May 22, 2019Under Control
The following article appeared in the July/August 2015 of Training & Conditioning.
When Larry Nance Jr., was selected in the first round of the 2015 NBA Draft by the Los Angeles Lakers, he joined a small group of athletes who have risen to the professional ranks despite battling Crohn’s disease. A significant factor in getting Larry to this elite level was managing his illness with a strict nutritional plan during his four years at the University of Wyoming.
Crohn’s is a chronic form of inflammatory bowel disease. It is thought to come from the body’s failure to regulate intestinal bacteria, and it affects nutrient absorption in the intestinal tract. If left unaddressed, Crohn’s can cause abdominal pain, malnutrition, lethargy, and other digestive issues.
The most important thing to know about creating a nutritional plan for an athlete with Crohn’s is that there is no “one size fits all” approach. Crohn’s symptoms are triggered by specific foods, which vary greatly among individuals. One key to managing the disease is therefore identifying these triggers.
Larry was diagnosed in high school and already knew that peanuts and most tree nuts were triggers for him by the time he arrived at Wyoming. But he hadn’t figured out all triggers or perfected his diet plan. That was what Sports Nutritionist Jackie Barcal, RD, and I hoped to do when we began working with Larry.
To start, we asked Larry to keep a food diary. After analyzing it, we recommended he increase his caloric intake, not only because of the demands of being an NCAA Division I basketball player, but also due to the malabsorption that can occur with Crohn’s. In addition, since vitamin D sufficiency has been shown to reduce the frequency and severity of Crohn’s symptoms, Larry supplemented his diet with 2000 mg of vitamin D daily.
Jackie had many follow-up conversations and meal observations with Larry to ensure he was meeting his nutritional needs. Once we felt confident that Larry was following his plan, we provided as-needed monitoring and constructive reinforcement.
However, there were occasional bumps in the road that caused us to reevaluate or tweak Larry’s nutritional plan. One obstacle came during Larry’s first winter of college, when he had severe stomach pain and cramps for several days and lost 30 pounds in a matter of weeks. He discovered the culprit was popcorn and added it to his do-not-eat list.
Larry also sometimes struggled with making good food choices. Like most college students, he turned to fast food on occasion, and his primary vice was the Burger King Whopper. He’d usually down two in one sitting, which, if followed by more fast food, almost always induced some Crohn’s symptoms for the next couple of days. Though everyone is allowed a guilty pleasure, it was important that Jackie and I helped Larry understand the importance of a proper and, in his case, more restrictive diet for performance and health.
One of the major problems with these kinds of Crohn’s flare-ups is that they prevent the patient from taking in enough food to maintain weight or keep energized. During Larry’s flare-ups, we tried to push items that were easy on digestion, such as soups and low-starch foods.
The final obstacle we faced in managing Larry’s condition had more to do with the ups and downs of college athletics than with the disease itself. Larry returned from ACL reconstruction surgery early in the 2014-15 season, and a high-protein diet was pivotal in providing him with the necessary nutrients for energy, muscle building, and recovery.
Later in the season, Larry contracted mononucleosis, missing four games and losing 20 pounds. Getting calories back in him through protein shakes and other nutrient-dense foods was instrumental in his return to the court.
Though Crohn’s may seem like a lot to handle, if treated correctly and managed with proper nutrition, athletes with this disease can excel just as much as their teammates, if not more. In Larry’s case, despite all the complications of Crohn’s, he grew from a 205-pound role-playing freshman to a 230-pound first team all-conference senior and NBA draft pick. Now, he’s looking forward to continued success at the next level.
Plan for PCOS
By Angela Grassi
Angela Grassi, MS, RDN, LDN, is the founder of The PCOS Nutrition Center in Bryn Mawr, Pa., where she provides evidence-based nutrition information and counseling to women with PCOS. She has written many books on the topic, including PCOS: The Dietitian’s Guide. She can be reached at: www.PCOSnutrition.com.
A year ago, “Katie,” a high school swimmer, started gaining weight-15 pounds over the course of a three-month training block. She also began noticing more acne on her face and back, and she stopped getting her period. Concerned, she went to the doctor, who diagnosed her with polycystic ovary syndrome (PCOS), a disorder that affects five to 10 percent of women of childbearing age.
PCOS is a hormonal imbalance characterized by high levels of androgens (i.e., male hormones such as testosterone). It affects both a woman’s reproductive and endocrine systems and is the main cause of ovulatory infertility. The overproduction of androgens can cause excessive hair growth on the face and body, hair loss, acne, skin problems, and heavy, irregular, or absent periods.
