Amy Stephens

MS, RDN, CSSD, CDCES

Licensed dietitian

specializing in sports nutrition

and eating disorders

Performance

Iron for endurance athletes

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Iron for endurance athletes

Iron levels for athletes

  • By Amy Stephens RDN CSSD
  • Edited by Amy Gregorek

Why iron deficiency is important

Iron is an important nutrient to endurance athletes because it carries oxygen and produces energy. Low levels of iron mean that fewer red blood cells are available to carry oxygen. Oxygen is essential to power muscles and the removal of metabolic waste so the body can function at peak performance. Many studies have reported the prevalence of iron deficiency in endurance athletes to be as high as 50% in females and 30% in males (Koehler 2012, Tan 2012). Although more common in female athletes, male athletes are also at risk for low iron. Often, athletes will report low energy levels or difficulty completing a workout, and later will find it’s iron deficiency. This post will review how iron impacts performance, symptoms of low iron, and how to prevent iron from impacting performance.

Iron for endurance athletes

Stages of deficiency

Dr. Peeling defined stages of deficiency and depletion (2007). What’s interesting about these stages is that iron stores can be depleted while hemoglobin levels remain within normal range. It’s not until stages 2 or 3 of deficiency that an athlete begins to see a performance impact. Before a substantial training block begins, assessing individuals’ risk factors and low iron risk factors is helpful. If an athlete has a drop in iron during a racing season, treatment can take a few weeks, which can have a detrimental impact on the racing schedule. A basic iron assessment contains the following labs:  ferritin, hemoglobin, and transferrin saturation. Your physician can order these tests and a sports dietitian can help interpret them and review best treatment options.  

> Stage 1—Iron deficiency (ID): iron stores in the bone marrow, liver and spleen are depleted (ferritin < 35 μg/L, Hb > 115 g/L, transferrin saturation > 16%). Treat with food first approach by including many iron-rich foods along with Vitamin C.

> Stage 2—Iron-deficient non-anemia (IDNA): erythro- poiesis diminishes as the iron supply to the erythroid marrow is reduced (ferritin < 20 μg/L, Hb > 115 g/L, transferrin saturation < 16%). Initiate iron supplements 65mg elemental iron. Can take 4-12 weeks to show results. 

> Stage 3—Iron-deficient anemia (IDA): Hb production falls, resulting in anemia (ferritin < 12 μg/L, Hb < 115 g/L, transferrin saturation < 16%). When levels are this low, consult with your physician about the cause and best treatment options.  

NOTE:  325 mg ferrous sulfate is equivalent to 65 mg elemental iron.

Risk factors for low iron

There are a variety of factors that contribute to low iron levels. Any one of these risk factors can cause iron levels to drop, and multiple risk factors will carry an even greater risk for low iron. Endurance athletes are at the greatest risk due to the hemolysis from the footstrike and blood loss in the gut while running and sweat.  During a training block, iron can drop 25-40% (McKay).

  • Menstruation for females
  • Underfueling/Low calorie intake (RED-S)
  • Endurance athletes
  • Altitude training
  • Vegan or vegetarian diets  
  • Have a history of low iron stores

Symptoms

Initially, symptoms are not overt, however, you may feel tired overtime or less of a desire to complete a workout. Most common symptoms include:  feeling lethargic, dizzy, negative mood, or poor performance (Sim).

Hepcidin

Hepcidin is a hormone released during exercise that inhibits iron absorption for 3-6 hours after a workout (Sim). This hormone regulates the amount of iron absorbed by the gut. Hepcidin levels are known to elevate 3-6 hours after a workout, thus reducing the amount of iron absorbed from food and supplements.

Iron- rich foods

There are two types of iron-rich foods – heme and non heme sources.  Heme sources are more bioavailable compared to plant-based iron sources. Up to 35% of heme versus 20% iron from plants are absorbed (Beard). An athlete can add a Vitamin C food to further enhance absorption. If iron stores are very low or you are at a higher risk for iron deficiency, you may require iron supplements in addition to dietary intervention. Currently, the RDI for iron men is 8mg and 18 mg for women.

Heme iron 

  • Beef
  • chicken
  • fish
  • turkey

Non-heme 

  • Lentils, beans
  • Chickpeas, hummus (especially if made with tahini)
  • Spinach
  • Apricots, prunes
  • Baked potato with skin
  • Enriched breakfast cereals (Cheerios)
  • Enriched pasta

Click here for a full list of iron-rich foods from the USDA database.

Sample meal ideas

Grilled chicken over rice with roasted red peppers.

Turkey sandwich on whole wheat bread with an orange.

Spinach salad with chickpeas, dried apricots, and lemon vinaigrette dressing.

Key points

Iron is an important nutrient involved with energy production and promoting oxygen uptake. Iron deficiency can negatively impact performance in athletes by reducing oxygen transferred to the cells and making the body work harder to produce energy.

Females, vegetarians, calorie-restricted diets (RED-S), endurance athletes and training at altitude increase the risk for low iron.

Symptoms of iron deficiency include fatigue, negative mood and poor performance.

Hepcidin is a hormone that reduces iron absorption for 3-6 hours following a workout. The best time to take an iron supplement or eat an iron rich meal is outside this window.

Best food sources of iron include meat, fish, poultry, dark green leafy vegetables. Combine iron rich foods with Vitamin C to enhance absorption.

