Case by Case

January 29, 2015
When poor nutrition stands in the way of an athlete's performance, it's time to act. These three case studies cover dietary hurdles encountered in basketball, cross country, and swimming.


In the world of sports nutrition, some advice is tried and true--eat lots of fruits and vegetables, drink plenty of fluids, and keep sugary snacks to a minimum. But in some instances, athletes require a more personal touch to address fueling deficiencies.

In this three-part article, veteran nutritionists share how they helped athletes with various dietary struggles. In one case, an elite basketball player was aiming to gain weight. In another, a high school runner with diabetes was experimenting with different diets. And, in a third, a swimmer was denouncing carbs in an effort to not gain weight.

With careful adjustments to diets, each athlete was able to overcome their unique nutritional problems and reach their goals. There was also a lot of education along the way. (Note that the names used here are not the athletes' real names.)

Adding Bulk

By Susan Kundrat

Susan Kundrat, MS, RD, CSSD, LDN, is Nutritional Sciences Program Director and Clinical Assistant Professor of Kinesiology at the University of Wisconsin-Milwaukee. She is the cofounder of RK Team Nutrition and serves as a consultant for several college and professional basketball teams. She can be reached at: kundrat@uwm.edu.


When freshmen male basketball players arrive on campus the summer before their first season of college ball, everything is new. There are daily strength and conditioning sessions, hours spent in team meetings and film study, and a focus on nutrition to help transform their bodies from high school athletes to bigger, stronger, and tougher college players.

For one player I recently worked with, Devon, this last item was critical. A talented player in high school, he had dominated other big men even though he was only 220 pounds at 6 feet, 11 inches tall. In pick-up games with his college teammates during that first summer, however, he was often unable to hold his own against players the same height with more muscle mass.

Therefore, one of the first challenges for Devon was to adjust to a new eating routine and gradually begin to gain weight. He arrived with about 198 pounds of lean mass and 10 percent body fat. Working with his coaches, the sports performance team set up a plan for Devon to gain 10 to 15 pounds his first year, another 10 to 15 pounds his sophomore season, and then maintain his weight between 245 and 250.

Like other athletes who have been asked to increase weight, Devon told me he had been trying hard to put on muscle the last few years, but his body "wasn't capable of it." No worries, I told him. With an individualized sports nutrition program, strength program, and the support needed to carry it out, I knew we could make it happen.

In high school, Devon practiced an average of two hours a day and lifted once or twice a week. At the college level, he was looking at more than three hours of practice a day, a significant increase in his training volume and intensity, and a greater focus on strength and agility work. This new regimen could burn upwards of 4,000 calories.

When Devon came to college, he was still following his high school diet, in which most of his calories came from simple sugars, fried foods, and snacks--breakfast was a granola bar and juice, lunch consisted of fast food and soda, and a balanced dinner was often followed by chips, cookies, and soda. This old meal plan wasn't properly fueling Devon to meet the increased demands of college ball. So at our initial consultation, Devon and I agreed on two simple goals for his new approach to nutrition:

- Fuel six to seven times a day with easy-to-implement meals and snacks.
- Use a simple meal plan and daily tracking sheet to record his intake.

Devon was eating roughly 4,000 calories and 130 grams of protein per day when he first arrived on campus. After my assessment, his strategy for gaining weight included 6,000 to 7,000 calories a day and 220 grams of protein (maximized at one gram per pound for weight gain).

The plan was split into three daily meals, pre- and post-workout fuel, and snacks. We emphasized meal timing, so Devon ate a bigger breakfast and lunch and consumed a shake and piece of fruit or a sports bar before workouts. That way, his body was well-fueled for practice and lifting. In addition, spacing out his calories and protein helped his body be in muscle-building mode all day long.

To fulfill this new nutrition plan, I advised Devon to focus on high-quality foods and fluids. He often took full advantage of prepared meals in the dining hall and training table, and I introduced him to basic recipes for high-protein, low-fat options he could make for himself, such as grilled chicken, grilled fish, and lean burgers. We worked on finding first-rate protein sources (like milk, yogurt, and eggs) to maximize lean muscle enhancement, as well. I also suggested he maximize calories from fluids like milk, chocolate milk, 100 percent juice, smoothies, and shakes. (See "On the Menu" below for a sample meal plan.)

This advice was especially pertinent during that first summer because Devon was sharing an apartment with another player until the dorms opened and would need to prepare many of his own meals. Since he had never been responsible for making his own food before, we had to teach him basic grocery shopping and cooking skills.

