Issue 129 sports nutrition case study by NH Publishing Ltd

NUTRITION MANAGEMENT

SPORTS NUTRITION: CASE STUDY Claire Chaudhry Community NHS Dietitian/ Freelance Dietitian, BCUHB (NHS) and Private

In Claire’s 15 years of experience, she has worked in acute and community NHS settings. Claire has taught nutrition topics at universities and colleges and regularly provides talks to groups, NHS and private. www.dietitian claire.com

For full article references please email info@ networkhealth group.co.uk

Protein requirements for athletes can usually be obtained through diet alone.1 Despite this, the protein supplements market has risen by 27% since 2014 and consumers in the UK spent £66 million on sports nutrition food and drink products in 2015.2 Many athletes believe that taking protein supplements will promote muscle building and enhance performance; however, the research evidence of using amino acid supplements and or protein supplements as an Ergogenic aid finds no clear benefits.3 In a BBC documentary, Journalist Rick Kelsey discusses the use of protein supplements with professors, athletes and suppliers. In the article, Professor Graeme Close from Liverpool John Moore’s University (LJMU), challenged a regular whey protein supplement

user to go without his supplement for six weeks. After the six weeks, the experiment revealed that the user had indeed built up his muscle by diet and activity alone, hence he didn’t require the protein supplements.4 The following dietary case study was a male client in 2016 who was also taking protein supplements: branch chain amino acids (BCAA) consisting of leucine, isoleucine and valine and also whey protein powder containing 21gm of protein per 25gm serving.

1 ASSESSMENT MALE, MARTIAL ARTIST - CLIENT B • Client B, male age 29, weight 91kg, height 186m • Multiple martial artist: - Brown belt Judo working towards black belt (trains once a week) - Brazilian Jujitsu working towards blue belt (trains twice a week) • Other regular activity: a weekly run, one to two hours of squash once a week, strength training at his gym four to five times a week up to an hour a time. Client B is a member of the BASC (British Association Shooting and Conservation),5 he shoots every fortnight and eats what he shoots. • Client B completed a food diary and consecutive physical activity level (PAL) diary for seven days in May 2016. PAL diary revealed that he averages one to three hours of intensive activity per day, divided into two sessions. In those seven days he had one day off training. • Client B was feeling tired after exercise and wanted to have a dietary analysis of his current dietary intake. Dietary aims of sports nutrition6 • Maintain sufficient dietary carbohydrate intake during training and competition: maintain energy balance and maintain muscle glycogen levels. • Maintain sufficient fluid intake, to maintain normal thermoregulatory function during exercise and prevent dehydration, which can reduce physical ability and increase fatigue.

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NUTRITION MANAGEMENT

Client B is a member of the BASC (British Association Shooting and Conservation),5 he shoots every fortnight and eats what he shoots. Photo: with thanks to Tom Sykes photography; wwwtomsykesphotography.co.uk

