ROLE OF NUTRITION IN INJURED ATHLETES

Transcription

1 ROLE OF NUTRITION IN INJURED ATHLETES PRESENTED BY: ALEX TAN SPORTS DIETITIAN NATIONAL SPORTS INSTITUTE OF MALAYSIA Management of Sports Injury Conference 2016 (Pre Sea Games Training)

2 OUTLINE Importance of nutrition to athletes Objective of nutritional management for injured athletes Stages of injuries Nutritional recommendation for different stages of injuries Protein Energy requirements Fat Micronutrients

3 INTRODUCTION Injuries are an unfortunate but unavoidable aspect of participation in sport. An injured athlete may be required to reduce training load or withdraw from training and competition. Nutrition intervention is often overlooked during the acute post-injury period and subsequent rehabilitation phase.

4 IMPORTANCE OF NUTRITION TO ATHLETES Provides a source of energy required to perform in training or competition. The food consumed can impact on athlete s strength, performance, quality of training and recovery. Apart from the type of food, the timing of food ingestion throughout the day also has an impact on the performance levels and the body ability to recover after workout.

5 Importance of nutrition to athletes Provide energy and nutrients required for body function Reduce risk of injury and illness Support growth and development Achieve/maintain an ideal body weight and physique Enhanced recovery between training sessions and competitions Maintain appropriate hydration levels

6 OBJECTIVE OF NUTRITIONAL MANAGEMENT FOR INJURED ATHLETES No one size fits all. Every individual is different and unique. Nutritional recommendation should be tailored to meet individual needs. Avoid malnutrition (eg. Deficiency of single or several micronutrients involved in immune function) Optimize wound/bone/tissue healing Minimize or reduce muscle atrophy Ensure sufficient energy and protein, as well as micronutrients intake

7 OTHER CONSIDERATIONS Boredom eating affects the nutritional quality & quantity Restrained eating fear of undesirable weight gain Length of immobilization and range of movement Energy cost of ambulation and rehabilitation Pre-surgery preparation optimally well nourished

8 Recovery period Return-to-play Physical implication Psychological impact Societal complications

9 Support system around the injured athlete Family & Friends Physiotherapist Medical Dietitian/ Nutritionist Coach Strength & Conditioning coach Injured Athlete Psychologist Biomechanist Physiologist Multidisciplinary approach for sport injury rehabilitation

10 STAGES OF INJURIES Stage 1: Inactivity and muscle atrophy Loss of muscle mass, strength and function Type & severity of injury determines the length of time for immobilization (days months) Stage 2: Active rehabilitation and return of mobility Reintroduction of exercise in the form of therapy Recovery of muscle size, strength and function often takes longer than the time it takes to atrophy (Jones et al. 2004)

11 INACTIVITY AND MUSCLE ATROPHY Total or partial immobilization (limb injury) induces changes to site-specific musculotendon remodeling resulting in skeletal muscle atrophy and subsequent reduction in strength and function (Silder et al. 2008) Muscle disuse reduces muscle mass at 0.5% per day (Phillips et al. 2009) Skeletal muscle atrophy occurs within the first 1 2 weeks after total immobilization (Adams et al. 2003) Skeletal muscle loss of approximately g has been reported from a single, immobilized leg (Wall et al. 2013)

12 Stage 1 Early stages of muscle disuse (1 2 weeks) Skeletal muscle loss Limb immobilization (Muscle disuse) affects Decline in metabolic health and functional capacity

13 Flow diagram of the metabolic and functional changes during immobilization Source: Adapted from Tipton (2010)

14 Stage 1: Inactivity and muscle atrophy Adapted from: Precision Nutrition Nutrition for Injury Recovery URL:

15 INFLAMMATORY RESPONSE Inflammatory response (initial physiological response to injury) is a critical component of the healing process (Lin et al. 1998) Both soft tissue and bone injuries result in inflammation to begin the healing process (Lorenz et al. 2008) Certain anti-inflammatory medications and nutrient supplements (suppress/eliminate inflammatory response) may not be ideal for optimal recovery in the early phase of tissue repair (Galland 2010)

16 Stage 1: Inactivity and muscle atrophy Adapted from: Precision Nutrition Nutrition for Injury Recovery URL:

17 Quality > Quantity Adapted from: Precision Nutrition Nutrition for Injury Recovery URL: nutrition-for-injury-recoveryinfographic

18 NUTRITION RECOMMENDATION FOR INACTIVITY AND MUSCLE ATROPHY

19 Injury Rate of muscle protein synthesis Rate of muscle breakdown Limb immobilization Muscle disuse atrophy leads to Decline in basal muscle protein synthesis rate Development of anabolic resistance to food intake Leucine

