Preparation of a Review Article for the Journal of Lifestyle Medicine: Hot Topics in Sports Nutrition for the Elite

Athlete
A Focused Area of Study Summary Report By Anna Mitchell For The University of Utah Division of Nutrition

Abstract In order to train consistently and compete successfully, elite athletes must consume adequate calories as well as meet specific fluid, macronutrient and micronutrient requirements. Despite a strong correlation between a balanced and adequate diet and athletic performance, research suggests that many athletes do not have adequate knowledge about their specific nutrition requirements for their sport, and very few athletes are meeting the recommendations. Inadequate nutrition knowledge has also been found in healthcare professionals that are most often sought after for nutrition advice by athletes. In order to improve awareness and knowledge regarding nutrition for sport, a review article was written for publication in the Journal of Lifestyle Medicine. The article highlighted various hot topics in sport nutrition for elite athletes as well as provided general nutrient recommendations. The journal to which the article has been submitted targets health professionalsincluding the professionals working with athletes. In addition, education was provided for the student-athletes at the University of Utah via bulletin board displays which conveyed information concerning nutrient recommendations and related hot topics. Education was also provided to the student -athletes through team nutrition talks, one-on-one appointments, and new athlete screenings.

Introduction Elite athletes are considered to be athletes who are competitive at a collegiate, professional, world-class, or Olympic level. In order to achieve peak performance, elite athletes must meet their energy, nutrient, and hydration needs.1 Proper nutrition allows an athlete to train consistently and improve performance. Elite athletes have unique physical demands that separate them from their non-elite counterparts. Energy needs are higher in order to support training and

performance.2 For the elite athlete, food is not only a necessity for life, but also a source of fuel for their training, performance, and recovery. For an elite athlete, performance will depend upon genetics, intensity of training, and appropriateness of dietary intake. While both genetics and training play a superior role in determining performance, proper nutrition is essential. Elite athletes are looking for any information that may give them an edge, and this information is often dietary. According to the International Association of Athletics Federations, well-chosen diets offer many benefits to all athletes including enhanced recovery between and within training and competition, reduced risk of injury and illness, consistency in performance, and establishment of an ideal body weight and composition.3 Elite athletes have additional demands that must be accommodated. Elite athletes travel for competition, experiment with supplementation, and have pressure from coaches, managers, and teammates to perform.1 Traveling for competition presents challenging circumstances. Athletes routines are disrupted by travel. Therefore, a greater risk for malnutr ition is associated with travel.4 Elite athletes often blindly use supplements. Froiland et al (2004) report that approximately 89% of Division I varsity athletes use supplements.5 These supplements include multivitamins, amino acids, ginseng, and calcium. Elite athletes frequently use a random approach when choosing supplements.2 Very few dietary supplements marketed for performance have evidence showing performance benefits.2 The pressure elite athletes receive to perform at the top of their field leads to misinformed and potentially dangerous dietary practices, such as crash diets and excessive protein intake.2 Despite their unique nutrition needs, the foundation of the elite athletes diet is a healthful, balanced diet. The general recommendations for nutrient and energy intake apply to elite athletes as well as the general population.1

Despite the numerous documented benefits of nutrition for athletic performance, research suggests that relatively few athletes are knowledgeable about their specific nutritional requirements for their sport, and even fewer athletes meet these requirements.1,6,7,8 In most cases, individuals including elite athletes who know and understand the dietary recommendations are more likely to meet the recommendations.8 Several studies have assessed the knowledge of elite athletes. Spendlove et al (2011) investigated the level of nutrition knowledge in elite Australian athletes and then compared the level of knowledge to that of a non-athletic group and a group trained in dietetics.1 The non-athletic group included University students and members of Scouts Australia. The group trained in dietetics included Australian undergraduate and postgraduate dietetic interns. Data showed that the average overall nutrition knowledge score on the General Nutrition Knowledge Questionnaire for the elite athletes was significantly lower than the average scores of the non-athletic group (p=0.002) and the group trained in dietetics (p=0.000).1 Based on the elite athlete and non-athletic groups responses to specific questions in this study, print and internet media seem to influence what they believe concerning nutrition.1 For example, despite the dietary guidelines emphasizing a carbohydrate rich, low fat diet, many of the study participants who were not included in the group trained in dietetics were unsure about the consumption of carbohydrate rich foods.1 Heaney et al (2011) performed a literature search for articles that tested the nutrition knowledge of competitive athletes and compared that level of knowledge to the knowledge of a non-athlete comparison group.8 Twenty-nine studies measuring nutrition knowledge were reviewed. When data from those twenty-nine studies were compiled, a few trends emerged. First, competitive athletes scored slightly higher than the nonathlete comparison group scored on sport-related nutrition questions. The second trend was the athletes scored lower on the general nutrition questions. Many misconceptions, such as the belief

that protein is the macronutrient needed for muscle contraction and the belief that vitamins and minerals provide energy, were mentioned in this literature review.8 Clearly elite athletes need a reliable source of nutrition information to aid them as they work toward peak performance. Data from Torres-McGehee et al. showed that collegiate athletes were most likely to seek nutrition advice from athletic trainers (ATs) and strength and conditioning specialists (SCSs). While the nutrition knowledge possessed by the ATs and SCSs was higher than that of coaches and athletes, their knowledge concerning micronutrients, weight management, and eating disorders was still inadequate.9 In addition, ATs and SCSs were often overly confident in incorrect answers, implying that misinformation may be passed on to the athletes.9 Similar inadequate nutrition knowledge has been found in other health professionals.10 Since these are the individuals that often provide nutrition advice to athletes, it is important that they are delivering accurate information. Since athletes often seek recommendations on the currently controversial or hot topics in sports nutrition, it is especially crucial that health professionals keep up to date on the latest sports nutrition topics that they may encounter.

