Jan 29, 2015
Cases Solved

Four athletes, four performance problems. Cases solved through nutrition.

By Beth Wolfgram

Beth Wolfgram, MS, RD, CSSD, CD, CSCS, is a sports dietitian in the University of Utah athletic department and for the NBA’s Utah Jazz. She is also an adjunct faculty member in the University of Utah’s Department of Nutrition. She can be reached at: [email protected].

If an ice hockey coach sees that a player needs to perfect his puck handling skills, he may spend some extra time with him on the ice after practice. If a basketball player is looking to improve her jump shot, her coach may give her a set of drills designed to help her meet that goal. If an offensive lineman is getting pushed around more times than he’s able to stand his ground, his strength and conditioning coach may add certain exercises to his workout program.

As these examples illustrate, each athlete’s performance needs, goals, and challenges are unique. It’s clear that an athlete’s work on the ice, court, field, and in the weightroom is a big factor in helping them perform their best. And since food is critical for fueling performance, building muscle mass, delaying fatigue, and enhancing recovery, nutrition also plays a big role. In many cases, it is the final piece to the puzzle for optimum performance.

In this article, I’ll recount the stories of four athletes who came to me for help with a need, goal, or challenge. As you’ll see, each athlete took a unique path, and it wasn’t always easy. (Note that aliases are used to protect the athletes’ privacy.)


Sasha, a Nordic skier at an NCAA Division I school, was experiencing extreme fatigue after her summer workouts, which included bicycling, running, roller skiing, and hiking. She also felt her energy level was low during training sessions and it seemed that recovering from workouts was becoming more difficult.

The team physician referred Sasha to me after her ferritin was measured at 25 nanograms per milliliter (ng/ml). Ferritin is a protein in the body that binds to iron, and low levels often indicate an iron deficiency. Normal levels vary, but the university where Sasha competed had an iron protocol in place that aimed for a ferritin level of at least 35 ng/ml for female athletes.

On the surface, Sasha had a pretty healthy diet for a college student. She ate cereal with milk for breakfast, a sandwich or leftovers for lunch, and vegetables with some type of meat for dinner. But after completing her nutrition assessment, I was concerned because she wasn’t taking in enough protein, iron, and overall calories.

As a female endurance athlete, Sasha was also at greater risk for an iron deficiency–which can have a negative impact on an athlete’s performance and overall health. On the positive side, her menstrual cycle was regular and not heavy, and she was sleeping about eight hours a night.

Strategy: We set a goal of improving Sasha’s ferritin level to at least 30 ng/ml. She had a history of low ferritin and had been using iron supplements off and on for a few years. Right away, I had Sasha focus on improving her dietary intake of iron to get her closer to consuming the recommended 18 milligrams per day. We focused on heme sources of iron since they are absorbed by the body better than non-heme sources.

To do that, I recommended she incorporate beef (which has between 2.5 and 4.5 milligrams of iron per three-ounce serving) into her diet four times a week and chicken or turkey (which both have about 1.0 milligram of iron per three-ounce serving) daily. This also helped increase her overall daily protein intake.

I also suggested she start eating cereals fortified with iron every morning. Grape Nuts, Kellogg’s Complete Bran Flakes, Quaker Oatmeal Squares, and Post Trail Mix Crunch all have more than 24 milligrams of iron per cup. Since studies have shown that vitamin C helps to improve the absorption of iron, Sasha added orange juice to her breakfast meals as well.

Finally, in addition to the long-term dietary changes, I asked Sasha to commit to taking an over-the-counter ferrous sulfate supplement of 325 milligrams daily. This would help her deficiency immediately and was something she most likely could discontinue after her ferritin level was in the desired range. We scheduled a follow-up appointment for three months later, and I checked in with Sasha regularly during the fall semester to ensure she was following the recommendations.

Outcome: At her three-month check-in, Sasha’s ferritin level was 30.90 ng/ml. And most importantly, she was feeling better. She said she had more energy during and after training sessions and felt she was training well.

Sasha continued following the dietary recommendations I had given her throughout the winter and had a successful ski season. When she reported for her physical the following August, her ferritin level was measured at 47 ng/ml–a great improvement in just one year.

