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    23 Nutrition in Exercise and Sports Performance Lisa Dorfman, MS, RDN, CSSD, LMHC, FAND KEY TERMS actomyosin exgogenic aid mitochondria adenosine diphosphate (ADP) fat adaptation strategy muscle dysmorphia (MD) adenosine triphosphate (ATP) female athlete triad (FAT) ryoglobin aerobic metabolism slyeemic index nutrition periodization anabolic effects slyeogen ‘oxidative phosphorylation anaerobic metabolism slycogen loading (glycogen supercom- _pseudoanemia androgenic effects pensation) respiratory exchange ratio (RER) anorexia athletica (AA) slycogenolysis, reactive oxygen species (ROS) athletic energy deficit (AED) glycolysis sports anemia creatine phosphate (CP) high-intensity interval training (HIT) The Athlete's Plate dchydroepiandrosterone (DHEA) hypohydration thermoregulation cating, exercise, body image (EBD) human growth hormone (HGH) Voumax disorders lactic acid Athletic performance is the culmination of genetics, proper taining, adequate nutrition, hydration, desite, and rest. Une derstanding sport-specific physiologic requirements for training and competition is integral lo oblaining sufficient energy, optimal levels of macronutrients and micronutrients, and adequate levels of fluids. Healthy eating habits and the use of supplements and sports foods may be necessary to support energy needs for training hard, achieving perfor- mance goals, and reducing the incidence of illness and injury. Energy and fuel requirements for training and competition also have to adapt for recovery between training sessions to reduce the risk of illness or injury and maintain appropriate body composition (International Olympic Committee [I0C), 2011). AN INTEGRATIVE APPROACH TO WORKING WITH ATHLETES: data and feedback from athletes to determine whether additional factors such as gut dysbiosis, food allergies or intol- cerances, dietary preferences or aversions, or disease processes may affect the overall absorption, assimilation, digestions, biotransformation, and transport of specific macronutrients, micronutrients, or fluids and ultimately affect performance potential ‘A comprehensive understanding of the relationship be- ‘tween optimal nutrition and exercise science also enables di ctitians and nutrition practitioners to appreciate the impor tance of ensuring adequate auttition for active individuals and to critically evaluate the validity of claims concerning utritional supplements and special dietary modifications to enhance physique, physical performance, and exercise tain ing responses. BIOENERGETICS OF PHYSICAL ACTIVITY ‘To advance the practice of dietitians working with Biness- minded individuals, cross-diseiplinary taining provides a broader and more comprehensive understanding and applica tion of the dietary needs for individuals who exercise. Fxercise nutrition is not limited to exercise physiology or nutrition but considers six core areas of study including the role of optimal overall health and longevity, optimal growth, peak physiologic function, energy balance and body composition, nutrition en- hancement, and safety. Genetics and individualized differences, exercise environ- ‘ments, and life stress also can affect the athlete's tolerance of specific nutrients, To prevent nutrient deficiencies, dietitians must integrate anthropometric, biochemical, and dietary 426 Exercise nutrition requires essential elements from food to fuel muscle contractions, build new tissue, preserve lean muscle ‘mass, optimize skeletal structure, repair existing cells, maximize ‘oxygen transport, maintain favorable fluid and electrolyte bal- ance, and regulate metabolic processes. ‘The human body must be supplied continuously with en- ergy to perform its many complex functions. Three metabolic systems supply energy for the body: one dependent on oxy (oxidative phosphorylation or aerobic metabolism) and the other two independent of oxygen (creatine phosphate and an- aerobic glycolysis or anaerobic metabolism). The use of one system over the other depends on the duration, intensity, and type of physical activity CHAPTER 23 Nutrition in Exercise and Sports Performance oy Adenosine Triphosphate: Ultimate Energy Source Regardless of the energy system used to generate power for ex- crcse, the body relies on a continuous supply of fuel through adenosine triphosphate (ATP), found within the mitochondria of the body. The energy produced from the breakdown of ATP provides the fuel that activates muscle contraction. The energy from ATP is transferred to the contractile filaments (myosin and actin) in the muscle, which form an attachment of actin to the cross-bridges on the myosin molecule, thus forming acto- myosin. Once activated the myofibrils slide past each other and cause the musee to contract. ‘Although ATP is the main currency for energy in the body, it is stored in limited amounts. Infact, only approximately 3 07 of ATP is stored in the body at