Description of Focused Area of Study In order to provide a resource on the latest controversial issues in sports nutrition to health care professionals, a review article was written on the topic of Nutrition for Elite Athletes. The collaboration with Katherine Beals, PhD RD as coauthor resulted in a manuscript which was submitted to the Journal of Lifestyle Medicine. This journal is an academic, peer reviewed journal designed for use by health care professionals such as primary care physicians, family practitioners, internists, and pediatricians. The Journal of Lifestyle Medicine publishes articles

on a variety of topics intended to help health care professionals direct their patients toward healthier lifestyles. The review article provided evidence-based sport nutrition recommendations for elite athletes as well as selected sports nutrition hot topics. The hot topics included new or controversial issues in sports nutrition that fit within the categories of macronutrient requirements, micronutrient requirements, and fluid requirements. Some examples of the hot topics that were covered in the review article included carbohydrate mouth rinses for performance enhancement, the role of antioxidants in athletic performance and recovery, the possible benefits of choline supplementation, the stimulation of muscle protein synthesis by types of proteins, and the potential detrimental effects of a very low fat diet. An outline of the review paper is found in Appendix A and the final copy of the review paper is found in Appendix B. The selection of the hot topics was made after reviewing recent sports nutrition journals and other publications and identifying which topics appeared to be the most recent and controversial. Journals that were examined for topics included Journal of the International Society of Sports Nutrition, the Clinical Journal of Sport Medicine, the Journal of Science and Medicine in Sport, and the Journal of Sports Sciences. Topics of significance in Pulse, the publication of the Sports, Cardiovascular, and Wellness Nutrition dietetic practice group of the Academy of Nutrition and Dietetics, were also considered. In addition, nutrition issues that were brought up with frequency on the Collegiate and Professional Sports Dietitians Association listserv were included in the review article. A thorough literature review was done on each topic covered in the review article. Relevant original research papers were found using PubMed searches. In addition, the reference

sections of review articles were used to identify original research papers. Many of the topics covered in the review article were topics that had been covered in university nutrition classes taken previously, such as the role of antioxidants and inflammation in recovery and the ideal protein type for muscle protein synthesis. Research papers referred to in class when covering these topics were used for the literature review. Dunford and Doyles textbook, Nutrition for Sport and Exercise, provided the information necessary to construct the general macronutrient, micronutrient, and fluid recommendations. For more updated and specific carbohydrate recommendations, the 2011 International Olympic Committee (IOC) consensus on carbohydrate recommendations for training and competition were used 2. For protein timing, a recently published (2011) article by Phillips et al. concerning dietary protein for optimum adaptation was used for recommendations12. Generalized fluid recommendations were derived from the American College of Sports Medicine position stand on exercise and fluid replacement 13. The importance of referring athletes with specific nutrition concerns to a Registered Dietitian was emphasized at the end of the review article. Individuals who want sport-specific nutritional strategies for training, competition, and recovery should seek the guidance of a qualified sport nutrition professional (i.e., a Registered Dietitian or Certified Specialist in Sports Dietetics). Referring athletes to a qualified sport nutrition professional is particularly important in light of the fact that inadequate nutrition knowledge has been found in health professionals, including athletic trainers, strength and conditioning specialists, and sports physical therapists
9.10

. In order to apply the knowledge gained through writing a review article on sports

nutrition guidelines for the elite athlete, nutrition education was provided for the University of

Utah athletes via bulletin board displays. The bulletin board that displayed the information is found in the basement of the Burbidge Academic Center right next to the office of the University of Utahs sports dietitian, Beth Wolfgram MS RD. The room the bulletin board is located in is a popular place for student-athletes to study. The displays were seen by these athletes using the space to study as well as all of the athletes who have appointments with Beth in her office. Tutoring and required study hours for student-athletes are held in the basement of the Burbidge Academic Center. In addition, the bulletin board is located directly above the drinking fountain; so many students read the board before or after hydrating at the fountain. A display of information was created for each of the following topics: carbohydrates, protein, and fluids. For each of these topics, recommendations were provided in an easy to understand manner. In addition, a hot topic was highlighted in a Did You Know? format. Colored graphs and figures were included to capture attention. The board focused on how nutrition will affect performance, rather than general health, since most collegiate athletes are more interested in how they can improve their performance than improving their overall health. Handouts and recipes (for the carbohydrate and protein displays) available for the student-athletes to take were included in pockets on the bulletin board. The handouts included detailed guidelines for elite athletes on the current topic. The recipes focused on meals or snacks that provided healthy amounts of the nutrient of focus. According to Beth Wolfgram MS RD, athletes are always looking for new recipes with minimal ingredients. Contact information for the sports nutrition department was provided on each handout so that the student-athletes could find out more about the topic if interested. Images of the three bulletin board displays are found in Appendix C. Each of the three bulletin board topics were displayed for four weeks during the fall semester. The carbohydrate display was on the bulletin board in September, the protein display

in October, and the fluids display in November. During the time that each topic was displayed, over thirty copies of each recipe posted were taken. Over the course of the month, an average of twenty information handouts was taken by student-athletes. Application of the knowledge gained on hot topics in sports nutrition was also done through team talks, one-on-one appointments with student-athletes, and new athlete screenings while interning with the University of Utah sports nutrition department. For weekly team talks with the womens soccer team, topics of interest were provided by the coaches and athletes on the team. Topics covered included carbohydrate needs during exercise, carbohydrate and protein needs post-exercise and essential fatty acids. For the football team, topics such as pre-exercise macronutrient needs and the importance of adequate carbohydrate in the diet were discussed. In one-on-one appointments, many athletes desired more information about timing of protein and carbohydrate around training. Information was provided concerning carbohydrate intake during exercise to enhance performance and carbohydrate intake after exercise to enhance recovery. The importance of protein intake within the anabolic window (approximately 1 hr prior to and/or after exercise) to optimize strength gains and muscle hypertrophy was also stressed. Another topic addressed was hydration. Many athletes are not starting exercise euhydrated or not replacing fluid losses following exercise. Strategies were developed to aid in meeting the fluid recommendations. At the start of the athletic year, each new student-athlete was screened by the University of Utah sports nutrition staff. Many students were taking protein supplements and desired more information about protein types and/or benefits of individual amino acid supplementation. Since many collegiate athletes struggle financially, suggestions were made for athletes to consume

milk instead of supplementing with expensive supplements containing whey or other protein types. Conclusions Meeting sport specific nutrient recommendations allows athletes to enhance recovery between and within training and competition, reduce their risk of injury and illness, have consistency in performance, and establish an ideal body weight and composition. Proper nutrition provides elite athletes with an edge over other athletes who are not meeting their nutrition recommendations. However, knowledge concerning nutrient recommendations among athletes and healthcare professionals working with athletes is lacking. Therefore, a review article was written for the Journal of Lifestyle Medicine highlighting topics of interest to many elite athletes and the health professionals who treat them. The article also provides general recommendations for macronutrients, micronutrients, and fluids. The Journal of Lifestyle Medicine is an academic, peer reviewed journal that targets health care professionals such as the professionals who may be working with athletes. In addition, the knowledge gained through writing the review article was shared with the University of Utah student-athletes through bulletin board displays, individual appointments with student-athletes, team nutrition talks, and new athlete screenings. Research shows that athletes who are knowledgeable about sport specific nutrition recommendations are more likely to meet these recommendations. By educating the athletes at the University of Utah, an increased number of athletes may be able to meet nutrition recommendations and, as a result, improve athletic performance.