First, nutrition interns led him on a personalized tour of a grocery store a few blocks from his apartment. Next, Devon acquired the necessary cooking equipment (pots and pans, George Foreman grill, blender, crock pot, and so on). Then, as part of summer team cooking classes, he began learning how to cook fast and easy meals. Knowing how to make high-calorie smoothies, grill meats on a Foreman grill, cook high-quality proteins in the crock pot, and prepare one-dish skillet meals was exactly what he needed to feel more comfortable being in charge of his own intake.

And since Devon, like many college students, was bound to eat out from time to time, I educated him on how to be smart about it. I told him to look for lean protein options first and build his meal around them.

To help Devon stay on track as he began his nutrition plan, he found it helpful to keep a copy of his meal plan with him at all times. There was one posted on his refrigerator, one in his locker, and another accessible on his phone. Devon's strength coach and athletic trainer were also on board with holding him accountable. They were aware of Devon's nutrition goals and regularly followed up with him to make sure he was sticking with the plan.

Devon's progress was monitored consistently during his first year through weekly nutrition meetings, regular weigh-ins with the strength coach, and intermittent body composition testing. From June to January in his freshman season, Devon gained 13.6 pounds of lean mass. But as is common with college athletes, the offseason was his prime time to put on significant weight, moving from 230 pounds to 247, including 15.5 pounds of lean mass. He was able to keep his playing weight between 238 and 242 pounds as a sophomore.

For Devon, staying the course with his nutrition plan even when it was most difficult made a big difference in his success. During the preseason and early season, he was training the hardest and burning the most calories, while also being extremely busy with classes, study hall, and travel. He understood that during heavy training, he was likely to maintain or even lose a little weight, only to maximize weight gain when training eased off. I assured him that if he stuck with the plan when life was most hectic, once his schedule eased up, he would continue to progress toward his weight goals.

As Devon's performance improved on the court, it reinforced how important his nutrition plan was to his success. Devon had set his sights on playing professional basketball, and his dream came true. After two productive college seasons--and adding more than 20 pounds of muscle--he went on to a career in the pros.


Fueling with Diabetes

By Marcey Robinson

Marcey Robinson, MS, RD, CDE, CSSD, is cofounder of Achieve Health and Performance in Basalt, Colo., where she works with athletes from all levels. In this case study, she combines her expertise in sports nutrition, exercise physiology, and advanced diabetes management. She can be reached at: marcey@achievehp.com.


I met Tyler during his sophomore year in high school while he was participating on the school's cross country team. Like many teenagers, his interests were varied and often-changing. One thing that set Tyler apart from his fellow teenage student-athletes, however, was Type 1 diabetes.

As an expert in the field of diabetes and exercise who has worked with a large number of athletes, I know that the disease doesn't have to interfere with sports participation. As long as athletes monitor their blood sugar frequently, pay careful attention to what they eat and how they fuel, and take the correct dosage of insulin at the appropriate times, blood sugar control and optimal performance is possible. I started working with Tyler because he wasn't doing any of those things.

His biggest issue was controlling his blood sugar levels around exercise and keeping them within the normal range of 80 to 180 mg/dL, but he often compounded the problem with improper fueling and poor diabetes management. When Tyler's blood sugar would drop, he would become dizzy, sweat, lose coordination, and even pass out. To avoid these episodes, he would skip his insulin injections all together, which would result in severely high blood sugar spikes and cause dehydration and fatigue.

The consequences of Tyler's blood sugar instability were affecting his athletic performance and had become a safety concern to his parents, teachers, and coaches. The high school's administrators were even considering banning Tyler from athletics due to his inability to manage his diabetes. However, I felt we could get things under control with a few nutritional tweaks.

When I started working with Tyler, I learned that he was following a Paleo diet after reading about its benefits for athletes. This diet relies heavily on meats and vegetables and cuts out a great deal of carbohydrate-containing foods, such as grains, legumes/dried beans, and dairy.

Tyler's decision to follow this meal plan and cut carbs presented obstacles to meeting his nutritional needs as an endurance athlete with diabetes. For instance, the daily carbohydrate recommendation for runners ranges between five and 12 grams per kilogram of bodyweight. Therefore, Tyler needed a minimum of 363 grams a day to supply on-demand fueling and allow for adequate muscle glycogen--the body's storage form of carbohydrate, which is broken down into sugar for fuel during exercise. However, his diet was supplying only 60 to 75 grams of carbohydrate a day.

In addition, for an athlete with diabetes, carbs serve a broader purpose--stabilizing blood sugar through maintenance of liver glycogen, which is broken down during periods of fasting to provide necessary energy to the brain and vital organs. And because Tyler's insulin regimen had not been adjusted to accommodate the lack of carbs from his Paleo diet, his blood sugars were fluctuating dramatically. The solution was a combination of decreasing his insulin and finding places to increase his carbohydrate intake.