Certain foods will compete with iron absorption, such as calcium and phytates.  

Speak with your physician or sports dietitian to help assess and treat iron deficiency.

References

Beard J, Tobin B.  2000. Iron status and exercise. Am J Clin Nutr. 72 (2):594S-597S.

Coates A, Mountjoy M, Burr J. Incidence of iron deficiency and iron deficient anemia in elite runners and triathletes. Clin J Sport Med. 2016.

Koehler K, Braun H, Achtzehn S, Hildebrand U, Predel H-G, Mester J, Schänzer W (2012) Iron status in elite young athletes: gender- dependent influences of diet and exercise. Eur J Appl Physiol 112(2):513–523

McKay, AKA, Peeling P, et al.  (2019a) Chronic adherence to a ketogenic diet modifies iron metabolism in elite athletes.  Med Science Sports Exercise.  51(3):548-555.

​​McKay et al. Iron metabolism: interactions with energy and carbohydrate availability. Nutrients. 2020 Nov 30.12(12); 3692

Ostojic SM & Ahmetovic Z. Weekly training volume and hematological status in female top-level athletes. Ahmetovic Journal of Sports Medicine and Physical Fitness; Sep 2008; 48, 3; ProQuest Nursing & Allied Health Source pg. 398

Peeling P, Blee T, Goodman C, Dawson B, Claydon G, Beilby J, Prins A (2007) Effect of iron injections on aerobic-exercise perfor- mance of iron-depleted female athletes. Int J Sport Nutr Exerc Metab 17(3):221–231

Sim et al. Iron considerations for the athlete: a narrative review. Eur J Appl Physiol. 2019 July; 119(7):1463-78

Tan D, Dawson B, Peeling P (2012) Hemolytic effects of a football-specific training session in elite female players. Int J Sports Physiol Perform 7(3):271–276

USDA database for iron rich foods

How to Restore Your Period as an Endurance Athlete

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How to Restore Your Period as an Endurance Athlete

  • By Amy Stephens RDN CSSD
    NYU Track & Field
  • Sara Fischer, Intern
    Track athlete at Hamilton College

Athletes burn tons of extra calories each day because of the high demands of their training. If their nutritional needs are not being met, they may be underfueling. For female athletes, underfueling poses a high risk for secondary amenorrhea, which is defined as the absence of three or more periods in a row by someone who has had periods in the past. It can lead to a variety of other health issues, specifically impacting bone health and lowering immunity. Unfortunately, secondary amenorrhea is extremely common in female runners. The good news is, it is possible for an athlete to regain their menstrual cycle and potentially reverse the effects caused by secondary amenorrhea. But how? 

The short answer is simple: exercise less, and eat more.  

The long answer is that it isn’t so simple for athletes. Many athletes may feel that they have no chance at regaining their menstrual cycle, because their lifestyle directly goes against the baseline rule of exercising less and eating more to restore their period. Additionally, some athletes may fear weight gain despite the fact that it may be necessary for them to restore their cycle. However, secondary amenorrhea is reversible, and here are 5 ways in which an athlete can make small changes in order to restore their period:

  1. Increasing Calories – Secondary amenorrhea is caused by a prolonged caloric deficit. The most important thing an athlete must do to restore their menstrual cycle, is to increase their caloric intake. It does not need to be a major lifestyle change or a completely new diet, adding in 1-2 nutritionally dense snacks every day might even do the trick. Adding between 350-450 calories per day above energy requirements, may be enough to restore an athlete’s menstrual cycle (Ciadella-Kam et al., 2014). However, if you are substantially under nourished, your body may require a higher level of calories to meet nutritional needs.

  2. Timing of Fueling – No matter what time of day it is, refueling as soon as possible after a run or a hard workout is essential for your body to properly recover. It is best to eat a snack or a meal within 30 minutes of finishing a run, to kickstart replenishing your glycogen stores. Additionally, eating as soon as possible after a workout is a great way to replenish the calories expended during the training session. By refueling, you are preventing your body from falling into a prolonged calorie deficit, thus supporting the goal of avoiding a caloric deficit for restoring the menstrual cycle.

  3. Dialing Back Training – Studies show that reducing exercise intensity restores estrogen production and hormonal balance. It may be beneficial for an athlete to dial back on their training, if they are struggling to regain their menstrual cycle after a period of time. However, there are some athletes that can restore their period by making nutritional changes, and continuing their normal training pattern. Focusing more on food timing around workouts may be supportive to athletes who need to be training year round.

4. Increasing Healthy Fats – Healthy fats supply the building blocks for female hormone production in the body. Increasing healthy fats when in secondary amenorrhea recovery supports the production of estrogen, progesterone, and healthy brain tissue. Healthy fats also support overall nutrient absorption, so consuming healthy fats allows your body to make the most out of all the other food you eat, ensuring that you are absorbing all the nutrients you need. Some easy ways to increase healthy fats can be from foods like full fat dairy products, avocados, fish, nuts and nut butters, seeds, and cooking with olive oil.