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References 1. Spendlove JK, Heaney SE, Gifford JA, Prvan T, Denyer GS, O'Connor HT. Evaluation of general nutrition knowledge in elite Australian athletes. Br J Nutr. 2011:1-10. 2. Dunford M, Doyle JA. Nutrition for sport and exercise. Belmont, CA: Wadsworth; 2012: 101-273. 3. International Association of Athletics Federation. Nutrition for Athletics: A Practical Guide to Eating and Drinking for Health and Performance in Track and Field. Monaco: IAAF. 2011:1-38. 4. Reilly, T., Waterhouse, J., Burke, L. M., & Alonso, J. M. (2007). Nutrition for travel. Journal of Sports Sciences, 25(S1), S125-S134. 5. Froiland, K., Koszewski, W., Hingst, J., & Kopecky, L. (2004). Nutritional Supplement Use Among College Athletes and Their Sources of Information. International Journal of Sport Nutrition and Exercise Metabolism, 14, 104-120. 6. Burke LM, Cox GR, Cummings NK, Desbrow B. Guidelines for daily carbohydrate intake: do athletes achieve them? Sports Med. 2001;31(4):267-299. 7. Grandjean AC. Diets of elite athletes: has the discipline of sports nutrition made an impact? The J Nutr. 1997;127:874S-877S. 8. Heaney S, O'Connor H, Michael S, Gifford J, Naughton G. Nutrition knowledge in athletes: a systematic review. Int J Sport Nutr Exerc Metab. 2001;21:248-261. 9. Torres-McGehee TM, Pritchett KL, Zippel D, Minton DM, Cellamare A, Sibilia M. Sports nutrition knowledge among collegiate athletes, coaches, athletic trainers, and strength and conditioning specialists. J Athlet Train. 2012;4(2):205-211. 10. Long D. Nutrition knowledge of sports physical therapists. J Orthop Sports Phys Ther. 1989:257-263. 11. Burke LM, Hawley JA, Wong SH, Jeukendrup AE. Carbohydrates for training and competition. J Sports Sci. 2011:1-11. 12. Phillips SM, Van Loon LJC. Dietary protein for athletes: from requirements to optimum adaptation. J Sports Sci. 2011;29(S1):S29-S38. 13. Sawka MN, Burke LM, Eichner ER, Maughan RJ, Montain SJ, Stachenfeld NS. American College of Sports Medicine position stand: exercise and fluid replacement. Med Sci Sports Exerc. 2007:377-390.

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APPENDIX A Outline for Review Paper I. Introduction to Sports Nutrition for Elite Athletes a. Higher calories and nutrient needs to support physical demands b. Unique needs and challenges of elite athletes i. Traveling for competition ii. Experimentation with supplements iii. Pressure from coaches, managers, and teammates to perform c. Assessment of nutrition knowledge in health professionals Macronutrients a. Carbohydrates i. General Recommendations 1. Daily recommendations 2. How much/what types before exercise? 3. How much/what types during exercise? 4. How much/what types after exercise? ii. Carbohydrate Mouth Rinsing 1. What is it? 2. When is it appropriate and who is it appropriate for? iii. Train low, Compete high 1. When could training low be appropriate? 2. Has the ability to utilize fat more easily during exercise translated to improved performance? b. Protein i. General Recommendations 1. Daily recommendations 2. How much/what types before exercise? 3. How much/what types during exercise? 4. How much/what types after exercise? ii. Protein types 1. Leucine a. Could leucine supplementation have a glycogen-sparing effect? b. Could leucine supplementation post-exercise enhance muscle protein synthesis? 2. Whey vs Casein a. What is the difference between the two protein types? b. Is whey superior to casein for stimulating muscle protein synthesis?
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II.

c. Fat i. General recommendations ii. Very Low-Fat Diets 1. What are the detrimental effects of dietary fat restriction? 2. How low is too low? iii. Essential fatty acids (omega 3 fatty acids) 1. Are the anti-inflammatory properties beneficial to the elite athlete? 2. Does supplementation with essential fatty acids lead to performance benefits? III. Fluid a. General recommendations i. Why is euhydration critical? ii. What are the general fluid recommendations? 1. How much before exercise? 2. How much during exercise? 3. How much after exercise? iii. How does one assess his/her hydration status? iv. What are salty sweaters? b. Hyponatremia i. Why does it occur? ii. Guidelines for prevention Micronutrients a. Antioxidants i. Is supplementation beneficial? ii. Can supplementation inhibit training adaptation? b. B vitamins i. Why are the B vitamins important for athletic performance? ii. Who is at risk for deficiency? iii. Is supplementation beneficial? c. Vitamin D i. What is the role of Vitamin D is bone health? ii. Which athletes could benefit from supplementation? d. Choline supplementation i. Is choline concentration reduced following exercise? ii. Can choline supplementation improve athletic performance? e. Iron i. Why is iron important for athletic performance? ii. What are the symptoms of iron deficiency anemia? iii. When is supplementation beneficial? Conclusion
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IV.

V.

APPENDIX B

Sports Nutrition Update Katherine A. Beals, PhD, RD and Anna Mitchell, BS University of Utah, Salt Lake City, UT