In order to meet his nutritional needs, Tyler had to consent to minor "cheating" within the confines of the Paleo diet. It was necessary that he consumed consistent carbohydrate-containing foods throughout the day, especially before and after exercise. We worked together to find opportunities to add carbs in his daily meal plan, such as loading up on fruit with meals and having a banana with almond butter and chocolate soy milk as a recovery snack immediately after a long training run.

However, we also needed to find a way to add carbohydrates during activity. Tyler's diabetes plan was to reduce his insulin prior to exercise, but the duration of his runs also required him to add carbs during workouts for fuel and to prevent his working muscles from stealing all the sugar in his blood. Tyler agreed to use sports drinks and take energy chews with him on long runs. By consuming them in calculated amounts at regular intervals to match his energy needs, he was able to avoid low blood sugars.

These changes helped Tyler sustain his energy level during runs and also allowed his body and muscles to recover more effectively afterward. His performance immediately improved, and his blood sugars typically stayed within a normal range while exercising.

Everything was going great. That is, until the capricious teenager in him emerged again. Tyler decided the Paleo diet was too difficult and switched to an environmentally friendly vegan diet instead.

From my standpoint, this was a wonderful change, as vegan diets allow bountiful carbohydrate foods that would help manage Tyler's diabetes and provide fuel for running, but it did raise a different set of challenges. With the influx of carbohydrate in his diet, Tyler began having elevated blood sugars and had to increase his meal insulin to help them stabilize. Since vegan diets can be low in protein, we also shifted the nutrient focus to assure adequate protein intake for proper muscle recovery. Tyler ate nuts, nut butters, soy protein, beans, and high-protein grains like quinoa to meet his needs for this nutrient.

Just when we had Tyler's vegan diet fine-tuned for his diabetes and exercise, my approach shifted for a third time when he changed his sport to rock climbing. Due to the anaerobic, high-intensity, interval nature of this sport, Tyler found that his blood sugars often ran high during exercise. This is the opposite of the low blood sugars he experienced when running, so his usual method of reducing his insulin and eating more carbohydrates made things worse.

The adrenaline released during rock climbing caused Tyler's body to quickly break down glycogen into sugar. This led to a blood sugar increase, which caused fatigue and made Tyler's muscles feel like lead weights.

The solution was adjusting his diet and insulin regimen once again. Prior to exercise, Tyler needed to take more insulin than before and have a balanced intake of protein, fat, and carbohydrate. This prevented too much sugar from entering his blood at one time and helped minimize the large spikes.

Despite its challenges, the switch to rock climbing was an important learning point for Tyler because he began to realize that all exercise did not have the same effect on his blood sugars. By adjusting his fueling strategy and insulin regimen, he again was able to achieve blood sugar control and optimal sport performance.

Working with Tyler has been a wonderful experience. Now a freshman in college, Tyler has all the tools he needs to continue his success as an athlete with diabetes. It has been rewarding to watch him overcome frustration, embrace fearlessness, and attack his athletic goals in a healthy way.


Different Strokes

By Dr. Christine Rosenbloom

Christine Rosenbloom, PhD, RDN, CSSD, FAND, is a sports nutrition consultant who works with athletes of all ages. She is Professor Emerita at Georgia State University and Editor in Chief of Sports Nutrition: A Practice Manual for Professionals, Fifth Edition. Christine can be reached through her website at: www.chrisrosenbloom.com.


As a 5-foot-8-inch, 150-pound, 15-year-old high school freshman swimmer, Kendra believed she was too heavy. She had read that carbohydrate-rich foods were fattening, so she decided to cut carbohydrate from her diet with the exception of fruit to lose weight.

At the time, Kendra was practicing three to four hours every day as she prepared to try out for her school's varsity squad, including work in the pool and dry land training. Her mother was worried that she was not getting enough carbohydrate to fuel such hard training. In addition, Kendra complained of fatigue and heavy arms and legs during swim practice. Despite the fact that she was an exceptional junior swimmer, Kendra's coach became concerned that her declining performance would keep her from making the team.

When I first met with Kendra, she described experiencing a three-inch growth spurt and a 12-pound weight gain over the previous 18 months. Kendra appeared anxious that she would continue to gain weight if she didn't cut calories from her diet.

From my perspective, Kendra didn't see how her reduced caloric intake and insufficient carbohydrate consumption affected her performance in the pool. Training with the high school team was harder and longer than she was used to, so her decreased fueling left her tired during swim practice, and she had lost some of her stamina. Lastly, she complained of mild, intermittent loose stools and diarrhea that I thought could be tied to her diet.

