix, and beans in salsa, chili, and hummus. He also began taking ferrous sulfate to keep his iron levels up.

For his vitamin D deficiency, James started supplementing with D3 at 5,000 IU daily. Vitamin D can be made in the body from sunlight as well, so James also made sure to spend 30 minutes a day outside in the sun with his skin exposed when he had time. He soon found himself with increased energy levels and improved recovery times.

Because of the drop in training, his body fat percentage began increasing. James also found it hard to maintain core strength, so we decreased his calorie intake to more closely match his decreased training load.

By the 2012 Olympic trials, at the age of 30, he was 6-foot-2 and 181 pounds and yet again, as strong in and out of the water as he had ever been. He swam times comparable to his previous performances as a 22- and 26-year-old. Though he didn't make the Olympic team, he was able to retire with confidence that he had done all he could to give himself the best opportunity possible. He had no regrets.

It was necessary for James to consider numerous factors throughout his career. His physical output decreased through the years, his injury changed his needs for several months during what should have been his prime, and his metabolic needs varied with his increasing age. Without making the changes that he did, he would not have been as successful as he was through the age of 30.

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