any one time (McArdle etal, 2013). This provides only enough energy for several seconds of exer- cise, and yet ATP must be resynthesized continually to provide 4 constant energy source. When ATP loses a phosphate, thus releasing energy, the resulting adenosine diphosphate (ADP) is combined enzymatically with another high-energy phosphate from creatine phosphate (CP) to resynthesize ATP. The con- centration of high-energy CP in the muscle is five times that of ATR Creatine kinase is the enzyme that catalyzes the reaction of CP with ADP and inorganic phosphate. Thisis the fastest and most immediate means of replenishing ATE, and it does so without the use of oxygen (anaerobic). Although this system has great power, itis time-limited because of the limited con- centration of CP found in the muscles (see Creatine later in the chapter) The energy released from this ATP-CP system will support an all-out exercise effort of only a few seconds, such as in a power lift tennis serve, or sprint. Ifthe all-out effort continues for longer than 8 seconds, or if moderate exercise i to proceed for longer periods, an additional source of energy must be pro- vided for the resynthesis of ATP, The production of ATP carries ‘on within the muscle cells through either the anaerobic or aer0- bic pathways, Anaerobic or Lactic Acid Pathway ‘The next energy pathway for supplying ATP for more than 8 seconds of physical activity is the process of glycolysis. In this pathway the energy in glucose is released without the pr sence of oxygen, Lactic acid is the end product of glycolysis. Without the production of lactic acid, glycolysis would shut down, The coenzyme called nicotinic acid dehydrogenase (NAD) is in limited supply in this pathway, When NAD is lim- ited, the glycolytic pathway cannot provide constant energy. BY converting pyruvic acid to lactic acid, NAD is freed to partici- pate in further ATP synthesis, The amount of ATP furnished is relatively small; the process is only 30% efficient. This pathway contributes energy during an all-out effort lasting up to 60 to 120 seconds, Examples are a 440-yard sprint and many sprint- swimming events, Although this process provides immediate protection from the consequences of insufficient oxygen, it cannot continue in definitely. When exercise continues at intensities beyond the body’s ability to supply oxygen and convert lactic acid to fuel, Iaetic acid accumulates in the blood and muscle, lowers the pH to-a level that interferes with enzymatic action, and causes fa tigue. Lactic acid can be removed from the muscle, transported into the bloodstream, and converted to energy in muscle, liver, or brain. Otherwise, it is converted to glycogen. Conversion to glycogen occurs in the liver and to some extent in muscle, par- ticularly among trained athletes. The amount of ATP produced through glycolysis is small compared with that available through aerobic pathways. Sub- strate for this reaction is limited to glucose from blood sugar ot the glycogen stored in the muscle, Liver glycogen contributes but is limited, Aerobic Pathway Production of ATP in amounts sufficient to support contin uued muscle activity for longer than 90 to 120 second: quires oxygen. If sufficient oxygen is not present to combine with hydrogen in the electron transport chain, no further ATP is made. Thus the oxygen furnished through respiration is of vital importance. Here, glucose can be broken down far more efficiently for energy, producing 18 to 19 times more ATP. In the presence of oxygen, pyruvate is converted to ace- tyl coenzyme A (CoA), which enters the mitochondria. In the mitochondria acetyl CoA goes through the Krebs cycle, which generates 36 to 38 ATP per molecule of glucose (Gee Figure 23-1). ‘Aerobic metabolism is limited by the availability of sub- strate, a continuous and adequate supply of oxygen, and the availability of coenzymes, At the onset of exercise and with the increase in exercise intensity, the capability of the cardiovascu- lar system to supply adequate oxygen is a limiting factor, and this is largely due to the level of conditioning. The aerobic path- way provides ATP by metabolizing fats and proteins. A large amount of acetyl CoA, which entets the Krebs cycle and pro- vides enormous amounts of AIP is provided by beta-oxidation of fatty acids. Proteins may be catabolized into acetyl CoA. or Krebs cycle intermediates, or they may he directly oxidized as another source of ATP, coves oe FIGURE 23-1 cry PART IV Nutrition for Health and Fitness Energy Continuum [A person who is exercising may use one or more energy path- ‘ways, For example, at the beginning of any physical activity, ATP is produced anaerobically. As exercise continues, the lactic acid system produces ATP for exercise. If the person continues to exercise and does so at a moderate intensity for a prolonged period, the aerobic pathway will become the dominant path- way for fuel. On the other hand, the