INTRODUCTION For athletes, food is not only necessary for life, but also essential for optimal training, performance, and recovery.1 According to the International Association of Athletics Federations, well-chosen diets offer many benefits to athletes including enhanced recovery between and within training and competition, reduced risk of injury and illness, consistency in performance, and establishment of an ideal body weight and composition.2 Despite the numerous documented benefits of nutrition for athletic performance, research suggests that relatively few athletes are knowledgeable about their specific nutritional requirements for their sport; and even fewer athletes meet these requirements.1,3,4,5 Moreover, athletes often travel for competition, experiment with dietary supplements, and experience pressure to alter body weight or body composition, which can lead to misguided and potentially dangerous dietary practices and subsequent nutritional inadequacies.6 Data from Torres-McGehee et al., showed that collegiate athletes were most likely to seek nutrition advice from athletic trainers (ATs) and strength and conditioning specialists (SCSs). While the nutrition knowledge possessed by the ATs and SCSs was higher than that of coaches and athletes, their knowledge concerning micronutrients, weight management, and eating disorders was still inadequate.7 In addition, ATs and SCSs were often overly confident in incorrect answers, implying that misinformation may be passed on to athletes. 7 Similar
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inadequate nutrition knowledge has been found in other health professionals. 8 Since these are the individuals that often providing nutrition advice to athletes, 7 it is important that they are delivering accurate information. Therefore, this paper will review the current macro- and micronutrient recommendations for athletes and address some of the currently controversial or hot topics in sports nutrition that health professionals might encounter. CARBOHYDRATES The provision of adequate carbohydrate is essential for the athlete, particularly the endurance athlete. The availability of carbohydrate during endurance exercise determines the intensity and duration of exercise that the athlete will be able to complete. Since carbohydrate storage in the body is limited, carbohydrate recommendations are designed to ensure adequate substrate for exercise and recovery. Carbohydrate Recommendations Daily carbohydrate recommendations recently published by the International Olympic Committee (IOC) are summarized in Table 1.9 Recommendations for carbohydrate intake during exercise are summarized in Table 2 and for post-exercise are summarized in Table 3.9 Table 1. Daily Carbohydrate Needs for Fuel and Recovery. Situation Low-intensity or skill-based activities Moderate exercise program (~1 hr/day) Endurance program (moderate-to-high intensity exercise of 1-3 hrs/day) Extreme commitment (moderate-to-high intensity exercise of 4-5 hrs/day) Carbohydrate Targets 3-5 g/kg/day 5-7 g/kg/day 6-10 g/kg/day 8-12 g/kg/day

Table 2. Carbohydrate Intake during Exercise to Enhance Performance. Situation During brief exercise During sustained highTime of Exercise <45 minutes 45-75 minutes
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Carbohydrate Targets Not needed Small amounts including

intensity exercise During endurance exercise including stop and start sports During ultra-endurance exercise

mouth rinse 1.0-2.5 hrs >2.5-3.0 hrs 30-60 g/hr Up to 90 g/hr

Table 3. Carbohydrate Intake after Exercise to Enhance Recovery. Situation < 8 hr recovery between two fuel demanding sessions Carbohydrate Targets 1.0-1.2 g/kg/hr for the first 4 hr then resume daily fuel needs. When CHO intake is suboptimal for refueling, adding protein will enhance glycogen storage. Consume adequate CHO, however the type, pattern, and timing of CHO-rich meals and snacks can be chosen according to what is practical and enjoyable.

> 8 hr recovery between two fuel demanding sessions

With shorter duration exercise (<1 hr), carbohydrate availability is not a limiting factor. However, research suggests that a carbohydrate mouth rinse may have performance benefits during shorter, more intense exercise. 10,11 The exact mechanism of the performance benefit is unknown. In addition, the amount of carbohydrate consumed prior to endurance exercise will effect substrate utilization during exercise. It is hypothesized that training with low carbohydrate availability will stimulate physiological adaptations that may promote endurance. This training method is referred to as training low. These two topics will be addressed in greater detail in the following paragraphs.

Carbohydrate Mouth Rinse The performance benefits of carbohydrate consumption during prolonged exercise (>1 hr) are well-documented and are believed to be attributed to the maintenance of glucose oxidation
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rates late in exercise when muscle glycogen stores have been depleted. 12 There is also increasing evidence to suggest that carbohydrate intake during shorter (<1 hr), more intense exercise may be beneficial,10,11 despite the fact that carbohydrate availability is not considered a limiting factor to exercise of this duration.13 While the precise mechanism(s) for the performance benefits of exogenous carbohydrate during short duration, high intensity exercise have not been clearly elucidated, it has been hypothesized that carbohydrates may be activating areas of the brain that are related to motivation.14,15 This theory has been tested by a number of researchers using a variety of carbohydrate delivery systems. 13,15,16 In one of the first studies to examine the possible non-metabolic effects of carbohydrate consumption on athletic performance, Carter et al. compared intravenous infusion of glucose to a carbohydrate mouth rinse on endurance cyclists and found that intravenous infusion of glucose did not improve time to complete a 40-km time trial. However, regularly rinsing the mouth with a carbohydrate solution during the exercise bout did have performance benefits. 17 Similarly, Pottier et al. found that ingesting a carbohydrate solution had no significant performance benefits for cyclists completing a 1-hr time trial; however, rinsing the mouth with a carbohydrate solution was associated with improved performance. 18 The hypothesis that carbohydrates may be activating brain areas that are related to motivation is supported by the study by Pottier et al. Subjects kept the beverage in the oral cavity for a longer period of time when mouth rinsing, compared to drinking the beverage, which allowed more time for central nervous system activation. 18 Based on research thus far, carbohydrate mouth rinsing may improve performance for endurance athletes during exercise lasting about 1 hour. Train Low, Compete High

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The relationship between muscle glycogen depletion and fatigue has prompted a great deal of interest in ways to spare muscle glycogen via nutritional and training manipulations and, thus, delay fatigue. One of the more recent and controversial methods focuses on training with low carbohydrate availability (i.e., train low), and, then competing with adequate carbohydrate stores to enhance performance (i.e., compete high). 19 Hypothetically, training with low carbohydrate availability will stimulate physiological adaptations which will ultimately spare muscle glycogen and promote endurance. Indeed, research does show that exercising with low muscle glycogen stores does amplify the activation of a number of signaling proteins that play direct roles in transcription and activity of transcription factors involved in mitochondrial biogenesis which could, theoretically, enhance fatty acid oxidation and, thus, reduce glycogen utilization. However, research has yet to show performance benefits from these physiological adaptations. In a study by Hulston et al., well-trained cyclists were randomly assigned to either train with low carbohydrate availability or adequate carbohydrate availability which was accomplished via the training schedule. Specifically, those in the low carbohydrate availability group trained twice every second day, while those in the adequate carbohydrate availability group trained once per day. Total carbohydrate intake was similar between the groups. The results indicated that cyclists training with low carbohydrate availability increased fat oxidation due to enhanced metabolic adaptations in the muscle. However, training low was no more effective than training with adequate carbohydrate availability on performance. 20 Similarly, Yeo et al. found that cyclists performance in a 1-h time trial was the same after daily or twice-everysecond-day training.21 Thus, despite physiological adaptations, there appears to be no performance enhancement associated with training with low carbohydrate availability.