5. Necessary Weight Gain and Increasing Body Fat – It is a common misconception among runners and other athletes that being thinner will improve performance. This is not true, and in fact having a body fat percentage that is too low can be dangerous. For menstrual health, body fat is crucial. Women that have a low BMI (body mass index) are producing less estrogen, which can lead to secondary amenorrhea. While everybody is different, and using BMI may not be an accurate representation of what is healthy versus what is not, if an athlete has a low BMI as a result of extremely demanding training as well as a calorie deficit, it is not healthy. This is especially the case if they suffer from secondary amenorrhea. If you have lost your menstrual cycle, even if you are not necessarily “underweight” as understood by the BMI scale, you may be at an unhealthy bodyweight for YOU. Gaining some essential body fat will support hormone health by aiding the production of estrogen, allowing your body to regain its menstrual cycle.

6. Shift away from the diet mindset – Deliberately limiting your food or food intake with the aim of losing weight can lead to changes in your metabolism and hormone balance. Ensure that you eating enough to sustain your physical activity and promote recovery. Seek guidance from a sports dietitian expert to accurately assess your nutrition requirements and create a well-balanced meal plan.

7. Pay attention to your body’s hunger cues – Feeling hungry is a sign that your body needs food. By ignoring hunger cues, your body’s natural rythms can become imbalanced. When you feel hungry, opt for a nutritious meal or snack to address your body’s needs.

 

In addition to misinformation regarding the effects and severity of amenorrhea in athletes, it is also common for people to believe that going on birth control will fix these issues. While the birth control pill can produce a “period” it’s actually a withdrawal bleed. It’s not a natural period where your body has enough nutrients to produce hormones. A withdrawal bleed is not a real period and it doesn’t indicate you are in calorie balance.

Your physician may suggest that, as an athlete, it’s ok to miss your period. As mentioned, losing a period is not healthy and indicates an imbalance with nutrition and exercise that requires attention. Prolonged amenorrhea can have long-term effects on bone health.

Ultimately, there is no formula for restoring your period. Everybody is different, and some methods may work better than others. Additionally, some people may regain their periods faster than others, but this does not mean that you should stop trying. Small changes over time build up, and eventually by using these tips you can restore your period and continue becoming the strongest and healthiest athlete you can be. 

Reach out to an informed physician or  sports dietitian who can provide additional guidance about restoring your cycle.



References

Cialdella-Kam, L.; Guebels, C.P.; Maddalozzo, G.F.; Manore, M.M. Dietary Intervention Restored Menses in Female Athletes with Exercise-Associated Menstrual Dysfunction with Limited Impact on Bone and Muscle Health. Nutrients 2014, 6, 3018-3039. 

 

De Souza MJ, Mallinson RJ, Strock NCA, Koltun KJ, Olmsted MP, Ricker EA, Scheid JL, Allaway HC, Mallinson DJ, Kuruppumullage Don P, Williams NI. Randomised controlled trial of the effects of increased energy intake on menstrual recovery in exercising women with menstrual disturbances: the ‘REFUEL’ study. Hum Reprod. 2021 Jul 19;36(8):2285-2297.

 

Hackney AC. Menstrual Cycle Hormonal Changes and Energy Substrate Metabolism in Exercising Women: A Perspective. Int J Environ Res Public Health. 2021 Sep 24;18(19):10024.

 

Ihalainen JK, Kettunen O, McGawley K, Solli GS, Hackney AC, Mero AA, Kyröläinen H. Body Composition, Energy Availability, Training, and Menstrual Status in Female Runners. Int J Sports Physiol Perform. 2021 Jul 1;16(7):1043-1048.

ENERGY BARS AND BITES​

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ENERGY BARS and BITES

  • By Amy Stephens RDN CSSD Sports Dietitian, NYU Track and Field
    Sara Fischer, Intern, Collegiate Runner

Athletes have high energy demands, and it can be difficult to meet these needs with meals alone. Energy bars and bites are a great way to offset hunger and fill in gaps between meals. Together with my intern, Sara, we created a list of energy bars and bites that we personally enjoy. These recipes can be easily prepared as a convenient way to meet nutritional needs.

Chocolate Peanut Butter Bites

 

Ingredients:

Directions:

  1. Combine all ingredients (except chocolate chips) in a food processor and pulse until well-mixed. If you don’t have a food processor, use instant oats.
  2. Add 2-3 Tbsp water to hold the mixture together.
  3. Remove from the food processor and stir in mini chocolate chips.
  4. Scoop mixture and roll into balls. Freeze until solid and store in the freezer or refrigerator.

 

 

 

Mint Chocolate Bites

Ingredients:

  • 1 cup rolled oats
  • 1 1/4 cups Medjool dates — softened and pitted (about 10 dates)
  • 1/2 cup peanut butter
  • 3 tablespoons mini chocolate chips
  • 1 tablespoon chia seeds  (optional)
  • 1 tablespoon ground flaxseed
  • 1/8 teaspoon salt
  • 3 tablespoons cocoa powder
  • 2-3 Tbsp water

Directions:

  1. To soften dates, leave in water for 10 min or add to boiling water for 5 min.
  2. Place the dates in the bowl of a food processor and pulse several times until the dates break into small bits and form a ball that sticks to the side of the bowl. 
  3. Add the oats, peanut butter, and salt. Pulse until the mixture is broken down and in small pieces but not completely smooth. Add the cocoa powder and pulse to combine. At this point, the dough will look like crumbs. Add 2-3 tablespoons of water until the mixture forms a paste. 
  4. Scoop some into your hand and press to roll it into a ball, it should hold together easily. If it seems too dry and isn’t holding together, add a little peanut butter; if it’s too sticky, add a few more oats. (The amount you need may vary based upon the brand of peanut butter you use and the moisture of the dates.)
  5. Roll the dough into balls of your desired size (I did slightly over 1 inch and ended up with 14 energy balls). 
  6. Place in the freezer or refrigerator to harden.