anaerobic pathway pro- vides most of the energy for short-duration, high-intensity «exercise such as sprinting; the 200-meter swim; or high-power, high-intensity moves in basketball, football, or soccer. How- ever, all of the ATP-generating pathways are turned on at the onset of exercise ‘The production of ATP for exercise is on a continuum that depends on the availability of oxygen. Other factors that influ- ‘ence oxygen capabilities and thus energy pathways are the ca- pacity for intense exercise and its duration. These two factors are inversely related, For example, an athlete cannot perform high-power, high-intensity moves over a prolonged period. To do this, he or she would have to decrease the intensity of the exercise to increase its duration (see Figure 23-2) ‘The aerobic pathway cannot tolerate the same level of inten- sity as duration inereases because of the decreased availability of oxygen and accumulation of lactic acid. As the duration of ‘exercise increases, power output decreases. The contribution of cenergy-yielding nutrients must be considered also. As the dura- tion of exercise lengthens, fats contribute more as an energy source, The opposite is true for high-intensity exercise; when intensity inereases, the body relies increasingly on earbohy- dates as substrate (eninutes) FIGURE 23-2 Relative contribution of aerobic and anaerobic fenergy during maximum physical activity of various durations, Note that 90 to 120 seconds of maximum effort requires $0% of the energy from each of the aerobic and anaerobic pro- cesses. This 's also tho point at which the lactic acid patnway for energy production is at its maximum. FUELS FOR CONTRACTING MUSCLES Protein, fat, and carbohydrate are possible sources of fuel for ATP generation and therefore muscle contraction. The glyco- lytic pathway is restricted to glucose, which can originate in dietary carbohydrates or stored glycogen, or it can be synthe- sized from the carbon skeletons of certain amino acids through the process of gluconeogenesis. The Krebs cycle is fueled by three-carbon fragments of glucose; two-carbon fragments of fatty acids; and carbon skeletons of specific amino acids, pri- ‘marily alanine and the branched-chain amino acids. All these substrates can be used during exercise; however, the intensity and duration of the exercise determine the relative rates of sub- strate use Intensity ‘The intensity of the exercise is important in determining ‘what fuel will be used by contracting muscles. High-intensity, short-duration exercise has to rely on anaerobic production of ATP. Because oxygen is not available for anaerobic path- ‘ways, only glucose and glycogen can be broken down anaero- bically for fuel. When glycogen is broken down anacrobicaly, it is used 18 to 19 times faster than when broken down aero- bically. Persons who are performing high-intensity workouts ‘or competitive races may run the risk of running out of muscle glycogen before the event or exercise is done as a re- sult ofits high rate of use. Sports that use the anaerobic and acrobic pathways also have a higher glyeogen-use rate and, like anaerobic athletes, athletes in these sports also run the risk of running out of fuel before the race or exercise is finished. Sports such as basketball, football, soccer, tennis and swimming are good examples; gly- cogen usage is high because of the intermittent bursts of high- intensity sprints and running drill, In moderate-intensity sports or exercise such as jogging, hiking, aerobic dance, gym- nastics, cycling, and recreational swimming, approximately half of the energy for these activities comes from the aerobic breakdown of muscle glycogen, whereas the other half comes from circulating blood glucose and fatty acids. ‘Moderate to low-intensity exercise such as walking is fucled primarily by the aerobie pathway; thus a greater proportion of fat can be used to create AIP for energy. Fatty acids cannot sup- ply all the ATP during high-intensity exercise because fat can- not be broken dowa fast enough to provide the energy: Also, fat provides less energy per liter of oxygen consumed than does shucose (4.65 keal/L of O; versus 5.01 kealfL of O;). Therefore ‘when less oxygen i available in high-intensity activities, there is a definite advantage for the muscles to be able to use glycogen because less oxygen is required. In general, glucose and fatty acids provide fuel for exercise in proportions depending on the intensity and duration ofthe ‘exercise and the fitness of the athlete, Exertion of extremely high intensity and short duration draws primarily on reserves of ATP and CP. High-intensity exercise that continues for more than a few seconds depends on anaerobic glycolysis. Daring exercise of low-io-moderate intensity (60% of maxi- ‘mum oxygen uptake [Vosmax]), energy is derived mainly from fatty acids. Carbohydrate becomes a larger fraction of the energy source as intensity increases until, at an intensity