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Not only has the research failed to show a performance benefit, but the very idea of train low, compete high is contradictory to generally accepted sports nutrition guidelines which promote consuming carbohydrates before, during, and after prolonged exercise bouts. 19 There are several problems associated with training low. First, the quality of training will decrease because athletes will be unable to train at a high intensity when glycogen depleted. Second, training in a low carbohydrate state increases the risk of injury, illness, and overtraining. 19 However, training low may make fat utilization more efficient, which may be beneficial for an athlete interested in weight loss. Since research shows no performance benefits from training low, competing high, athletes should consume adequate carbohydrate daily and train in a carbohydrate sufficient state. PROTEIN Although the protein needs of athletes have been a controversial subject for many years, most sports nutrition experts agree that an athletes protein requirements are high er than those of their sedentary counterpart.22,23 Indeed, some research suggests that protein needs of athletes may be more than two times greater than those of non-athletes. The current protein recommendations for endurance and strength/power athletes are summarized in Table 4. 6 Modifications to these recommendations should be made based on the intensity, duration, and frequency of the individual athletes training regimen. The protein recommendations for before, during, and after exercise are shown in Table 5.24

Table 4. Daily Protein Requirements for Endurance and Strength Athletes. Type of Athlete Endurance athletes (moderate intensity and/or duration) Endurance athletes (high intensity and/or prolonged duration) Strength athletes (maintenance and/or low intensity training) Strength athletes (lean tissue accrual and/or high intensity training) Protein Requirements 1.2-1.3 g/kg/d 1.4-1.6 g/kg/d 1.2-1.4 g/kg/d 1.5-1.7 g/kg/d

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Table 5. Protein requirements before, during, and after exercise. Time in Relation to Exercise Before exercise During exercise After exercise Protein Recommendations Small amount of protein (~10-20 g) if not consuming protein immediately post exercise Protein added to CHO during exercise likely has no additional benefit provided there is adequate CHO consumed Small amount of protein (~20 g) immediately post exercise (within 1 hr)

Because of their higher energy intakes, most athletes consume adequate (if not excessive amounts of) protein. This is particularly true for strength/power athletes. 25 Nonetheless, there are a few athletic populations who are at risk for inadequate protein intakes. These populations include vegetarians, growing athletes, female endurance athletes, and athletes with inadequate energy intake.22 Perhaps more important than the amount of protein, is the timing of protein intake around exercise. Research suggests that there is an anabolic window (approximately 1 hr prior to and/or after exercise) during which protein should be consumed to optimize strength gains and muscle hypertrophy.23,26 However, whether consuming protein prior to or after exercise would be more advantageous remains unclear. Protein type also seems to have an effect on muscle protein synthesis (MPS). Interestingly, only essential amino acids seem to be needed to effectively stimulate post exercise MPS.24,26 In fact, leucine alone has been shown to independently stimulate the proteins that regulate MPS.27 These two topics will be addressed in greater detail in the following paragraphs. Leucine Leucine, along with valine and isoleucine, are branched-chain amino acids (BCAA). The BCAAs are essential amino acids (meaning they cannot be synthesized endogenously) and are

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unique in that they are predominately metabolized by the muscle (as opposed to the liver). 28 Of the BCAA, leucine has gained the most attention due to its higher oxidation rate during endurance exercise, particularly when muscle glycogen stores are low. 28 Because of its central role in protein synthesis and ability to act as an energy substrate, there has been increasing interest by both athletes and researchers in the efficacy of leucine as a supplement. In a study by Blomstrand et al., endurance-trained cyclists performed two trials of exhaustive exercise with reduced glycogen stores. Subjects were given in random order an aqueous solution of BCAA or flavored water during each of the exercise bouts. Results suggested that BCAA ingestion during exercise may have a glycogen-sparing effect since only a small decrease was found in muscle glycogen concentration in the BCAA trial, whereas a significant decrease was found during the placebo trial. 29 Dreyer et al. examined the effects of BCAA on MPS in resistance trained (RT) athletes who were randomly assigned to receive either a placebo solution or leucine-enriched essential fatty acid and carbohydrate solution one hour post-exercise. Data suggested that ingestion of a leucine-enriched essential fatty-acid and carbohydrate solution one hour after resistance exercise enhanced MPS. 30 Whey vs Casein As previously mentioned, the type of protein that is most useful for promoting MPS has been the topic of interest for athletes and researchers alike. Specifically, research has focused whey vs. casein. Although both milk proteins, they have distinct biochemical properties which impacts their digestion, absorption, and metabolism, and, perhaps, effects on MPS. Whey is a soluble protein and is digested and absorbed relatively quickly, resulting in a rapid increase in the amino acid pool and subsequent increase in cellular amino acid uptake. In contrast, casein is a relatively insoluble protein and is digested and absorbed more slowly, causing a more

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gradual increase in the blood amino acid pool and a delayed amino acid uptake. The differences in their metabolism have led to the hypothesis that whey may be superior to casein for stimulating MPS;31 however research supporting the superiority of whey over casein for MPS is scarce. In fact, most research indicates that the two work synergistically and that supplementation with both together is better than either one separately. For example, Kerksick et al. found that supplementing the diet of resistance trained subjects with a protein supplement containing whey and casein promoted greater increases in fat-free mass after 10 weeks of heavy resistance training when compared to supplementing with whey protein alone. 32 Tipton et al. found that both casein and whey proteins led to a positive amino acid balance despite their differences in digestive properties.33 Since whey and casein are naturally found in cows milk, it seems reasonable (and less expensive) to suggest that athletes consume milk vs. supplementing with expensive supplements containing whey and protein. 34 FATS Fats are an essential part of an athletes diet. Fats serve as the primary energy source at rest and during low-intensity exercise. In addition, the energy density of fats is important to athletes who are expending a great deal of calories daily. 6 Fats also provide the essential fatty acids (which will be discussed in more detail later) and, the presence of fats in the gastrointestinal tract enhance the absorption of fat-soluble vitamins.6 The general recommendation for fat intake is 20-35% of total calories;6 but, in order to meet carbohydrate and protein requirements, athletes should probably aim for fat intake of 15-30% of energy intake. As will be discussed below, inadequate intake of dietary fat has the potential to negatively impact athletic performance in a number of ways. Very Low-Fat Diets