Energy bar 

Inspired by wellplated

Ingredients:

Directions:

    1. Line an 8×8- or 9×9-inch baking pan with parchment paper, leaving an overhang on two sides like handles.
    2. Place the peanut butter, honey, and coconut oil in a medium heatproof bowl. Set the bowl over a saucepan of water and bring the water to a simmer over medium to medium-high heat. (Do not let the water boil, and make sure the water does not touch the bottom of the mixing bowl.) Stir and heat until the mixture is smoothly combined. Remove the bowl from the saucepan and turn off the heat
    3. Add the oats, protein powder, flaxseed, cinnamon, and salt to the bowl with the peanut butter mixture. Stir to combine. The mixture will seem very dry at first but will come together as you stir. It won’t be sticky but should hold together when pressed.
    4. Fold in the chocolate chips or cranberries. (If the mixture is still fairly warm, pop the bowl into the refrigerator for a few minutes to let it cool. Cooling the mixture will prevent the chocolate from melting. Don’t worry if they do melt a little—the bars will still be delicious!)
    5. Press evenly into the prepared pan and refrigerate for 1 hour or until firm.

    6. Lift the bars from the pan using the parchment handles and transfer them to a cutting board. Slice into bars as desired and enjoy.

Pumpkin energy bites 

Inspired by pinchofyum

Ingredients:

  • 2 cups oats
  • 1/2 cup canned pumpkin puree
  • 1/4 cup almond butter or peanut butter
  • 1/4 cup chia seeds
  • 1/4 cup pumpkin seeds
  • 1 teaspoon vanilla extract
  • 1/2 teaspoon cinnamon (optional, see notes)
  • 1/2 cup maple syrup or honey
  • generous pinch of salt
  • 1/2 cup dark chocolate chips

Directions:

  1. Pulse all ingredients (except chocolate chips) in a food processor until well-mixed.
  2. Add chocolate chips and pulse a few more times until they are in small pieces.
  3. Scoop mixture and roll into balls. Freeze until solid and store in the freezer or refrigerator.

Energy Bites By Sara Two Ways

IG  @eatzbysara 

Coconut Cashew Energy Bites

Ingredients:

  • 1 cup oats
  • ½ cup cashew butter
  • ¼ cup honey
  • 1 cup shredded coconut
  • Optional: 2 tbsp vanilla protein powder

Maple Cinnamon Energy Bites

Ingredients:

  • 1 cup oats
  • ½ cup almond butter 
  • ¼ cup maple syrup
  • 2 tbsp chia seeds
  • *(for this recipe I recommend Justin’s Maple Almond Butter for flavor)*

Directions for both recipes:

  1. Mix all ingredients together in a large bowl
  2. With your hands, roll the mixture into balls (you can make them any size you like, I usually make them about 1-2 inches in diameter. This way, the recipe yields about 12-15 bites.



NYC MARATHON NUTRITION PANEL​

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NYC marathon nutrition panel

  • By Amy Stephens RDN CSSD, Sports Dietitian for NYU Track and Field

If you’re a marathon runner, you’ll appreciate this presentation. On July 16th, 2023, I was invited to participate in the NYC Marathon nutrition panel hosted by NYRR. We covered a lot of important topics for runners such as: hydration, fueling, gear, and how to prevent hitting the wall. There were over 1,000 individuals on live stream and 50 attended at the NYRR Run Center. Below is the YouTube link for the full talk. 

How Social Media Affects Athletes

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How social media affects athletes

  • By Amy Stephens RDN CSSD
    Sara Fischer, Intern
  • Edited by Amy Gregorek

Social media can be a great place for athletes to connect with other athletes, share content about their own journeys, and follow their favorite pros. However, social media can also become a toxic environment for those who are not cognizant of its impact.

 

  • Social media can be a catalyst for negative thoughts about body image, caused by comparison to others. It is impossible to  know whether an account owner is editing their photos, posing in a certain way, or the relationship they have with their own bodies. With that said, comparison to others on social media often becomes an unavoidable truth.
  • Creators may use social media as an outlet to spread information or advice on topics like training, nutrition, and “tips for athletes” despite not always being licensed professionals. It is important to consume  information written by professional, credible sources because the viral wellness tips or popular hashtags shared online can be polluted with misinformation. For an innocent scroller, differentiating the two can be challenging.
  • Social media may cause an athlete to think their own wins are not good enough. For example, a runner may feel proud of themselves for running 6 miles without stopping, and then they may open Instagram and see that another runner ran 7 miles at a faster pace, and their pride can turn into disappointment.
  • Social media promotes quick fixes. Too often athletes get caught up in looking for the easy and fast route, whether that be to heal an injury or improve their performance. If something online looks easy, it probably isn’t true.
  • Social media platforms provide medical advice for various symptoms often obtained from unreliable sources. This poses a significant risk to consumers and hinders an athlete from seeking a thorough evaluation by a qualified medical professional. Relying on untrustworthy information can impede and delay a timely delivery of care. 