20 PROTEIN Insufficient total dietary protein intake impedes wound healing (Arnold & Barbul 2006; Demling 2009) Sufficient protein intake is required for synthesis of collagen and other proteins in the repair process (Lorenz & Longaker 2008) Protein intake stimulates muscle protein synthesis (MPS) both at rest and following exercise, resulting in positive muscle protein balance (Wilkinson et al. 2007; Tang et al. 2009) Due to the anabolic resistance in the immobilized muscle, increasing total protein intake does not have the same stimulatory effect on MPS in the injured muscle compared to non-injured muscles in athletes (Lorenz & Longaker 2008)

21 EFFECT OF TOTAL PROTEIN INTAKE ON MPS Elevated protein intakes as high as 2.0 g/kg/day when spread over the day may be advantageous in preventing fat-free mass loss (Nutrition and Athletic Performance Position Statement 2016 American College of Sports Medicine, Academy of Nutrition and Dietetics, and Dietitians of Canada) Maximal rate of MPS is highest in response to intakes of high biological value protein at between g ( g/kg BW) consumed in a single meal (Witard et al. 2014)

22 EFFECTS OF SPECIFIC AMINO ACIDS ON MPS Essential amino acids (EAA), particularly leucine may assist in the amelioration of muscle loss during immobilization (Baptista et al. 2010) Increasing leucine intake may help to increase protein synthesis in the absence of anabolic resistance

23 Food Sources Containing 2 grams Leucine Adapted from: Sports Dietitians Australia July 2011 Protein and amino acid supplementation Food Amount Protein (g) Milk (skim) 600 ml 22 Soy beverage 900 ml 33 Milk powder (skim) 60 g 22 Cheese (reduced fat cheddar) 70 g 22 Cheese (cottage) 140 g 25 Yoghurt (skim, natural) 350 g 20 Yoghurt (skim, flav.) 400 g 21 Whey Protein Isolate 17 g 16 Egg (whole) 3 eggs 19 Beef, poultry, seafood (raw) 120 g 25 Almonds 130 g 26 Tofu 400 g 48 Kidney Beans (drained) 350 g 23 Lentils 380 g 18 Bread 9 slices 28 Rice (white, cooked) 6 cups 26

24 TIMING OF PROTEIN OR AMINO ACID INTAKE ON MPS Consuming protein every three hours throughout the day may result in greater stimulation of muscle protein synthesis in athletes during periods of resistance training than ad libitum protein intake (Moore et al. 2012; Areta et al. 2013) This type of structured timing may exert similar stimulatory effects in athletes with muscle atrophy from disuse or injury (Paddon-Jones et al. 2004) Ingestion of high biological value protein at ~0.3 g/kg BW acutely after exercise promotes maximal protein synthesis (Hendy et al. 2012)

25 PROTEIN RECOMMENDATION Daily protein intake Amount Type Timing of ingestion g/kg/day grams/meal BCA - Leucine Every 3 4 hours (4 6 meals daily)

26 1 palm size of meat / fish cutlet 20 grams protein 1 chicken drumstick 15 grams protein 1 ekor ikan kembong 15 grams protein 1 piece of lean meat 7 grams protein 1 cup milk (250 ml) 8 grams protein 1 whole egg 7 grams protein ¾ piece tofu 7 grams protein

27 ENERGY REQUIREMENTS DURING RECOVERY FROM INJURY Energy balance is important to maximize recovery rates. Injured athlete has reduced energy requirements compared to their needs during regular training. Some athletes continue to eat the same amount of energy despite a reduction in training, leading to weight gain. The guidance of a sports dietitian can help athletes adjust their energy intake to their specific needs as energy requirements vary at different stages of recovery and are determined by the severity of the injury.

28 Energy Balance Energy Intake Energy Expenditure Calories from food Fear of weight gain Eating out of boredom Loss of appetite Basal metabolic rate Physical Activity Thermic Effect of Food 60% 30% 10% Weight maintenance

29 Energy Balance Energy Intake Energy Expenditure Calories from food Basal metabolic rate Physical Activity Thermic Effect of Food 60% 30% 10% Weight loss

30 Energy Balance Energy Intake Energy Expenditure Calories from food Basal metabolic rate Physical Activity Thermic Effect of Food 60% 30% 10% Weight gain

31 ENERGY REQUIREMENT Energy Intake Total energy expenditure is likely to decrease during immobility, particularly if the immobilized limb is involved in ambulation. However, higher energy needs are required, especially in the early stages of injury to assist with healing process. Resting metabolic rate (RMR) can be up to ~20% higher than usual requirements during severe injuries (Frankenfield 2006). Energy cost of ambulation When using crutches, energy expenditure can be 2 3 times higher compared to normal walking (Waters et al 1987).