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Athletes may consume very low fat diets for a number of reasons. Some athletes mistakenly believe that dietary fat will make them fat (or inhibit body weight/fat loss) and, thus, try to avoid it at all costs. Other athletes may inadvertently limit fat intake while trying to maximize carbohydrate and protein intakes. Regardless of the reasons for dietary fat restriction, the results can be detrimental to the athletes health and performance including inadequate intakes of the essential fatty acids and fat soluble vitamins, inability to absorb fat soluble vitamins, and inadequate energy intake.35 For example, Harvath et al. found that athletes on a low fat diet were not able to consume the recommended levels of several vitamins and minerals as well as the required amount of calories.36 Similarly, Tomton and Hostmark found that vitamin E intake was inadequate in endurance athletes whose diets were low in fat and calories. 37 It is also hypothesized that very low-fat diets may impair performance since they decrease the amount of intramuscular triglyceride (IMTG) available for use as a substrate in endurance exercise.38 A study by Harvath et al. examined the effects of increasing dietary fat intake from approximately 15% of total calories to approximately 45% of total calories without compromising carbohydrate intake. Results demonstrated that endurance performance was improved by this dietary change.36 Finally, low fat diets may put athletes at increased risk of injury. Gerlach et al. used food frequency questionnaires and injury incidence reports to determine the relationship between energy intake, energy availability, dietary fat, and lower extremity injury in female runners training at least 20 miles/week. He found that injured runners had significantly lower intakes of total fat and percentage of kilocalories from fat compared with non-injured runners.39 Omega-3 Fatty Acids

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The omega-3 fatty acids (alpha-linolenic acid, eicosapentaenoic acid, and docosahexaenoic acid) cannot be synthesized in the body and, thus must be consumed. Among various other functions, the omega-3 fatty acids have been shown to act as regulators of antiinflammatory compounds.40 Since strenuous training has been shown to cause both an acute inflammation and long-term suppression of the immune system, interest in potential benefits of omega-3 fatty acid supplementation for athletes has increased. 6 Despite the anticipated ergogenic effect of omega-3 fatty acids, research thus far has not demonstrated a benefit. For example, Henson et al. examined the effects of 6 weeks of supplementation with EPA compared to a placebo on trained cyclists on exercise performance, inflammation, and immune measures before and after a 3 day period of intense training. The intense training including cycling 3 hours/day at 57% of maximum power output with 10 km time trials for the final 15 minutes of each 3 hour bout. Data showed that 6 weeks of supplementation with EPA increased plasma EPA and DHA levels, but had no effect on performance and did not offset the inflammation with training.41 Similar results were found by Raastad et al. in a study examining the effects of omega-3 fatty acid supplementation in welltrained soccer players.42 Since research has not demonstrated a performance benefit associated with supplementation with omega-3 fatty acids, the recommendation is to include enough fats in the diet to provide the essential fatty acids. 43 FLUID AND ELECTROLYTES Maintaining adequate hydration status during exercise is critical for normal thermoregulatory, metabolic, cardiovascular and nervous system function, not to mention optimal athletic performance. Dehydration resulting in as little as a 2% body weight (BW) loss as water increases body core temperature, heart rate, glycogen utilization, perceived exertion, and, consequently, negatively impacts performance.44 If fluid loss continues, metabolic, nervous
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system, and cognitive function become impaired and the likelihood of heat exhaustion or heat stroke dramatically increases.44 In addition, excessive electrolyte loss, which often accompanies fluid losses, may alter normal nervous system and cardiac function, lead to the development of muscle cramps, and/or cause life threatening shifts between extra- and intra-cellular fluid compartments.44 Conversely, excessive consumption of hypotonic beverages may precipitate dilutional hyponatremia resulting in cerebral or pulmonary edema and even death. 44 Generalized fluid intake guidelines that are applicable to all athletes are difficult to make, since fluid requirements vary vastly from athlete to athlete. Thus, individualized recommendations should be made based on an athletes sweat rate, body weight loss during exercise (Table 6).44 Table 6. General fluid recommendations for before, during, and after exercise. Time in Relation to Exercise Pre-exercise Fluid Recommendations Begin exercise in a state of euhydration. Prehydration should begin several hours before the start of exercise in order to allow time for absorption. The goal is to prevent excessive dehydration or changes in weight. Replace fluid losses

During exercise Post-exercise

Athletes can assess their hydration status subjectively from urine color and volume as well as by more objective measures such as urine specific gravity or osmolality measurements. 45 Change in body mass during a bout of exercise can also provide insight about the adequacy of hydration practices. Weight loss should not exceed 2% of total weight. 45 In addition to fluid, sweat contains numerous electrolytes, the most abundant of which is sodium.6 Sodium concentration in sweat ranges from 10-70 mEq per liter.44 Athletes who have
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sweat sodium concentrations closer to the high end of that range are considered salty sweaters. These athletes are prone to sodium deficits, muscle cramping in the heat, and, in endurance events, exercise induced hyponatremia.46 Stofan et al. found that sweat sodium losses were greater in cramp-prone football players than in football players who had no cramping history. 47 Sweat sodium concentration is determined by genetics, diet, heat acclimatization, sweat rate, age, and gender.46 When an athlete is sweating at a light rate, sodium can be absorbed in the sweat gland.6 However, when the rate of sweating increases, no significant reabsorption can occur and a greater amount of sodium is lost. Exercise Associated Hyponatremia Exercise associated hyponatremia (EAH) is a condition that usually develops due to excessive fluid replacement that exceed fluid losses via sweat combined with inadequate sodium intake.48,49 Other factors that predispose an athlete to the condition include female gender, exercise duration > 4 hrs, low body weight, extreme temperatures, and use of NSAIDS.48,49 Athletes with EAH can present with or without symptoms, the most common of which are altered mental status, confusion, and seizures.49 Currently, there is no research supporting the ingestion of carbohydrate replacement beverages containing sodium for the prevention of EAH, likely because most commercial drinks do not contain enough sodium to decrease the risk of EAH.49 However, drinking these beverages may decrease the rate of serum sodium decline.49 Guidelines that encourage athletes to consume as much fluid as possible during exercise should be modified.50 In addition, athletes at risk for EAH should ensure adequate consumption of dietary sodium either via meals or strategic consumption of salty snacks. MICRONUTRIENTS

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Research clearly shows that an adequate intake of essential micronutrients (i.e., vitamins and minerals) is important for training, competition, and the overall health of the elite athlete. What remains somewhat controversial is whether athletes have greater micronutrient requirements than their sedentary counterparts or if micronutrient intakes exceeding the RDA can enhance performance. According to the Dietary References Intakes, published by the Institute of Medicine (IOM), the micronutrient needs of athletes are no greater than those of their sedentary counterparts. Moreover, the elevated energy requirements among athletes more than likely compensate for any micronutrient deficit incurred as a result of regular strenuous exercise provided energy needs are met and a variety of foods are consumed.51,52 Nonetheless there are some athletes that may be at increased risk for micronutrient inadequacies including those who restrict energy intake, avoid or eliminate certain foods from their diet, or consume an overall poor diet.43 The micronutrients that may be insufficient in the diets of these athletes are described in more detail in the following paragraphs. Antioxidants Oxidative stress occurs when the bodys inherent antioxidant defenses are surpassed by reactive oxygen and nitrogen species (RONS). An imbalance between pro-oxidants and antioxidants is associated with muscle damage and impaired muscle function.53 Research suggests that exercise, particularly of a high intensity and/or prolonged duration, causes significant increase in RONS that could potentially exceed the bodys antioxidant capacity Thus, it has been suggested that supplementing with dietary antioxidants such as vitamins C, E, and beta-carotene may have a benefit for attenuating the oxidative stress caused by training.53 Nonetheless, while antioxidant supplementation has been shown to decrease the oxidative stress associated with intense training it does not seem to translate into improvements in athletic