level of 85% to 90% Vozmax, carbohydrates from glycogen are the principal energy source, and the duration of activity is limited (see Figure 23-3), CHAPTER 23 Nutrition in Exercise and Sports Performance (Ha Muscle triglycerides lasma FFA lasma glucose (fed) Iasma glucose (fasted) Ti Muscle glycogen a 65% of VO, max 2 ggegeags 3 g B z 3 2 1 2 3 4 Duration of exercise (hours) FIGURE 23-3 Principle Energy Source and Exercise Duration, Duration ‘The duration of a training session determines the substrate used during the exercise bout. For exemple, the longer the time spent exercising, the greater the contribution of fat as the fuel, Fat can supply up to 60% to 70% of the energy needed for ultracndurance events lasting 6 to 10 hours. As the duration of exercise increases, the reliance on aerobic metabolism becomes greater, and a greater amount of ATP can be produced from fatty acids. However, fat cannot be metabolized unless a continuous stream of some carbohy- drates is also available through the energy pathways. There- fore muscle glycogen and blood glucose are the limiting factors in human performance of any type of intensity oF duration Effect of Training ‘The length of time an athlete can oxidize fatty acids as a fuel source is related to the athlete's conditioning, as well as the ex- ercise intensity. In addition to improving cardiovascular sys- tems involved in oxygen delivery, training increases tae number ‘of mitochondria and the levels of enzymes involved in the aero bie synthesis of ATE, thus increasing the capacity for fatty acid metabolism. Increases in mitochondria with aezobic training are seen mainly in the type HA (intermediate fast-twitch) muscle fibers. However, these fibers quickly lose their aerobic capacity with the cessation of aerobic training, reverting to the genetic baseline, ‘These changes from training result in a lower respiratory ‘exchange ratio (RER), (also called respiratory quotient [RQ]), which is RQ = CO, eliminated / O, consumed; lower blood lactate and catecholamine levels, and a lower net muscle glyco gen breakdown at a specific power output. These metabolic adaptations enhance the ability of muscle to oxidize all fuel, especially ft NUTRITIONAL REQUIREMENTS OF EXERCISE Energy The most important component of suecessfel sport training and performance isto ensure adequate calorie intake to support energy expenditure and maintain strength, endurance, muscle sass, and overall health. Energy and nutrient requirements vary with age, gender, weight, height, raining/sport type, fre- quency, intensity, and duration; typical diet, diet history, history of restrictive and disordered eating; endocrine and environ- ‘mental conditions such as heat, cold, and altitude. Estimating «energy intake is challenging to accomplish, especially in sports that ae less well studied (Driskell and Wolinsky, 2011). Individuals who participate in an overall fitness program (ie, 30 to 40 min/day, thee times per week) can generally meet their daily nutritional needs by following a normal det providing 25 to 35 keal/kg/day or roughly 1800 to 2400 calories a day. However, energy requirements for athletes training 90 minutes a day has been suggested to be 45 to 50 KeaVkg/day, andl in certain sports For example, the 50-kg athlete engaging in more intense training of 2 to 3 hoursiday five to six times « week or high- volume training of3 to 6 hours in one to two workouts per day 5 to 6 days a week may expend up to an additional 600 to 1200 calories a day above and beyond REE, thus requiring 50 to 80 keal/kgiday or roughly 2500 to 4000 keal/day. For elite athletes or heavier athletes, daily calorie needs can reach 150 to 200 kcal/kg, or roughly 7500 to 10,000 calories a day, depending fon the volume and intensity of different training phases Estimation of Energy Requirements Resting metabolic rate (RMR) or resting energy expenditure (REE) can be measured using indizect calovimetry or estimated by using predictive equations. Indirect calorimetry involves using a hand-held device such as the MedGem calorimeter or stabolic cart typically used in exercise physiology or zesearch settings to measire a person’ oxygen consumption to determine EMR or basal metabolic rate (BMR). Measuring RMR or BM is more accurate than using prediction equations. Predictive equations are used to estimate RMR/BMR when technical equipment, such as a metabolic cart, is not available. ‘Whe Cunningham equation has been shown to be the best pre- dictor of RMR or REE for active men and women followed by the Harris Benedict equation (Rodriguez etal, 2009). DeLorenzo developed an equation that also has been shown to be accurate specifically with male strength and power athletes such as those in water polo, judo, and karate (Academy of Nutrition and Dietetics [AND, 2014; DeLorenzo etal, 1999) If the sports dietitian has body composition data inchuding percent bodyfat the REE can be calculated as shown in Box 25-1 ‘Once