32 EFFECTS OF ENERGY BALANCE ON MPS Decreased muscle synthesis is the major contributor to muscle loss (Glover et al 2008) Insufficient energy intake leading to negative energy balance can accelerate the loss of muscle mass (Biolo et al. 2007) A well-muscled male expends approximately 500 kcal/day on muscle protein synthesis even without considering physical activity (Wolfe 2006) Routine assessment of energy intake, body mass and body composition during immobilization as well as rehabilitation is warranted to address the common fear of excessive weight or fat gain during injury.

33 CALCULATING ENERGY REQUIREMENT Harris-Benedict Equation Men: BMR = (13.75 x W) + (5 x H) (6.75 x A) Women: BMR = (9.56 x W) + (1.85 x H) (4.67 x A) weight (W) in kilograms (kg), height (H) in centimeters, and age (A) in years. Total Energy Expenditure = BMR X Activity Factor X Injury Factor

34 Adjustments in energy requirements Activity factors Comatose: 1.1 Confined to bed: 1.2 Out of bed (ambulatory): 1.3 Normal activities of daily living (ADLs): 1.5 Reference: Academy of Nutrition and Dietetics. Evidence Analysis Library. Available at Injury factors Surgery: Minor: Major: Skeletal trauma: Head trauma: Infection: Mild: Moderate: Severe: Burns (% body surface area [BSA]): <20% BSA: % 40% BSA: >40% BSA:

35 JK is a basketball player who suffered from a knee injury. He is 24 years old, weighs 80 kg and 180 cm tall. Basal Metabolic Rate = (13.75 x W) + (5 x H) (6.75 x A) = 1905 kcal/day Energy needs when sedentary = 1905 x 1.2 (activity factor) = 2286 kcal/day Energy needs with daily training/competition = 1905 kcal/day x 1.7 (activity factor) = 3239 kcal/day Immobilization Energy needs during recovery = 1905 kcal/day x 1.2 (activity factor) x 20% (increase in metabolism due to injury) = 2743 kcal/day Rehabilitation

36 OMEGA-3 FATTY ACIDS Widely associated with anti-inflammatory and immune-modulatory properties (Galli et al. 2009) Fish oil supplements depress the inflammatory response and shows positive immunosuppressive effect on people with ongoing excessive inflammation (e.g. chronic arthritis) (Galli et al. 2009)

37 OMEGA-3 FATTY ACIDS Long-term supplementation with omega-3 fatty acids (4 g per day consisting of 1.86 g EPA & 1.50 g DHA) has been shown to augment anabolic sensitivity to amino acids and thus enhance rate of MPS in healthy individuals of all ages (Smith et al. 2011) Recommendation for dosage of the inflammatorylimiting effect of n-3 FA supplements vary from 1-2 g/day to 4 g/day (Rangel-Huerta et al. 2012)

38 OMEGA-6 FATTY ACIDS Omega-6 fatty acids also have immune-modulatory effects and oppose the inflammatory-limiting effects of omega-3 fatty acids. Low ratio of omega-6:omega-3 is a useful recommendation for enhancing anti-inflammatory effects (Simopoulos et al. 1999)

39 OMEGA-6 FATTY ACIDS However, there is no current consensus about the low ratio dietary omega-6:omega-3 as protective in inflammatory conditions (American Heart Association). Thus, this serves as a justification for caution in using omega-3 fatty acid supplements in athletes. Consuming balance dietary fat is still recommended to healthy as well as injured athletes.

40 TYPES OF FAT Promotes inflammation Trans-fats Omega 6 fats Saturated fats Inhibits inflammation Monounsaturated fats (MUFA) Omega 3 fats Adapted from: Precision Nutrition Nutrition for Injury Recovery URL:

41 Examples of Omega-3 Examples of Omega-6 Oily fish (salmon, sardines), olives oil, flaxseed oil Sunflower oil, safflower oil, peanut oil, soy oil, corn oil, cottonseed oil, sesame oil,

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43 MICRONUTRIENTS Wound healing is impaired in malnutrition and linked to sub-optimal micronutrient status of, for example zinc, vitamin C and vitamin A. Sufficient intake of calcium and vitamin D during healing from fractures is important to optimize bone formation.