POOR TIMING Mike was a running back who came to me during the off-season before his senior year in high school. He wanted to make sure he was doing everything he could to maximize his performance and be healthy, including eating right. He also wanted to lose about 10 pounds before the next season began.

I learned that a typical weekday for Mike meant skipping breakfast, having an energy bar or sandwich for lunch because of his class and practice schedule, then eating a large family dinner late in the evening, which usually consisted of steak or chicken and rice. Mike also admitted to snacking every night on chips, cookies, and whole milk while studying. On the weekends, he would often go out to eat with his friends.

Mike was six feet tall and weighed 235 pounds. He was working hard in the weightroom–strength training four times a week and running or doing conditioning work two times a week. Based on this information, I calculated his energy needs to be approximately 3,500 calories per day for weight maintenance and 3,200 calories per day if he wanted to lose weight and body fat.

I immediately knew that Mike’s challenge was not just how much food he was consuming, but the timing of when he ate. He was eating very little during the day when his body needed the fuel for classes and practice, and he would overeat at the end of the day because he was so hungry. Then he would go to bed stuffed and frustrated that he ate so much. Rather than focusing on decreasing calories, we focused on fueling his body more evenly during the day and making healthier food choices overall.

Strategy: I showed Mike what a healthy day would look like if he divided his calories into several smaller meals instead of consuming the majority of his calories at dinner and late at night. Initially, he was not eager to add in breakfast, so I suggested a snack or “mini meal” like a peanut butter and jelly sandwich with a piece of fruit or yogurt with cereal mixed in. I explained that the goal was to get him in the habit of eating something in the morning that would fuel his body for the day ahead.

I also suggested making lunch a part of his daily routine. This meant planning ahead and making something the night before so he could grab it from the fridge when he left in the morning. The sandwiches that he was sometimes eating were great options since they were balanced with carbohydrates, protein, and some fat–He just needed to eat them on a consistent basis.

Mike added a small snack like a sports bar or container of chocolate milk after practice so that when he got home for dinner or ate out with friends he wouldn’t feel famished and be likely to overeat. (Chocolate milk is also a great recovery beverage, so there was an added bonus to this choice.) His dinners remained similar, just a little smaller. And I had him switch his nighttime snack to two-percent milk and just a few cookies instead of an entire sleeve.

Outcome: Mike checked in with me several times a week for support. He would often call when he was out to eat and together we would decide what the best options were for him. It took a lot of dedication and discipline for him to get both breakfast and lunch in. And of course, some days were better than others.

Over the next two months, Mike’s diet improved drastically. He decreased his weight to 224 pounds while maintaining his strength in the weightroom. It was also important that he didn’t feel deprived. We had not eliminated his favorite foods, but instead changed the timing of his meals to properly fuel his body. Mike continued to work on his eating habits during the summer and had a great senior year before earning a scholarship to play football at an NCAA Division I college.


Greg was referred to me by his college tennis coach at the beginning of his freshman year. His coach felt he had great potential, and that if he could lose some weight and reduce his body fat, an even better player would emerge. Greg was red-shirting his freshman year, which gave us plenty of time to work on these goals.

Weighing in at 190 pounds and registering 17-percent body fat, Greg’s coach wanted to see the six-foot tall athlete lose 15 pounds. Greg’s activity level was already high–he was conditioning three times a week and playing tennis six times a week–so it was obvious his diet needed to change.

Living on campus and eating mostly in the dining hall, Greg’s daily diet included eggs and hash browns for breakfast, pasta or a sandwich for lunch, and pasta or sometimes meat and vegetables for dinner. He did not eat snacks during the day and didn’t keep any food in his dorm room.

Greg felt that he was a healthy eater and worked out regularly, so he wasn’t sure if his coach’s goal of losing 15 pounds was realistic. I also questioned the coach’s focus on body weight and was concerned about Greg getting enough fuel for his workouts if we were to lower his caloric intake to stimulate weight loss. So I talked with both Greg’s tennis coach and strength and conditioning coach to ensure we were all delivering the same message. We agreed that if his strength, endurance, or overall performance started to diminish, we would reevaluate Greg’s goals.