REE has been calculated, the total energy expenditure (TEE) canbe estimated using energy expenditure from physical activity. Because metabolic equipment is expensive, requires considerable taining to use, and is not practical outside SSS y cee RMA {ealoresiday) = 500 + 22% MA = resting metabo rt n beey mass Body Mass in logrars! PART IV Nutrition for Health and Fitness research settings, indirect methods can be employed and in clude heart rate monitors, pedometers, or accelerometers. Other indirect methods are to Use a daily activity factor as a base to which is added calories expended in exercise, which are caleu- lated by multiplying the calories expended per minute of exer- cise times the amount of time spent in that activity, known as METS, metabolic equivalent of task (Driskell and’ Wolinsky, 2011; see Chapter 2). Heart rate monitoring to estimate energy expenditure is based. fon the assumption that there is a linear relationship between heart rate and oxygen consumption (VO,). Pedometers measure ambulatory distance covered, which isa limitation of the method because it does not consider other types of physical activities such as weightlifting, cycling, or yoga. Accelerometers have the advan- tage of measuring all activities, are easy to wear, and can give feedback for long periods of time. Other personal fitness devices hhave been developed in recent yeats, although no method is as accurate as measuring directly with a metabolic cart. ‘A method for calculating total energy expenditure using ac- tivity factors provided is shown in Box 23-2, BOX 23-2 Calculating D: rue uied ‘Cunningham Formula [RMR o REE (resting eneray expenditure in kealrles/day! ~ 500 + (22x Lean Body Mass LBW In klegrams ho Fer exampl 175-pound 795k athlete with 10% ood fat Ag of fat = wight = 735 kg x 10 = 79 by fat Lan body mess = tote weight ~fe weight = 795 ~ 79 = 716 49 of LM REE — 500 + 22% 716g LEM) ~ 2075 calories. Energy To Determine EEPA—Energy Expended for Physical Activity anu Calores expended in a day using: hin res gounecpntanps! Physica fpa"PA Intensity sable? hp or Specie eslove expenditures fr afore’ weighs wing htpwweanutibase eomfenereaaih or (Can mutts REE by the activity factor using 1200 = sedentary fle or ne exercise) 1375 = ont setve fodout 39 minutes of moderte vainng, + to 3 ysient 1.550 = moderately ectve [5 minutes of moderate taining, 3705 days! ‘weet! 1.725 = very active traning fort hour 6 0 7 dayshveet) 11800 = ext atve very hare traning incusing weight tng, 23 ays! ‘weet! To continue the examph ‘The EEPA for |7pound athlete who is wining hard would be the fallong: FREE 2078 kealries) x act factor (1.8) = 3842 total Kealores for BEE and ECP To continue the exam: Thermie efect of oa {TEF| = she total kesores for REE and EEPA x “0% = 2642 x0.1 = 29¢kealores Total daly eneray requireme cabris! ~ 4296 eal, Total daly eneray requirements ~ 4336 healories total «calories 942+ TEF (296 ‘Thompson J, Menore MIN, Presicted and measured resting metabolic ‘ate of male and female endurance athletes. J 4m Diet Aor. 1996 Jan; 961 30.8 Meeting calorie needs for many fitness-minded ot elite, in- tensely training individuals can be a challenge regardless of the accuracy of the formulas used to predict energy needs. For high school and college athletes, disruptive sleep pat- terns and accommodating academic, social, and training sched- ules often lead to skipped meals, high frequency of unplanned snacking, use of sport shakes and bars in lieu of whole food meals, and late-night snacking while studying, or socializing online or with friends. Adult athletes with family and work re sponsibilities are also meal challenged when juggling daily taining schedules with carpools, work deadlines, and accom- ‘modating children’s eating schedules, which ultimately can compromise the quantity, quality, and timing of meals and sgxcally affect energy, stzength levels, and overall health, In ete athletes, consuming enough food at regular intervals without compromising performance is challenging, particularly when athletes are traveling abzoad, are at the mercy of aizport food, foreign food schedules, unfamiliar training facilities, de- lays, and unforeseen events such as weather-postponed geme and competition schedules, All athletes regardless of age and lifestyle demands can be better prepared by packing snacks and ready-to-eat meals, which are essential for keeping energy in- lakes adequate to support overall health and performance. ‘Meeting the daily energy needs and the appropriate macro- nutrient distribution for active individuals may necessitate the use of sports bars, drinks, and convenience foods and snacks in addition to whole foods and meals, Dietitian nutritionists should stay open minded and be flexible in accommodating lifestyles and eating behaviors when designing meal plans for ‘maximum sport performance WEIGHT MANAGEMENT Although lean body mass has been associated with positive health