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performance.53 In fact, there is some research indicating that antioxidant supplementation may actually have a negative effect on performance. Close et al. found that supplementation with ascorbic acid before and after muscle-damaging exercise hindered the recovery process, which could be detrimental to future performance.54 RONS produced during moderate exercise aid in muscle cell adaptations to exercise and are essential to the functioning of every cell. 55 High doses of antioxidants may prevent these beneficial adaptations from occurring and therefore hinder performance.53 The recommendation for elite athletes concerning antioxidants is that they follow the guidelines for adults regarding fruit and vegetable intake rather than taking an antioxidant supplement.56 B-vitamins The B-vitamins, including thiamin, riboflavin, niacin, vitamin B6, pantothenic acid, biotin, and choline, function as co-enzymes in the energy-producing pathways of the body, while folate and vitamin B12 are required for red blood cell production and cell regeneration. The Bvitamins are found in whole grains, dark green vegetables, dairy products, nuts, and meat. There is some limited research showing that physical activity increases the requirements for the Bvitamins; however, this increased need can generally be met through the greater energy intakes of most athletes.57 Nonetheless, there are some athletes who are at risk for B-vitamin deficiency including those who restrict calories or eliminate foods groups such as dairy products or meats. 57 For these individuals efforts should be made to find alternative food sources of the vitamins and, if insufficient food sources can be found a supplement containing 100% of the RDA should be considered.

Vitamin D

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Historically, calcium has received most of the attention when it comes to nutrients important for bone health. However, accumulating evidence suggests that vitamin D is as important if not more important for bone metabolism particularly from a regulatory standpoint. In addition to bone health, vitamin D plays a key role in the regulation of the growth and maintenance of the nervous system and skeletal muscle, immune function, and inflammatory regulation.58 Currently, the RDA for vitamin D is set at 600 IU for individuals <70 years and 800 IU for individuals >70 years.59 Research suggests that athletes are generally not meeting the RDA for vitamin D.58,60,61 This is especially true for athletes who may have insufficient UVB exposure because they live at northern latitudes, train mostly indoors or during non-peak hours (i.e., early in the morning or late in the afternoon/evening), have dark skin pigmentation, or regularly use sunscreen. 58,61 Ideally, athletes should be screened biannually for vitamin D status, particularly for high -risk athletes such as those with history of stress fractures, frequent illness, bone and joint injury, or who have insufficient UVB exposure.58 Serum 25(OH)D concentration is considered the best indicator of vitamin D status and while some discrepancy exists amongst the medical community, a value of < 30 ng/mL is generally suboptimal.58 For athletes with sub-optimal serum 25(OH)D status, daily supplementation with 2000-6000IU of vitamin D3 for 6-8 weeks followed by a maintenance period of 600-2000 IU/day may be required to return to optimal vitamin D status.62 If high risk athletes are unable to be screened, supplementation with vitamin D at the RDA level will be beneficial. And all athletes should strive to get adequate vitamin D through modest sun exposure as well as through dietary intake of fatty fish, egg yolks, and fortified dairy products.58 Choline

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Choline is a nutrient that has recently garnered attention as a potential ergogenic aid, particularly for endurance athletes. Choline is a precursor for the neurotransmitter acetylcholine which is important for signal transmission during muscle contraction. Some studies have suggested that plasma choline concentrations decline during some types of prolonged physical activity. Low levels of choline in the muscle cell could result in a reduction in the force of muscle contraction, which could negatively impact endurance performance. Buchman et al. found a significant decrease in free choline concentration following a marathon run, suggesting an impairment of neuromuscular transmission during the race. 63 Similarly, Sandage et al. reported that plasma choline levels were reduced in male runners after a 20 mile run. 64 Nonetheless, there is no conclusive evidence that decreases in choline levels significantly affect athletic performance.65 Research has also not supported a benefit of choline supplementation from a performance standpoint. Sandage et al. reported that ingestion of a choline supplement before and half way through a 20 mile run maintained plasma choline concentrations, but they did not measure performance, so the implications of this physiological effect is unknown. 64 Athletes can readily meet their choline requirements by consuming meat, fish, eggs, milk, soy products, nuts and/or seeds. Iron Iron is an integral part of hemoglobin, which is essential for oxygen uptake and transport to the working muscle.66 Iron also functions in energy production and heme oxidative metabolism;66 thus, rendering it a key nutrient in athletic performance. Elite athletes, especially endurance athletes, are at an increased risk of iron deficiency due to prolonged phases of intense exercise, muscular injuries, increased turnover of red blood cells, and increased loss of iron in

30

sweat and urine.66 Premenopausal female endurance athletes have the highest risk of developing iron deficiency, especially if their diets provide inadequate calories and/or lack iron-rich foods.6 The hallmark symptoms of iron deficiency anemia in the athlete include extreme fatigue, decreased aerobic capacity, and compromised immunity.67 The research is somewhat controversial with regards to whether or not iron deficiency without anemia produces overt symptoms or negatively impacts athletic performance. 68 Nonetheless, possible performance decrements aside, athletes with non-anemic iron deficiency should strive to increase their intakes of iron-rich foodsincluding meats (particularly red meats), beans, fortified cereals and dark green vegetables-- to prevent the development of iron deficiency anemia. 6 Iron supplementation should be considered when an athlete with iron deficiency anemia is unable to obtain adequate iron from the diet.69 CONCLUSION In order to train consistently and compete successfully, athletes must consume adequate calories as well as meet specific fluid, macro- and micronutrient requirements. Carbohydrates are the most important fuel for the elite athlete, particularly the elite endurance athlete. Adequate intake of carbohydrates before during and after exercise is imperative for optimal endurance performance. Recent evidence suggests that even in shorter events, carbohydrates may provide performance benefits. Most experts agree that dietary protein requirements for athletes are slightly higher than those of their sedentary counterparts; however, a varied diet that meets energy needs will generally provide adequate protein for the athlete. Controversy currently exists with respect to the benefits of one form of protein over the other (i.e., casein vs whey) or specific amino acids. Until further research confirms otherwise, athletes should only focus on the amount and timing of protein intake. Ingesting foods or drinks that contain approximately 10-20 grams