Strategy: Greg and I set a goal for him to lose about one pound per week in order to meet the long-term goal of 15 pounds of weight loss by the end of the semester. I calculated his calorie needs to be between 3,200 and 3,400 per day for weight maintenance and between 2,700 and 2,900 per day for weight loss. But I didn’t focus on counting calories. Instead, I gave Greg the simple advice to include fruit with breakfast, vegetables with dinner, and protein at each meal so he wouldn’t be hungry and crave high-fat foods.

We also discussed the pros and cons of keeping a food log. Although doing so is time consuming, Greg felt that it would help him be aware of his intake, make healthier choices, and stay on task with his goals.

Once a week, Greg weighed in with his strength coach and worked on one or two areas of his diet that I recommended he change based on his food log. For example, the first week, I suggested switching from two-percent milk to one-percent or skim and cutting back on fruit juices by instead drinking low- or no-calorie beverages. Every two to three weeks, we met in person to discuss challenges such as knowing an appropriate portion size, eating well in the dining hall, making healthy choices while eating out, and fueling his body for practice.

As the weeks passed, his diet began to include a lot of fruits and vegetables, as well as whole grains and other foods high in fiber. At one point, Greg was so motivated that he told me he wanted to eliminate all junk foods in hopes of speeding up his weight loss. I discouraged eliminating these entirely, which prompted a good discussion about enjoying the food you eat, the concept of moderation, and how depriving yourself can actually backfire. Greg made the smart decision to incorporate some type of small treat daily. (For a more detailed look at Greg’s food log, see “Writing It Down” below.)

Outcome: With simple changes and no intentional cutback on daily calories consumed, Greg lost five pounds in the first month. After 10 weeks, he lost another seven pounds and reported that he was still feeling strong and playing well. There were a couple of times when Greg reduced his daily calories too much, and it was immediately obvious because he reported feeling weak, light headed, and dizzy in his food log. But as time progressed, he became more in tune with his body and knowledgeable about how to fuel it without depriving himself.

After 15 weeks, Greg made amazing progress! He weighed in at 172 pounds and his body fat was down to 10.7 percent. His fruit and vegetable consumption had improved from one to two servings a day to five to six servings per day. And he became very proficient at timing his meals and snacks around workouts so his energy level and performance rarely suffered. Just as important, Greg learned a lot about good nutrition that will stay with him throughout his life.


While conducting incoming athlete nutrition evaluations one August, I discovered Julie had a history of disordered eating. She had been involved in gymnastics her whole life–a sport in which eating disorders and disordered eating are still very common. Like many gymnasts, her coaches focused heavily on her weight throughout her career. It was not acceptable for her weight to fluctuate, even when she was injured.

When I first met with Julie, she was not interested in working on her eating patterns. Although many people had expressed concerns to her previously, she had always ignored them, saying she “didn’t think she had a problem.” The club team that she previously competed for was infamous for having gymnasts with disordered eating and full-blown eating disorders. The coaches weighed their gymnasts frequently and made comments about their bodies and weight. This made it difficult for Julie to be at peace with her own body.

Over the next few years, she struggled with injuries and her weight fluctuated numerous times before she approached me. She was ready to work on eating healthier and taking care of herself.

Strategy: Julie had many deeply ingrained thoughts and perceptions about her body and nutrition. Like many athletes with eating disorders and disordered eating, she had plenty of rules about how much food she could consume, what foods she could or couldn’t have, and how much she should weigh.

Julie came to me at the end of the season and we met weekly for four months. Each week we set small, realistic goals for her. The first area we worked on was establishing basic healthy eating patterns and maintaining a healthy body weight.

Together, we developed a modified meal plan that included safe and familiar foods, yet fueled her body with adequate calories and macronutrients. This plan did not give exact guidelines for types of foods and amounts, but did offer suggestions to show what a “healthy” day of eating three meals and three snacks would look like.

Julie found the meal plan helpful because it gave her permission to eat and took away the pressure of figuring out what she could eat. She felt a sense of relief. Every few weeks I would also challenge her to try one of the “scary” foods she normally didn’t allow herself to eat.

Since the mental health piece was beyond my scope of practice, I referred Julie to a therapist who specialized in eating disorders and disordered eating and she met with him weekly. The therapist was a sounding board for Julie to discuss her anxieties and fears, as well as self esteem issues and the body image distortion that was so prevalent for her. This was invaluable to helping her develop a healthy relationship with her body.