Where should athletes get their information?

  • Injury recovery/Diagnosis: Their own medical doctor (MD), physical therapist (PT) or coach 
  • Fueling/Nutrition: Registered Sports Dietitian/Nutritionist who focus on fueling for performance
  • Training plan/lifting plan: Directly from their coach, physical therapist, or athletic trainer 

*Make sure the person providing advice has training in the specified area.

How to use social media in a positive way?

Be a conscious consumer! Seek out accounts that promote a positive body image and convey positive messages. If certain posts spark feelings of dread, sadness, or uneasiness, it may be beneficial to unfollow those accounts. 

Be skeptical when it comes to products and services endorsed by influencers lacking relevant education or expertise in the field. It’s important to remember that their primary goal is to sell a product or service. They may present the product in an appealing manner to achieve that objective. 

There is no supplement, powder or pill that will help you perform better. The key is to follow a well-balanced diet, prioritize recovery, and follow a suitable training plan.

How To Eat If You Are Training for a Marathon

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How To Eat If You Are Training for a Marathon

  • By Amy Stephens RDN CSSD
    Sara Fischer, Intern

The way you nourish your body is equally important as your training and strength exercises. As a sports nutritionist based in NYC, I frequently encounter questions regarding dietary recommendations for individuals preparing for a marathon. In collaboration with my intern, Sara Fischer, we have developed this guide specifically tailored to individuals participating in the NYC marathon or any fall marathon, providing valuable insights on how to fuel your body leading up to the 26.2-mile journey.

What to eat

CALORIES:

  • It is important for runners to eat a well rounded, nutrient rich, balanced diet. First and foremost, runners need to ensure they are eating enough calories. Because running requires a lot of energy, it is extremely important that runners are in an energy balance to prevent underfueling. Underfueling leads to serious health effects. 

Energy requirements are not static throughout a marathon training block. As the training volume intensifies, higher levels of nutrients become essential. The energy demands may be less on recovery days, but it is equally important to continue fueling to restock glycogen and repair muscle tissue. 

A common mistake is to underfuel on recovery days. Recovery days require an adequate amount of nutrients to help the body recover for the next workout. Energy is required for cross-training, daily activities such as attending work or class, errands, or commuting. It’s possible that you may not require as many snacks during these lower intense periods.

CARBOHYDRATES:

Runners need to focus on a carbohydrate rich diet. If you are training for a marathon, you are spending most of your time either recovering from a run, or preparing for another one. Since running requires glucose from the bloodstream, your body is in need of carbohydrates to replenish those glycogen stores after workouts. Runners should aim for 60-70% of their calories from carbohydrates. 

Over time, with adequate carbohydrates, the body gradually increases the amount of glycogen that can be stored in muscles and liver. Proper fueling throughout training can increase your overall glycogen storage capacity. Glycogen is one way to help prevent “hitting the wall”. This occurs when runners have not properly trained, run too fast on race day or under fuel on race day.

In order to maximize glycogen stores, runners should aim to consume 7-10 grams of carbohydrates per kilogram of body weight, daily. The average runner should aim for 475-700 g/day. This can be met by eating carb-rich meals spread into three meals plus two-to-three snacks.

PROTEIN:

Protein is broken down into amino acids which are essential for building and repairing damaged tissue. Eating protein throughout the day is also helpful to maintain the immune system and prevent muscle breakdown. Eating too much protein can displace other important nutrients that are necessary to optimize sports performance. Aim for 1.5-1.7 grams protein/kilogram which is about 20-30 grams with meals and 10-15 grams for snacks.

HEALTHY FATS:

It is crucial that runners include healthy fats in their diet. Healthy fats are necessary to absorb fat soluble vitamins, they help to lower injury risk, and regulate energy levels. Healthy fats are a great source of omega-3’s which have been shown to reduce inflammation. In order to keep the diet balanced, aim for approximately 20-30% of calories from fats.

VITAMINS:

Runners need to make sure they are giving their bodies adequate vitamins. Vitamin D and Calcium are particularly important for bone health, specifically reducing the risk of stress fractures. Iron is important to keep you energized. Iron deficiency can lead to decreases in performance. B vitamins are essential to energy production.

How to eat around your workouts

Before a run, especially if the run is 60 minutes or longer, your body will need fuel beforehand. Your pre-run snack should be rich in carbohydrates, and eaten at least 30 mins to an hour before you head out. Avoid high fiber foods as they are difficult to digest and may lead to discomfort during the workout.

  • Pre-run snack examples include a banana, toast with peanut butter, homemade energy balls, dates, dried fruit, granola bar or Clif bar.

For runs lasting less than 60 minutes, fueling is optional. If you experience hunger, consuming snacks and fluids can be beneficial for sustaining energy levels.

For a run lasting longer than 90 minutes, your body might need additional carbohydrates. Your body processes approximately 60g carbs per hour of exercise, so during these longer sessions you will need to start fueling within 45 minutes, and continue to consume 30-60g carbs/hour for the duration of the run. 

  • You can accomplish this by eating things like energy gels, easy-to-eat dried fruit, go-go squeeze applesauce, or even gummy bears. You can also put a spoonful of honey mixed with something like coconut water into your water bottle to make a carb and electrolyte rich sports drink.