This condition is also associated with insulin resistance-the cells’ inability to respond to insulin as it transports glucose into muscles and tissues. Therefore, many women with PCOS will experience weight gain in their abdominal area, difficulty losing weight, intense cravings for carbohydrates, and hypoglycemic episodes.
The primary treatment approach for PCOS is diet and lifestyle modification. So after Katie’s doctor prescribed her an oral contraceptive to regulate her menstrual cycles and clear up her acne, she was referred to me.
By the time Katie and I started working together, she had put on another 15 pounds, mostly in her abdominal area. The weight gain occurred despite Katie’s workout regimen in and out of the pool, affecting her body image as well as her performance. She also reported feeling tired a lot, was hungry “all the time,” had frequent mid-morning bouts of low blood sugar, and strongly craved sweets, which frustrated her as she tried to lose weight.
My first step was to have Katie complete a weekly food diary to get a look at what she was eating. It showed that Katie would typically have two big bowls of a low-fiber, sugary cereal (leaving the milk in the bowl), a banana, and eight ounces of juice for breakfast. Lunch (“starving”) was a yogurt, fruit, and a bagel from her school cafeteria, followed by a protein bar for a snack just before practice. Her typical dinner (again, “starving”) was usually six to eight ounces of meat or fish, vegetables, several helpings of pasta, and two to three brownies for dessert.
Right away, I noticed Katie was getting approximately 65 percent of her calories from carbohydrates, mostly from refined sources that were worsening her insulin resistance. Likewise, consuming too many carbohydrates at one time-by having two or three servings of pasta at dinner, for example-was spiking Katie’s insulin levels.
Although carbs are the preferred fuel for athletes, those with PCOS need to balance them to manage insulin and glucose levels, weight, and athletic performance. I instructed Katie to follow a meal plan averaging around 50 percent of her calories from carbohydrates, which involved eating 30 to 45 grams of carbohydrates per meal and 15 to 30 grams per snack. I also told her to focus on eating whole grain carbohydrates to keep her satisfied longer, such as slow-cooked oats, quinoa, brown and wild rice, and sprouted grain bread.
Beyond decreasing her total carbohydrates, I encouraged Katie to increase her protein and fat intake at breakfast and lunch to satisfy her longer and better manage her insulin levels. In addition, including a mid-morning snack with protein, such as an apple with peanut butter, helped stabilize Katie’s blood sugar so she wasn’t starving by lunch.
Once we got Katie’s carbohydrate, protein, and fat intake figured out, we addressed any potential nutrient deficiencies. There is evidence that athletes with PCOS have higher rates of oxidative stress and inflammation. Antioxidants may be helpful at keeping these issues at bay, so I encouraged Katie to eat a variety of anti-inflammatory foods such as nuts, fish, fruits, olive oil, vegetables, and legumes.
The oral contraceptive that worked to address Katie’s irregular periods can also interfere with vitamin B12 absorption. To prevent a vitamin B12 deficiency, I recommended a multivitamin.
Putting all of Katie’s nutritional needs together, I was able to create a new meal plan for her to follow. Here’s a sample day’s menu:
Breakfast: Egg sandwich (two eggs, one slice of cheese, one sprouted grain English muffin) and one cup of strawberries
Snack: Smoothie with half of a banana, chocolate protein powder, milk, and peanut butter
Lunch: Salad with grilled chicken, vegetables, avocado, olive oil and vinegar, and one cup of lentil soup
Snack: Apple, cheese, and whole grain crackers
Dinner: Grilled salmon, one cup of brown rice, and green beans with almonds.
After modifying Katie’s diet and addressing some of her nutrient deficiencies, I suggested she get blood work done to check for other imbalances. Her lab results showed that she was deficient in vitamin D, which is common in women with PCOS.
Low levels of vitamin D in this population are associated with poor mood, worsened insulin resistance, and weight gain. For athletes, it can also decrease physical performance and increase the incidence of stress fractures. Since few foods contain vitamin D (dairy foods are the main source), I started Katie on a daily supplementation of 5,000 IU of vitamin D.
Katie’s blood work showed that her Hemoglobin A1C (HA1C), a marker of diabetes risk, was elevated as well, up to 5.5 percent from 5.2 percent one year prior (over 5.7 percent is problematic). Katie’s doctor prescribed her metformin to lower her insulin levels and risk for diabetes.
At her one-month follow-up session with me, Katie reported feeling more energetic. She felt she had better control over her cravings and was eating fewer sweets. In addition, having a mid-morning snack prevented her from feeling hypoglycemic and ravenous at lunchtime.