benefits, negative health outcomes are associated with ‘excessive loss or gain of body mass, Although weight classifica tions in sports such as youth and sprint football, wrestling, lightweight crew, and boxing were designed to ensure healthy, safe, and equitable participation, few published and widely ac- cepted weight and body composition standards exist, and the governing organizations for these sports have no mandated weight control practices. Only sprint football and wrestling consider the components of an athlete's weight and body com- position as well as the safety considerations for achieving and ‘maintaining that body size In 1997 specific rules and guidelines were implemented by the NCAA to ensure safe weight control practices in wrestling, applied early in the competitive season and conducted on a regular basis to ensure prevention of dehydration and other wweight-cutting behaviors. In 2006 the National Federation of State High School Associations adopted similar standards for determining body weights, although they are not accepted or enforced universally Weight Loss In efforts to maximize performance or meet weight criteria determined by specific sports whether itis in the case of “‘mak- ing 2 lower weight” in sports such as martial ars, sailing, rov- ing, or wrestling, or reaching a higher weight for power lifting, football, or baseball, many athletes alter normal energy intake to either gain or lose weight, Although such efforts are some- times appropriate, weight reduction or weight gain programs CHAPTER 23 Nutrition in Exercise and Sports Performance may involve elements of risk, especially when the pressure to lose or gain weight is expected in an unrealistically short amount of time. For some young athletes achievement of an unrealistically low weight or conversely a high weight with the use of weight gainer or other supplements can jeopardize growth and development. ‘The goal weight of an athlete should be based on optimizing health and performance and be determined by the athlete's best previous performance weight and body composition. Adequate time should be allowed for a slow, steady weight loss of ap- proximately 1 to 2 pounds each week over several weeks, Weight loss should be achieved during off-season or preseason when competition is not a priority, A weight loss planning guide can be found online at the AND Sports Nutrition Care Manual. The National Athletic Trainers Association (NATA) suggests the lowest safe weight should be calculated at no lower than the weight determined by the low reference body fat composition delineated by sex and age. The lowest safe weight can be defined as the lowest weight sanctioned by the governing body at which a compelitor may compete (Turocy et a, 2011). When no stan dard exists, participants would be requited to remain above a certain minimal body fat. The highest safe weight should be calculated using a value no higher than the highest end of the range satisfactory for health: 10% to 2296 body fat in males and 20% to 32% in fernales (Turocy et al, 20113 see Table 23-1). Weight Gain ‘To accomplish a healthy weight gain of lean muscle tissue, 500 to 1000 additional calories per day can be added in addition to steength training, which will dually increase muscle strength. ‘The rate of weight gain depends on the athlete's genetic make- up, degree of positive energy balance, number of rest and recov ery sessions a week, and exercise type. WEIGHT MANAGEMENT AND AESTHETICS Disordered Eating Although drive, perfection, and attention to detail are the hall- ‘marks of talented athletes, they are also some of the personality tuaits associated with the development of cating disorders (see Chapter 22), Disordered eating behaviors among athletes can be difficult to detect given the tendencies of athleves to maintain rigid nutritional requirements, follow intense training sched- ules, and push through fatigue and pain. Disordered eating behaviors specifically in athletes have been termed anorexia athletica (AA), where the ultimate goal is to perform at one’s best as opposed to thinness in and of itself being the goal. Athletes who are mote vulnerable to AA are those who participate in “lean-build” sports, such as cross country running, swimming, gymnastics, cheerleading, dance, yoga, and wrestling, who may think they need to be a certain ere Pere Body Fat Standard Lowest reference body {at for el Lowest reference Body ‘atforedlescer's Hea boayfotranaes Cerrar orc weight or body type, often far less than what itis realistic to at- tain and maintain to be competitive, This desite to he unzealis- tically light or lean may lead to restrictive eating, bingeing and purging, and excessive training far beyond what is required for their sport. Female Athlete Triad Chronic dieting by female athletes can lead to the female awlete triad (FAT), which consists of three interrelated health

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