44 MICRONUTRIENTS VITAMIN Vitamin A Assists with cell growth and development Reverse post-injury immune suppression Assist in collagen formation Vitamin C Associated with hydroxyproline synthesis, necessary for collagen formation and important component in wound healing and repair of damage to bone, ligaments and tendon injuries. Enhances neutrophil and lymphocyte activity

45 RECOMMENDED NUTRIENTS INTAKE OF MALAYSIA (RNIM) 2005 Age (years) Recommendation (mg/day) Children Adolescents 65 Adults 70 Pregnant women 80 Breastfeeding women 95 Athletes (prolonged, strenuous exercise) Upper Limit (mg/day) 2000

46 FOOD HIGH IN VITAMIN C 500 mg 1000 mg ½ guava 228 mg Highest 250 mg 1 whole kiwifruit mg 1 slice of papaya 113 mg 1 whole lemon 91 mg 1 whole orange 57 mg Lowest Reference: Food Composition Guide Singapore (2003) Nutrient Composition of Malaysian Food (1988)

47 CREATINE May potentially decrease the rate of muscle loss associated with immobilization. Enhance resistance exercise-induced muscle hypertrophy (Hespel & Derave 2007) Unfortunately, the evidence in the limited number of studies to date is equivocal. Varied results between studies were likely to be attributed to differential responses of arms and legs to immobilization. Monitoring is needed to see if there is any effects (swelling or inflammation) after consumption

48 NUTRITION RECOMMENDATION FOR REHABILITATION

49 NUTRITION RECOMMENDATION FOR REHABILITATION Primary nutritional goal is to support muscle growth and increased strength with rehabilitation and retraining. Meeting energy and protein requirements is critical (Tipton & Wolfe 2004; Rennie et al. 2010) Moderate serves of high biological value protein at each meal and snack, and rapidly digested proteins rich in leucine (e.g. whey protein) following resistance/rehabilitation training are recommended. Limiting carbohydrate intake during rehabilitation is not recommended because low intakes during and following exercise impair MPS and net muscle protein balance (Howarth et al. 2010)

50 Flow diagram of the metabolic and functional changes in muscle and tendon when activity is restored Source: Adapted from Tipton (2010)

51 RETURN TO PLAY NUTRITION GOALS Energy requirement differs during each phase. Consume adequate calories intake to meet the physical activity demand Consume adequate protein intake ( gram/kg BW). Each meal should contain g protein. Aim for whole grains such as whole grain rice, oatmeal, whole meal bread, quinoa. Consume more carbohydrates during rehabilitation phase compared to immobilization phase. Strive for a better fat balance by increasing omega-3 intake & cut back on omega-6

52 Immobilization Phase Adequate calories Adequate protein (amount? + leucine) Sufficient vitamins and minerals Limit alcohol intake Include omega-3 rich foods Plenty of fruit and vegetables Rehabilitation Phase Increased calories Increased protein Sufficient vitamins and minerals Limit alcohol intake Include omega-3 rich foods Plenty of fruit and vegetables

53 FOCUS NUTRIENTS TO AID HEALING Wound healing Energy Protein Zinc Vitamin C Bone Health stress fractures Energy Protein Calcium Vitamin D Vitamin A

54 Adapted from: mysportscience.com Nutrition for recovery tendon injuries URL:

55 Adapted from: mysportscience.com Nutrition for recovery from muscle injury URL:

56 FUTURE RECOMMENDATION Refer to dietitian for nutritional intervention and support after injury/surgery Include dietitian as part of the multidisciplinary rehabilitation team. Monitor and evaluate athlete s progress throughout the rehabilitation period Objective of nutritional management should focus on consuming adequate energy and protein to maintain lean muscle mass during immobilization and rehabilitation.

57 TAKE HOME MESSAGE There is no "magic bullet" to speed the recovery process View with caution any treatment process or supplement that promises rapid recovery from injury. Although vitamins and minerals play key roles in the healing process, there is no evidence that mega doses of vitamins, or minerals will speed recovery.

58 LIST OF REFERENCES 1. Burke L. and V Deakin, eds. (2015), Clinical Sports Nutrition, 5th edition. Sydney: McGraw Hill. 2. Tipton KD. Nutrition for Acute Exercise-Induced Injuries. Ann Nutr Metab 2010;57(suppl 2): Wall BT, Morton JP, Van Loon LJC. Strategies to maintain skeletal muscle mass in the injured athlete: nutritional considerations and exercise mimetics. Eur J Sport Sci. 2015;15(1): Precision Nutrition. Nutrition for Injury Recovery. Available at URL:

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