By her six-month follow-up, Katie continued to report positive developments. Her lab results showed she was no longer deficient in vitamin D, and her HA1C had reduced to 5.2 percent.
Sticking to her nutritional plan helped Katie lose eight pounds. As a result, she said her swimming was “better than ever!” More importantly, she now has the nutritional tools to manage her PCOS effectively for the rest of her life.
By Andy Hrodey
Andy Hrodey, MS, LAT, is Assistant Athletic Trainer at the University of Wisconsin, working with the men’s ice hockey team and spirit squads. He can be reached at: [email protected].
It’s during preparticipation physicals that incoming athletes often explain their dietary restrictions to the sports medicine staff, so I’m used to issues like food allergies and insensitivities. Last year, however, I heard a new one: “John,” a men’s ice hockey player here at the University of Wisconsin, revealed he had carnitine palmitoyltransferase 2 (CPT2) deficiency. His freshman season was full of learning, adapting, and adjusting his nutrition plan to accommodate this condition.
Individuals with CPT2 deficiency lack the carnitine palmitoyltransferase enzyme, which is responsible for moving long-chain fats into the mitochondria where they are broken down for energy. Without adequate amounts of energy, CPT2-deficient athletes may struggle with long, intense periods of exercise and are at an increased risk for muscle weakness, pain, cramping, and possible episodes of rhabdomyolysis. While there’s no cure for CPT2 deficiency, the best form of treatment is to incorporate a low-fat, high-carbohydrate diet to maximize energy production.
Having been diagnosed eight years prior to his arrival at the University of Wisconsin, John felt like he had a good understanding of his condition and was managing it well. He was following the recommended diet, staying hydrated, and consuming extra snacks and drinks before, during, and after hard practices and games to keep his energy up.
In collaboration with the team’s strength and conditioning coach and physician, we decided to keep John on the same nutrition plan he had been following. We made sure he had a variety of high-quality carbohydrates to choose from at team meals, and we provided him with many types of energy bars, gels, shakes, and quick snacks to supplement his diet during practices and games.
Here’s a look at a sample day’s menu for John:
Breakfast: Bagel, cereal, fruit
Lunch: Sub sandwich, baked chips or pretzels, carbohydrate-rich sports drink
Dinner: Chicken, pasta, vegetable or salad
Snacks: Energy bars, fruit, bagels, protein shakes.
With a nutrition plan in place, the season started with minimal issues, and John practiced and played without restriction. But despite his early success, John hit a snag after the eighth game of the season. The team had returned in the middle of the night from a set of back-to-back contests in Colorado. John had not eaten enough after the second game, and the late return to campus further threw off his fueling schedule. By the next day, he was diagnosed with a fairly severe case of rhabdomyolysis that required a five-day stay in the hospital.
While in the hospital, John, the team physician, and I consulted with a doctor and registered dietitian, both of whom specialized in genetic and metabolic disorders. They advocated that John remain on the high-carbohydrate diet once he returned to campus but gave him suggestions for selecting more appropriate foods and drinks. In addition, they recommended John begin taking a powdered supplement made from medium chain triglycerides (MCT) to give his body calories and produce energy around his enzyme deficiency.
Once John was discharged from the hospital and cleared to return to class, the dietitian requested he keep a three-day nutrition log. It gave us a way to see his schedule and advise him on the best times to eat and drink. We also monitored John’s weight, and he continued with the MCT supplementation.
The results of the nutrition log showed that despite trying to stick with high-carb food options, John occasionally consumed calories from fat that his body couldn’t use. He was advised to seek out lower-fat versions of the foods he often ate. For instance, instead of muffins, we told John to choose whole grain breads, which are a good source of complex carbohydrates and have less fat. Similarly, we told John to remove beef from his diet in favor of poultry and fish and switch to low-fat dairy products from full fat.
Over the next four or five weeks, John gradually returned to full participation. Diet and nutrition remained the focus throughout his recovery. With the help of the dietitian, we determined that John should consume 3,300 calories per day and use six packets (around 600 calories) of the MCT powder daily.
The MCT supplement was also essential in avoiding any further episodes of rhabdomyolysis following late-night travel. John added it to most of his recovery items, shakes, and sports drinks to ensure he got the post-game calories he needed. With a solid nutrition plan in place, John finished out the remainder of the hockey season without any further CPT2 complications.
The issues surrounding John’s CPT2 deficiency allowed everyone involved to learn more about the condition and develop a better nutritional plan to help him compete at an elite level. Cooperation and education among specialists, team medical staff, and team coaches was also important in helping John succeed.