After a run, your body needs to replenish its glycogen stores. Refuel after runs by eating a balanced meal or snack high in protein and carbs. It is best to eat this within 30 minutes to an hour of finishing a run, so that you can kick start the recovery process and be ready to go for your next session. Prioritize recovery food especially on tough workout days or if you are planning a double workout session.

How to hydrate

  • Hydration requirements are individualized. Sweat rates depend on many factors such as: genetics, gender, heat acclimation, exercise intensity, humidity, etc. A sweat test is a great way to determine individual sweat rates. 
  • Easy runs: 1-2 hours before your run, drink 10-20oz of water. During your run, it is your choice whether you want to sip on water throughout. After your run, replenish the lost fluids with 35-70 oz of water with electrolyte. Take note of your hydration level prior to running. If you begin your workout in a dehydrated state, you will need to consume fluids regardless of the duration. Additional fluids will aid in replenishing lost fluids from previous workouts and prevent further dehydration.
  • Long runs/tempos: 1-2 hours before your workout, drink 10-20oz of water. During your run, drink 4-8oz of water every 20 minutes, with electrolytes. After your workout, replenish the fluids with 35-70 oz of water with electrolytes.

References

Burke L, Hawley J, Wong S & Jeukendrup A.  Carbohydrates for training and competition, J Sp Sc, 2011. 29:sup1, S17-S27.

Coyle, E. F. Fluid and fuel intake during exercise. J Sp Sc 2004. 22: 39–55.

Jeukendrup, A. E. and Chambers. Oral carbohydrate sensing and exercise performance. Current Opinion in Clinical Nutrition and Metabolic Care, 2010. 13: 447–451.

Sawka MN, et al. American College of Sports Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007. 39(2):377-90.

Eating Disorders in Athletes: Impact on Performance

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Eating Disorders in Athletes: Impact on Performance

  • By Amy Stephens RDN CSSD
  • Edited by Amy Gregorek

Eating disorders affect an athlete both mentally and physically and have significant impacts on performance. This blog will discuss the prevalence of eating disorders, identify warning signs in athletes, distinguish the differences and similarities to relative energy deficiency syndrome (REDS), and provide resources for those struggling to seek help. Eating Disorders are a  serious issue for everyone, but especially for athletes. Nutrition requirements are high and the inability to fuel an athlete’s body will lead to worsening of disordered eating, injuries, and overall decline in performance. 

The most common forms of eating disorders are anorexia, bulimia and binge eating disorder. Anorexia refers to restriction of food and refusal to meet nutritional needs, typically resulting in extreme weight loss. Bulimia is defined by consuming a large quantity of food in a short period of time, followed by a desire to “get rid” of the food through vomiting, exercise, or medications. Often, athletes can have a combination of both. Binge eating disorder is another type of eating disorder characterized by consuming a large quantity of calories in a short period of time. In one study, up to 84% of athletes were found to have subclinical disordered eating, and engaging in maladaptive eating and weight control behaviors, such as binge eating, excessive exercise, strict dieting, fasting, self-induced vomiting, and the use of weight loss supplements (Chatterton, Clifford). Evaluation by a physician or therapist can determine the severity and  best form of treatment.

Eating disorders do not discriminate as they affect all races, genders, and socioeconomic classes.  Some populations have higher rates of eating disorders. Eating disorders are most commonly screened and diagnosed between the ages 12-19, but can occur at any age. The earlier an athlete is diagnosed, the more likely they are to recover and reverse any damage to their bodies. The longer an eating disorder behavior is untreated, the more difficult the treatment and full recovery become.

Prevalence

  • 13.5% of athletes struggle with an eating disorder (Ghoch).
  • Up to 45% of female athletes and 19% of male athletes struggle with an eating disorder (Bratland-Sanda)
  • In a study by Petrie, 19.2% of athletes surveyed had maladaptive eating behaviors such as restricting food intake, limiting food choices, excluding large groups of foods, and purging behavior.

Risk factors for developing eating disorders in athletes

Certain sports that are weight dependent and focus on leanness pose a bigger risk for eating disorders. Both male and female athletes are at risk.

In addition, athletes who have recently undergone stressful events such as an injury are at a greater risk for developing an eating disorder. Athletes who have been struggling with poor performance might want to restrict food and blame the body.

 

There are additional societal contributions that can lead to eating disorders. It’s important to be aware of these factors so proper education for athletes and coaching staff can help prevent disordered eating among athletes.

Societal contributions include:

  • A fixation on thinness and the need to have a certain appearance in order to be happy or successful
  • Social media’s tendency to reinforce negative body image by giving attention to overly thin athletes
  • Restrictive diet plans promoted by ill-trained professionals
  • Society’s fixation on toxic positivity and the need to seek perfectionism to achieve one’s goals 

All of these practices promote unhealthy relationships with the body and eating patterns. Athletes are no exception. Weight dependent sports not only encourage unhealthy dietary practices, but reward them. The thinner athletes promote themselves as having reached their performance levels due to their thin body type. Misinformation from friends, coaches, and media can cause an athlete  to try and achieve an inappropriate level of thinness that causes physical and mental harm to their body. Eating disorders are often overlooked if the athlete is performing well. 