31

of protein before or immediately after training sessions will maximize protein synthesis and aid in recovery. Dehydration, if sufficiently severe, can impair athletic performance; thus, athletes should be well hydrated before exercise and drink sufficient fluid during exercise to limit dehydration to less than about 2% of body mass. Sodium should be included when sweat losses are high. During recovery from exercise, rehydration should include replacement of both water and salts lost in sweat. Athletes who restrict energy intake and/or who consume nutrient poor diets are at increased risk for micronutrient deficiencies, particularly the B-vitamins, iron and vitamin D. Although frequently utilized, there is no evidence to suggest that antioxidant supplementation can improve athletic performance and accumulating evidences suggests it may actually have negative consequences. For individual guidance on energy, nutrient and fluid needs, athletes should seek the guidance of a qualified sport nutrition professional (i.e., a Registered Dietitians or Certified Specialist in Sports Dietetics) who can help them develop sport-specific nutritional strategies for training, competition and recovery.

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39. Gerlach KE, Burton HW, Dorn JM, Leddy JJ, Horvath PJ. Fat intake and injury in female runners. J Int Soc Sports Nutr. 2008;5(1):1-8. 40. Gleeson M, Nieman DC, Pedersen BK. Exercise, nutrition, and immune function. J Sports Sci. 2004;22:115-125. 41. Henson DA, Nieman DC, McAnulty S, Jin F, Maxwell K. N-3 polyunsaturated fatty acids do not alter immune and inflammation measures in endurance athletes. FASEB J. 2009;543(11). 42. Raastad T, Hostmark AT, Stromme SB. Omega-3 fatty acid supplementation does not improve maximal aerobic power, anaerobic threshold and running performance in welltrained soccer players. Scand J Med Sci Sports. 1997;7:25-31. 43. ADA, ACSM, Dietitians of Canada. Nutrition and athletic performance: joint position statement. Med Sci Sports Exerc. 2009;709-731. 44. Sawka MN, Burke LM, Eichner ER, Maughan RJ, Montain SJ, Stachenfeld NS. American College of Sports Medicine position stand: exercise and fluid replacement. Med Sci Sports Exerc. 2007:377-390. 45. Maughan RJ, Shirreffs SM. Development of individual hydration strategies for athletes. Int J Sport Nutr Exerc Metab. 2008;18:457-472. 46. Eichner ER. Genetic and other determinants of sweat sodium. Curr Sports Med Rep. 2008:S36-S40. 47. Stofan JR, Zachwieja JJ, Horswill CA, Murray R, Anderson SA, Eichner ER. Sweat and sodium losses in NCAA football players: a precursor to heat cramps? Int J Sport Nutr Exerc Metab. 2005;15:641-652. 48. Davis DP, Videen JS, Marino A, et al. Exercise-associated hyponatremia in marathon runners: a two-year experience. J Emerg Med. 2001;21(1):47-57. 49. Rosner MH, Kirven J. Exercise-associated hyponatremia. Clin J Am Soc Nephrol. 2007;2:151-161. 50. Noakes TD, Sharwood K, Speedy D, et al. Three independent biological mechanisms cause exercise-associated hyponatremia: evidence from 2,135 weighed competitive athletic performances. Proc Natl Acad Sci. 2005;102(51):18550-18555. 51. Lukaski HC. Vitamin and mineral status: effects on physical performance. Nutrition. 2004;20(7-8):632-44. 52. Volpe SL. Micronutrient requirements for athletes. Clin J Sport Med. 2007;26(1):119-30. 53. Peternelj T, Coombes JS. Antioxidant supplementation during exercise training. Sports Med. 2011;41(12):1043-1069. 54. Close GL, Ashton T, Cabel T, et al. Ascorbic acid supplementation does not attenuate post-exercise muscle soreness following muscle-damaging exercise but may delay the recovery process. Br J Nutr. 2006;95(5):976-81. 55. Gomez-Cabrera M, Domenech E, Vina J. Moderate exercise is an antioxidant: Upregulation of antioxidant genes by training. Free Radic Biol Med. 2008:126-131. 56. Williams SL, Strobel, NA, Lexis LA, Coombes JS. Antioxidant requirements of endurance athletes: Implication for health. Nutr Rev. 2006;64(3):93-108. 57. Woolf K, Manore MM. B-vitamins and exercise: does exercise alter requirements? Int J Sport Nutr Exerc Metab. 2006;16:453-484. 58. Larson-Meyer DE, Willis KS. Vitamin D and athletes. Curr Sports Med Rep. 2010;9(4):220-226.

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59. Ross AC, Taylor CL, Yaktine AL, Del Valle HB. Dietary reference intakes for calcium and vitamin D. Washington D.C.: The National Academies Press; 2011: 1-14. 60. Lovell G. Vitamin D status of females in an elite gymnastics program. Clin J Sport Med. 2008;18(2):159-161. 61. Constantini N, Arieli R, Chodick G, Dubnov-Raz G. High prevalence of vitamin D insufficiency in athletes and dancers. Clin J Sport Med. 2010;20(5):368-371. 62. Holick MF, Binkley NC, Bischoff-Ferrari, HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an endocrine society clinical practice guideline. J Clin Endocrin Metab. 2011;96(7):1-20. 63. Buchman AL, Jenden D, Roch M. Plasma free, phospholipid-bound and urinary free choline all decrease during a marathon run and may be associated with impaired performance. J Am Coll Nutr. 1999;18(6):598-601. 64. Sandage BW, Sabounjian L, White R, Wurtman RJ. Choline citrate may enhance athletic performance [abstract]. Physiologist. 1992;35:236. 65. Penry JT, Manore MM. Choline: an important micronutrient for maximal enduranceexercise performance? Int J Sport Nutr Exerc Metab. 2008;18:191-203. 66. Reinke S, Taylor WR, Duda GN, et al. Absolute and functional iron deficiency in professional athletes during training and recovery. Int J Cardiol. 2010;156:186-191. 67. Suedekum NA, Dimeff RJ. Iron and the athlete. Curr Sports Med Rep. 2005;4(4):199202. 68. Hass JD, Brownlie T IV. Iron deficiency and reduced work capacity: a critical review of the research to determine a causal relationship. J Nutr. 2001;130(2S-2):676S-688S. 69. Zoller H, Vogel W. Iron supplementation in athletesfirst do no harm. Nutrition. 2004;20:615-619.

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APPENDIX C

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