2 IDENTIFICATION OF NUTRITION AND DIETETIC DIAGNOSIS Client B’s diet summary Over the seven days, Client B’s diet was varied; protein sources were chicken and venison. A variety of dairy sources included cheese, yoghurt, full fat milk and a variety of carbohydrate sources from pasta, potatoes (white and sweet), with different breads and a high fibre breakfast cereal. He consumed no alcohol and no caffeine (apart from the odd chocolate bar). In the seven days no fish or fish products were consumed. His average daily fruit and vegetable portion intake was around three daily, mostly coming from steamed vegetables and salad. He also consumed branch chain amino acids (BCAA) 5gm (three out of seven days) and whey protein powder 25gm (five out of seven days) mixed with either water or milk (the whey protein, milk and water were added to Client B’s dietary intake. BCAA were not added). Using a nutritional analysis programme based on McCance and Widdowson,7 Client B’s average mean daily macronutrients and micronutrients were calculated and compared with his individual requirements. Kilocalories (kcal) - Mean intake of 3,335kcals daily which was within his estimated range of 3,151-4,464kcals.8 Protein - He consumed a mean average of 214gm* of protein daily (averaging 2.3gm per kg). His protein intake daily ranged from the lowest at 92gm (around 1gm per kg) to a maximum intake of 304gm (around 3.3gm per kg). This level was above his estimated calculated requirements of 109gm-154gm (1.2-1.7gm per kg per day).9 His mean average intake of protein provided 26% of his total kcals, when in fact it should be around 15%. As he is a regular shooter of venison and grouse, he is not limited with obtaining animal protein sources. The Manual of Dietetic Practice states that having more than 1.5gm per kg of protein daily may carry health risks, e.g. kidney disease and demineralisation of bone, thus high levels of protein intake should be avoided. *Note that the BCAA were not added. Carbohydrate - He consumed a mean average of 390gm of carbohydrate daily (averaging 4.2gm per kg). His carbohydrate intake ranged from the lowest at 267gm (around 2.9gm per kg) to a higher level of 512gm (around 5.6gm per kg). This level was below the recommendations of sports nutrition: between 50-70% of kcals should come from carbohydrate or 6-8gm per kg per day (546-728gm). His mean average intake of carbohydrates provided 44% of his total kcals. Client B’s diary also showed that there were regularly long gaps between eating, in particular after exercise ranging from three to six hours. Fat - Total mean average fat intake was 112gm which provided 30% of his total kcal intake. Out of the total fat intake, his mean saturated fat intake was 45gm (providing 14% of his total kcals), his trans fat was 2gm (providing 0.6% of total kcals). The average male should aim to have no more than 30g of saturated fat a day and trans fat consumption aiming for less than 2% of total kcal consumption.10 Client B’s diet showed that although his fat % was low at 30%, his saturated fat consumption was higher than the recommended intake for the general population. His trans fat consumption was lower than the recommendations. Fibre - 23gm of non-starch polysaccharide (NSP) and 25gm of Association of Official Analytical Chemists (AOAC) daily fibre consumed from Client B was meeting the daily recommendation from the SACN report 2015, 18gm-30gm daily.11

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Fluid - Client B’s mean fluid intake over seven days was 1,595mls coming from full fat milk and water. His lowest amount of daily fluid intake was 513mls, his highest was 1,857mls. Therefore, some days he was not meeting his fluid requirements, estimated using 8-35mls per kg from A Pocket Guide to Clinical Nutrition, or the recommendation of males, aiming for a minimum of 2,000mls a day.12 Vitamins and minerals - The average mean intake of his vitamins and minerals shown met his required DRVs - RNIs for Client B.13 A dietetic plan was devised to meet the dietetic aims and to suit his lifestyle.

Fig 1: Sports nutrition recommendations = % of 3 macronutrients from total Kcals.

Fig 2: Client Bs average % of macronutrients from total Kcals over 7 days

3 PLAN NUTRITION AND DIETETIC INTERVENTION Client B had an hour-long consultation and the following points were discussed: • Increase carbohydrates and increase the timings of food, in particular carbohydrate foods Client B was often leaving a gap of up to six hours of not eating despite having a high PAL. We discussed the addition of fruit smoothies as an extra snack during the day, which would also increase his fruit intake. Also advised to increase the portions of pasta, potatoes and rice with his meals. Encouraged to monitor weight weekly to ensure weight remains stable. • Fat intake, advised to reduce saturated fat (SFA) Client B’s natural yoghurt was not low fat and a large proportion of his saturated fat came from this, also hard cheese and full fat milk. Advised to change to low fat yoghurt and semi-skimmed milk and add in snacks high in monounsaturated fat, e.g. nuts. Meat choices of grouse and venison contain slightly less saturated fat per 100gm than chicken (SFA gm per 100gm; grouse is 0.8gm, venison is 0gm and chicken is 2.1gm). We also discussed how to look at food labels more clearly in relation to fats. • BCAA and whey protein not required Client B’s average protein intake with the whey protein added was too high, therefore he did not require any BCAA or the whey protein supplements. Portions of protein rich foods reiterated at mealtimes in relation to easing delayed onset muscle soreness (DOMS) around 15-25gm of protein within an hour after exercise can help with muscle recovery.14 The BCAA which he purchased contained various synthetic E numbers, in particular E110 (yellow), E129 (orange) and E133 (bright blue). Although these E numbers have been approved in foods in Europe in small amounts, there continues to be concern that children and adults can suffer from side effects from the stated E numbers, e.g. skin or rhinitis allergies and behaviour changes. However, there is currently not enough strong evidence to show this for everyone, some products do contain a warning on the label. Client B decided to stop the protein supplements. • Increase fluid intake Ideas provided to increase his fluid intake either through a homemade isotonic drink before, during and after intensive activity and or drinking more water/semi-skimmed milk. Fruit smoothies were also encouraged to increase fluid and carbohydrate intake. • Oral health As he was given dietary advice to increase his amount and frequency of carbohydrates and also the usage of isotonic drinks before during and after training, good oral health was actively encouraged.