Difference between eating disorders and Relative Energy Deficiency Syndrome (RED-S)

Relative Energy Deficiency Syndrome (REDS) is a new classification of symptoms identified in 2014 by International Olympic Committee Mountjoy. REDS is characterized by low calorie intake in relation to energy exerted during exercise. REDS was formerly named “The Female Athlete Triad Syndrome because it affected three key systems in the female body:low calorie intake, menstrual irregularities, and lowered bone density. The term REDS is new but the condition has been in existence for a long time. Simply put, exercising too much and not eating enough causes an imbalance in which the body cannot function at optimal levels. What’s most interesting to me is that someone with REDS can be any body weight. The difference between REDS and an ED is that REDS is an unintentional mismatch of calories. Once an athlete with REDS is evaluated and educated about an appropriate amount of calories to sustain daily exercise and body functions, the deficit is corrected and the body can function properly. ED is further explored if the athlete is unable to willingly consume calories to support energy expenditure.

Sometimes it may not be obvious or easy to diagnose REDS or eating disorders. Someone can be a normal weight but is exercising too much and refueling inadequately. In this instance, athletes may feel that they are eating well, but in truth, are not eating enough calories to support exercise.

Signs of chronic underfueling that warrant further screening to determine if disordered eating is present

  • Females – change in menstrual cycle, can be longer or lighter periods, it is NOT normal for a female athlete to miss a period

  • Males – low testosterone and growth hormone. Both are natural performance enhancing hormones made by the body. Low levels can negatively affect sport performances, muscle growth, and energy production. Also important for serotonin uptake for the brain, it can lift mood. (Skolnick)

  • Hormonal changes can lead to stress fractures and ultimately osteoporosis

  • Frequent injuries to bones and soft tissues

  • Isolated, eats alone

  • Withdrawn behavior

  • Sudden changes with diet or food choices

  • Noticeable fluctuations in weight, both up and down

  • Irritability

  • Lethargy, difficulty finishing a workout

  • Digestive issues such as bloating (often mistaken for IBS), gas, diarrhea (this is often worsened by further restricting suspected nutrients)

  • Decrease in sports performance

  • Difficulty sleeping

  • Not seeing improvements in performance despite increasing workouts

  • Depressed immune system

  • Decreased cognitive functioning (lower blood sugar supplied to brain)

Treatment

Treatment often begins with an evaluation by a physician, eating disorder dietitian, and therapist. Once the patient is evaluated, they are recommended to the best form of treatment depending on their situation. The dietitian will create a plan that provides adequate calories to support daily expenditure. It can be challenging to find the right physician to help especially since there are differing opinions among professionals. In my experience, missing a period leads to complications related to menstrual cycle and bone growth. It is important to  let your doctor know if you’ve lost your period for more than three months as this can be related to underfueling or the result of underlying medical conditions. Your doctor can help guide you to the best treatment approach.

Resources for help

There are many resources to help. If you or someone you are close to might have an eating disorder, here are some important resources that can help:

    • Visit your doctor and explain why you are concerned. Be sure to ask if your doctor works with eating disorders.
    • For college athletes, visit your health center and explain why you are concerned. The health professionals can conduct proper screenings and assessments.
    • Seek out a sports dietitian (ask if they have experience with eating disorders)
    • See a school psychologist
    • If you think you have an eating disorder, speak to a trusted family member or friend and share your concerns. Eating disorders are isolating so speaking out is a step in the right direction.
    • Seek out supportive teammates and coaches and share your eating concerns. They can help you locate the best resources for an evaluation and assessment.
    • National Eating Disorders Hotline (NEDA) 1-800-931-2237

 

  •  

References

Bratland-Sanda S, Sundgot-Borgen J. (2013). Eating disorders in athletes: overview of prevalence, risk factors and recommendations for prevention and treatment. Eur J Sport Sci, 13(5):499-508.

Chatterton, J. M., & Petrie, T. A. (2013). Prevalence of disordered eating and pathogenic weight control behaviors among male collegiate athletes. Eating Disorders, 21(4), 328-341.

Clifford, T., & Blyth, C. (2018). A pilot study comparing the prevalence of orthorexia nervosa in regular students and those in university sports teams. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, 24(3), 473-480.

Conviser, J. H., Schlitzer Tierney, A., Nickols, R. (2018). Essential for best practice: treatment approaches for athletes with eating disorders. J of Clin Sports Psych, 12.

Ghoch, M. E., et al. (2013). Eating disorders, physical fitness, and sport performance: a systematic review. Nutrients, 5:12.

Mehler, P.S., Sabel, A.L., Watson, T. and Andersen, A.E. (2018). High risk of osteoporosis in male patients with eating disorders. Int. J. Eat. Disord, 41: 666-672.

Mountjoy M, Sundgot-Borgen JK, Burke LM, et al. (2018). OC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Brit J of Sports Med, 52:687-697.

Petrie, Trent, Greenleaf, Christy,  Reel, Justine, Carter, Jennifer. (2018). Prevalence of Eating Disorders and Disordered Eating Behaviors Among Male Collegiate Athletes. Psych of Men & Masculinity, 9: 267-277.

Scott CL, Plateau CR, Haycraft E. (2020). Teammate influences, psychological well-being, and athletes’ eating and exercise psychopathology: A moderated mediation analysis. Int J Eat Disord, 53(4):564-573.

Shufelt CL, Torbati T, Dutra E. (2017). Hypothalamic Amenorrhea and the Long-Term Health Consequences. Semin Reprod Med, 35(3):256-262. 