Before I could offer nutritional advice to remedy some of these issues, I wanted to know what Kendra had been eating. I convinced her to keep a three-day food and training log for analysis. My review of the food log revealed that Kendra had cut out grains and starchy vegetables from her diet but was consuming large quantities of fresh and dried fruit, nonfat milk, and yogurt. Overall, her calorie and carbohydrate intake was too low to support her training.

Here is a breakdown of Kendra's average daily consumption from her food logs:

- Calories: Kendra was taking in roughly 2,010 calories a day. According to online energy calculators from the Academy of Nutrition and Dietetics's Sports Nutrition Care Manual, her total daily energy expenditure was between 3,850 to 4,200 calories. Therefore, she was meeting only half of her recommended energy intake.

- Carbohydrate: Kendra's food logs showed she was eating approximately 200 grams of carbohydrate, or 2.95 grams per kilogram of bodyweight (g/kg/bw) a day. Athletes who are engaged in moderate- to high-intensity exercise should consume six to 10 g/kg/bw of carbohydrate daily. Even using the low end of that estimation, Kendra should have been eating 405 to 470 grams of carbohydrate a day.

- Protein: She was consuming about 150 grams of protein daily, or 2.2 g/kg/bw, from eating a large portion of lean meat with every meal and snacking on nuts throughout the day. The recommended daily dose of protein for endurance athletes is 1.2 to 1.4 g/kg/bw, so someone of Kendra's size should have been taking only 82 to 95 grams.

- Fiber: Kendra's fiber intake was 55 grams per day, more than double the recommended intake of 26 grams for a 15-year-old girl.

After my food log analysis, I spoke with Kendra and showed her the numbers. Together, we came up with a nutrition plan that would increase her calorie and carbohydrate intake and decrease her consumption of protein and fiber.

Adding small meals before early- morning swim practices and snacks after workouts were my way of bumping up Kendra's daily intake of calories and carbs. A review of her food and activity logs revealed that she was not timing her nutrient intake around her training sessions. By eating small snacks throughout the day, she would be able to meet her twin goals of increasing calories while supporting training. By boosting her carbohydrate consumption, she would be providing the building blocks for glycogen stores to her muscles, which would improve stamina.

I addressed her concern about "carbs being fattening" by explaining that the media often demonizes a nutrient. At present, that nutrient is carbohydrate, but that didn't mean carbs were bad for her. We discussed the importance of consuming quality carbs that provide nutrients, such as whole grains, starchy vegetables, fruit, and low-fat dairy, as opposed to nutrient-poor carbs like soft drinks, candy, and fruit drinks.

For our new focus on breakfast, Kendra and I devised a week's worth of meals that she could eat in the car while her dad drove her to morning practices. These breakfast choices would provide the key nutrients needed to fuel her properly after an overnight fast: quality carbs, protein, healthy fat, vitamins, and minerals. By eating a substantial morning meal, Kendra started her day with enough calories and carbohydrates for activity.

These breakfast options included:

- A cup of instant oatmeal with dried cherries and pistachios plus a cup of fat-free milk
- One hardboiled egg and two slices of nine-grain toast with margarine and jam and 16 ounces of water
- Almond butter on a plain mini-bagel and fat-free milk
- Two slices of cheese on whole grain bread and 16 ounces of water
- Peanut butter on a toasted whole grain English muffin and eight ounces of fat-free milk
- Eight ounces of low-fat vanilla Greek yogurt with four ounces of granola cereal and four ounces of berries plus eight ounces of 100 percent fruit juice
- Two slices of turkey wrapped in a flour tortilla and six ounces of 100 percent fruit juice.

Incorporating post-training snacks helped boost Kendra's calorie and carb intake while also helping with recovery. When deciding on a snack, I advised Kendra to look for items that provided high-quality protein with some carbs to help repair muscles and stimulate muscle protein synthesis. Some of her favorites included hummus with whole grain crackers and baby carrots, whole grain cereal with fruit and fat-free milk, fruit-flavored kefir, microwavable tomato soup with cheese cubes and crackers, yogurt with honey and chopped walnuts, and low-fat chocolate or strawberry milk.

In addition to increasing her carbohydrate intake, I advised Kendra on ways to lower her protein consumption. The easy fix was to cut meat portions in half and limit nuts. Nuts are a healthful snack food that provide good fats, nutrients, vitamins, and minerals. Plus, they have the crunch needed to satisfy an athlete's munchies.