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NUTRITION MANAGEMENT 4 IMPLEMENT NUTRITION AND DIETETIC INTERVENTION Discussed in the consultation: • Comparisons of dietary intake with recommendations. • Examples of Client B’s newly adapted meal plans. Extra literature was supplied, e.g. portion sizes, snack ideas, labelling information, isotonic recipe and BDA food facts – Fluids.15 5 MONITOR AND REVIEW Client B’s testimony: “After completing the seven-day diet diary, I underwent a consultation session with Claire to discuss the findings, confirm the good points of my diet and highlight areas for improvement. Although I had a reasonable understanding of the importance of protein in sport, carbohydrates and fuelling the body was something I was confused with. Claire was able to talk me through the process using simple scientific explanations and bringing them into context in terms of diet. Claire explained that although I had been consuming sufficient protein, I had been taking insufficient levels of carbohydrates on board, as well as leaving too much time between exercise and eating. “In the following two weeks after the consultation, I have been consuming slow releasing carbohydrates immediately after training or consuming one of my main meals. I have noticed a drop in post-workout fatigue and no longer feel the ‘lull’ in my activity levels which I once had and considered to be normal. Fat intake was also an issue with my diet. I was consuming too much fat from saturated sources and insufficient levels of good fats. Claire listed the many sources of mono-unsaturated fats and what amounts I should try to be consuming on a daily basis (which I now acquire mainly with nuts, seeds and olive oils). This awareness now allows me to analyse food labels more accurately and has allowed for a much healthier balanced diet. “Although I generally consumed sufficient amounts of vegetables, my diet did tend to lack fruit, mainly due to a dislike of texture with some fruits. Claire directed me to some ideas for fruit smoothies incorporating yoghurt and honey. Being full of taste and easier to consume in bottles, I am now consistently reaching my target of five items of fruit and vegetables each day. “Some diet changes can be difficult, others are incredibly easy. One easy example in my case was switching from full fat milk to semi-skimmed milk which allowed me to still obtain the benefits of this protein and calcium source with lower levels of fat than before. As the milk is consumed with breakfast cereal, I haven’t noticed a change in taste at all. “Finally, as well as changes in health, I have noticed small financial advantages to having my diet assessed. I previously purchased Branch Chain Amino Acid supplements to ensure that I was obtaining a sufficient amount of protein each day. Claire calculated that I was already obtaining enough in my diet and with the changes I was to incorporate with her guidance, I would not need any further supplements as the correct levels would come from my diet alone. Another handy financial saving was making my own isotonic drinks at home. Simple, cheap and easy to do, which I otherwise would never have known. “The changes I have made under this professional guidance are not only sensible and achievable, but since I now understand more of the science behind healthy diet plans, I feel more knowledgeable and in control than I have in the past.” 6 EVALUATION Email received June 2017 from Client B: “A year on, I’m feeling far better, as I’ve carried on and kept things consistent. The plan was easy to stick to. I feel I have more energy than I used to before; taking the appropriate carbs on at the right time and being more hydrated has definitely helped. In March, I competed for my Judo black belt and I passed, I had five fights and won all five. The final three fights were all in a row, one straight after the other with no break; this shows how things have improved.”