Skolnick A, Schulman RC, Galindo RJ, Mechanick JI. (2016). The endocrinopathies of male anorexia nervosa: case series. AACE Clin Case Rep, 2(4):e351-e357.




Hydrating in heat and humidity

by

Hydrating in heat and humidity

  • By Amy Stephens RDN CSSD
  • Edited by Amy Gregorek

Water is the forgotten nutrient

Exercise produces heat and leaves the body as sweat to stay cool. Studies have repeatedly shown that losing more than 2% body weight impacts performance (James). More sweat is produced when the temperatures are higher or when humidity is high. Dehydration results in an increase in one’s core temperature, reduced cardiovascular function and imparied exercise performance.

Essentially, dehydration increases an athlete’s perceived effort and reduces the ability to continue exercising at a high level (Nybo). If you’re overheating, the body will prioritize cooling itself versus rapid energy production (James).

Role of sweat

During exercise, the body produces heat and energy. Sweat is the body’s built-in cooling system that enables the body to make more energy. In warmer temperatures, exercise raises core temperatures at a faster rate which require more water expelled through the skin to keep the body cool. As temperatures increase, our bodies respond by sweating more. However, humidity compounds this problem by preventing evaporation. In situations where humidity levels are high, as we experience on the east coast all summer long, there is more moisture in the air and the sweat does not evaporate. As a result, the body’s core temperature increases, making exercise seem harder.

Dehydration affects performance

Many studies have shown that a 2% loss in body weight will impair performance (Lewis). The body has to work harder to keep the heart pumping to produce energy and muscles firing. Not only does it feel harder when you are dehydrated, but your body is also producing energy at a slower rate.

As core temperatures increase, energy metabolism shifts from aerobic production to anaerobic and this causes a buildup of anaerobic by-products that stimulate fatigue.  This process occurs at a faster rate in hot and humid conditions.  Fuel source shifts from fatty acids to glucose and amino acids and creates more hydrogen and lactic acid (Burke 2015). The heart receives less blood and therefore, less oxygen is delivered to working muscles. This makes exercising even more difficult in warmer conditions. Muscles have a harder time contracting when they’re overheated and premature fatigue can set in (Nybo).

Cramping

If you lose too much water, the risk of cramping is increased. Humidity increases risk of dehydration which causes an imbalance of electrolytes, especially potassium, magnesium and sodium. These electrolytes are lost at high levels through the skin and have a significant impact on cramping (Jung).

Symptoms of dehydration

  • feeling thirsty
  • lightheaded
  • fatigue
  • dry mouth
  • urinating less often
  • infrequent, dark colored urine

Dietary recommendations in the heat

Fluid requirements are individualized. Establish your sweat rate by using a sweat test to better estimate the amount of sweat you lose in one hour of exercise. Once you know how much fluid your body loses, you can more precisely match your fluid requirements. Estimate fluid losses by using a sweat rate calculator to input your weight and fluids. Calories do not need to be increased when exercising in heat (Burke).

  1. Start drinking fluids when you wake up. Have a glass of water before you drink coffee!
  2. Before exercising, urine should be a pale yellow color.
  3. Exercise in the beginning or end of the day when it’s cooler
  4. Don’t chug water without electrolytes, this can lead to hyponatremia.
  5. You will rehydrate faster when fluids contain electrolytes and carbohydrates. This helps stimulate thirst and retain fluids consumed (Baker & Jeukendrup 2014).

Hyponatremia is caused by drinking too much water and not enough electrolytes. Make sure to have salt or nuun tablets handy. Water follows electrolytes and when you sweat, you lose both!

The color of your urine is the best indicator of hydration. Aim for pale yellow, shade 1 or 2 on the chart is ideal. Clear urine can indicate fluid overload and hyponatremia. If your urine is dark yellow before a run, delay the start until you can drink more fluids.

References

Baker & Jeukendrup. Optimal composition of fluid replacement beverages. Comp Physiol. 2014;4:575-620.

Burke L. Nutritional needs for exercise in the heat. Comp Biochem Physiol Mol Integr Physiol. 2001; 128: 735-48.

Burke L. Clinical Sports Nutrition, 5th edition. 2015.

Cory M, et al. Resistance training in the heat improves strength in professional rugby athletes. Sci Med in Football. 2019;3:198–204.

James LJ, et al. Does Hypohydration Really Impair Endurance Performance? Methodological Considerations for Interpreting Hydration Research. Sports Med. 2019 Dec;49(Suppl 2):103-114.

Jung A, et al. Influence of Hydration and Electrolyte Supplementation on Incidence and Time to Onset of Exercise-Associated Muscle Cramps. J Athl Train. 2005; 40: 71–75.

Lewis J, et al. Does Hypohydration Really Impair Endurance Performance? Methodological Considerations for Interpreting Hydration Research. Sports Med. 2019;49:103-114.

Nybo & Sawka. Performance in the heat physiological factors of importance for hyperthermia-induced fatigue. Compr Physiol 2014;4:657-89.

Lau W, et al. Effect of oral rehydration solution versus spring water intake during exercise in the heat on muscle cramp susceptibility of young men. J of the Intl Soc of Sp Nutr. 2021; 18 (1).

optimize health and performance

Amy Stephens, MS, RDn, CDces, CSSD

Licensed dietiTian

specializing in sports nutrition and eating disorders

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