However, by consuming too much of a good thing, Kendra displaced some carbohydrate in her diet and added to her already high fiber intake. I directed Kendra to an online chart that covered recommended portion sizes for nuts to give her a better idea of proper serving sizes.

An added benefit of reducing Kendra's nut portions was that it helped decrease the amount of fiber she was consuming. We discussed that while fiber was a healthy dietary component to include in her diet, too much of it was likely contributing to her mild diarrhea.

To cut back, I told Kendra to eat less fresh fruit and decrease her portion sizes of dried fruit and nuts. I also had her switch from eating a high-fiber protein bar pre- and post-workout to items like yogurt and granola cereal, fat-free milk and cereal, or a banana with peanut butter.

Kendra was on board with all of my recommended changes, but before I could fully implement them, it was imperative that we discussed her concerns about gaining weight. Like many young girls, Kendra was concerned about her body image. While she did not have an eating disorder, she was fixated on her weight. Her body mass index was well within the appropriate range, and I assured her that her weight was acceptable for her height, age, gender, and sport. By showing her that she was at a healthy weight and still growing, she agreed that she needed fuel to perform at her best in the pool.

With Kendra's fears about her weight assuaged, she began to slowly incorporate the dietary changes I recommended. By eating breakfast and adding post-workout recovery snacks, she gradually increased her carbohydrate intake to a healthier zone of six g/kg/bw. And once Kendra decreased her fiber intake, her gastrointestinal issues were resolved. The only dietary change she had trouble with was decreasing protein portions. However, as long as she was getting sufficient carbohydrate, I could accept a slightly higher-than-recommended protein intake.

A few tweaks to Kendra's nutritional plan helped return her performance to peak levels, and she ended up making her high school's varsity swim team during her freshman season. She gained only one or two pounds as a result of the dietary changes, and ended up growing another inch by the end of the school year. Kendra is currently still competing on her high school squad and no longer experiences fatigue or gastrointestinal complaints.


SIDEBAR: ON THE MENU
Here's a sample day from the nutrition plan developed to help a college basketball player
gain weight and put on muscle.

Meal One
Three-egg omelet with ham, cheese, and veggies
Two slices whole wheat toast or a muffin
One piece of fresh fruit
Two glasses of chocolate milk and two glasses of orange juice

Meal Two
Two turkey and cheese or roast beef and cheese sandwiches
Bowl of pasta, rice, potatoes, or other starch
Bowl of fresh fruit or two pieces of fresh fruit and a bowl of yogurt
Two glasses of 100 percent juice and two glasses of lemonade

Snack One
Pre-workout shake and one banana

Snack Two
Post-workout shake and one 16-ounce sports drink

Meal Three
Eight ounces of grilled fish, lean meat, or chicken
Bowl of pasta, rice, potatoes, or other starch
Bowl of veggies
Dessert
Two glasses of skim or chocolate milk and two glasses of 100 percent juice

Meal Four
12-inch sub sandwich or two hamburgers
Homemade smoothie
Pretzels or chips



SEARCH for Products
SEARCH for Vendors

A Rebounder With Versatility

Medicine ball exercises are a staple of many workout routines. Whether the goal is performance enhancement by strengthening the core or helping an athlete rehab from an injury, medicine balls are versatile piece of equipment that can get the job done. But most strength coaches and athletic trainers don’t have enough time available to catch … CLICK TO READ MORE...

Author and Strength Coach Mike Mejia Praises VersaClimber

“Over the course of the past twenty years I’ve trained hundreds of clients that run the gamut from average Joe’s to professional athletes and in all that time, I’ve never come across a cardio piece that comes anywhere near the Versa Climber!” says Mike Mejia M.S., CSCS, author of The Men’s Heath Better Body Blueprint, … CLICK TO READ MORE...

Indoor Pool Surface Solution

Mateflex has indoor pool surfacing that is safer and more enjoyable to walk on than concrete. Mateflex offers perforated tiles to allow water to drain through that can cover up old, unsightly concrete or just spruce up a new area with a colorful design. The interlocking tiles dry quickly while keeping your feet out of … CLICK TO READ MORE...

The Evolution of the Lifting Platform

The days of the above ground weightlifting platform may be a thing of the past. More and more high schools, colleges, and professional strength and conditioning facilities who are either building a new facility or renovating an existing facility are going away from the traditional above ground lifting platform and choosing the inlaid platform, which … CLICK TO READ MORE...

Teaching Principles: Neck Rotation

Coach Bill ‘Jake’ Jacobs goes back to the basic teaching principles with Neck Rotation. View his demonstration.  CLICK TO READ MORE...

VIEW MORE ARTICLES