As we continued meeting, Julie and I discussed the challenges she felt she was facing and wanted to work on. For example, she was weighing herself several times a day when we started meeting, but after several weeks together she agreed to weigh herself only once a week–a major step for her.

As we progressed, I began to address the concept of intuitive eating and how to work with her body, not against it. Over the years, Julie had learned to tune out her feelings of hunger and satiety, so intuitive eating was a very foreign concept to her. We used the hunger/satiety scale in addition to her food log to help guide her. Much like a pain scale, a hunger/satiety scale allows athletes to rate their level of hunger on a zero-to-10 scale (zero being famished and 10 being uncomfortably full).

The idea was to get Julie to figure out how to honor to her body–to eat when she was hungry and to stop when she was full. Though she was confused at first because she wasn’t used to feeding her body when it was hungry, she eventually figured out how to feed it effectively. (For a downloadable hunger/satiety scale, go to: www.training-conditioning.com/HungerSatietyScale.pdf.)

Outcome: Working with Julie was a process that included many steps forward but also some steps backward. Julie was slowly able to move away from the disordered eating habits that had plagued her for years–like weighing herself frequently and depriving herself of certain foods. She began to focus more on how she felt overall, her energy level, and how her performance correlated to her eating.

Her injuries healed and she began performing very well in the practice gymnasium and the weightroom. Julie continued to work on intuitive eating and listening to her body’s signals while the meal plan provided the structure that she needed. She also kept visiting her therapist, whom she found to be very helpful in dealing with her body image concerns, anxiety, and stress level.

Julie went on to have an excellent gymnastics season and remained injury-free. But more importantly, she developed a much healthier relationship with her body and with food.


As a sports dietitian, I try to find the right formula to help each athlete I work with perform their best. This means understanding each of their unique needs, goals, and challenges, then making the right dietary and lifestyle recommendations. To be most effective, I aim to do five things:

Include the athlete in the process. They know their body best and typically have great input about what their challenges are and what is realistic for them in their daily life.

Gain the athlete’s confidence. This means being a reliable and trustworthy source for nutrition recommendations that will work for them.

Keep things simple and realistic. All too often, athletes come to me wanting to completely overhaul their diet. But I have found that making multiple drastic changes at once is not manageable for most. Instead, I keep recommendations easy to follow and suggest making only one or two changes at a time.

Take into account the lifestyle of the athlete. This could include their living arrangements, financial situation, if they are working full-time, or if they’re carrying a full class load. The challenges that typically arise for a college freshman living in the dorms are very different from those of a veteran professional basketball player. The more I understand an athlete’s day-to-day life, the better I am able to help them.

Work as part of the multi-disciplinary team. This includes keeping the lines of communication open between coaches, athletic trainers, team physicians, strength and conditioning coaches, sport psychologists, and the athletes themselves. All of us must work together if the athlete is going to maximize their performance.


The following details two daily entries from the food log that Greg started keeping while we were working together. By comparing week one to week 15, you can see the vast improvements he made in food choices.

From week 1

10 a.m. (snack) -Strawberry milk -Sports bar

12:30 p.m. (lunch) -Turkey, ham, and cheese sandwich with mayonnaise -Cheese quesadilla -Two chocolate chip cookies -Two-percent milk -Sports drink

6:15 p.m. (dinner) -Salad consisting of iceberg lettuce and dressing -Two pieces of chicken cordon bleu, potatoes, and green beans -Hot chocolate -Two chocolate chip cookies -Two-percent chocolate milk -Raspberry iced tea

From week 15

8:15 a.m. (breakfast) -Raisin Bran cereal with skim milk -Banana -Scrambled eggs -Tea

11 a.m. (snack) -Yogurt -Apple

12:30 p.m. (lunch) -Turkey, ham, and cheese on a whole wheat wrap with lettuce, tomato, peppers, cucumbers, and a small amount of mayonnaise -Crystal Light -Skim milk -Apple

4:30 p.m. (snack) -String cheese -Grapes

6:30 p.m. (dinner) -Large salad consisting of spinach, tomatoes, cucumbers, carrots, peppers, broccoli, and light dressing -Pulled pork sandwich -Crystal Light -Skim milk -Pear


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