Top Nutrition Concerns Seen in Adolescent Sports Medicine

Trying to figure if your young athlete needs iron to boost performance?

Uncertain if water or sports drinks would be be the best choice for the next practice or game?

Looking for healthy post-game snacks that will assist in muscle recovery?

Hearing a lot about protein and creatine supplements but not sure if adolescent athletes should use them?

You've come to the right place for practical answers to these and many other nutrition questions that I regularly hear in my sports medicine practice.

In appreciation of CHOC Children's Hospital inviting me to speak on Top Sports Nutrition Concerns Seen in Adolescent Sports Medicine first at their RDs in Practice – Pediatric Sports Nutrition conference and following up with a Pediatric Grand Rounds on the same subject,  figured I would compile a list of past blog posts that will form the backbone of those presentations.

• Should I Take Extra Iron to Boost My Performance?

• What is the Best Fluid Choice for Young Athletes?

• Chocolate Milk: A Solid Post-Game Snack Choice

• 5 Sensible Tips Guiding Nutrition and Recovery After Exercise

• What is the Role Of Iron Supplementation in Non-Anemic Endurance Athletes?

• General Nutrition Guidelines from Children and Sports Guide

Click on the above links to view the relevant post.

Eager to hear of any additional nutrition or other sports medicine based questions- will offer initial responses via email but always available for office consultations and more in-depth recommendations

Should I Take Extra Iron to Increase My Athletic Performance?

Given an  important  role in hemoglobin, which is the part of the red cell that optimizes oxygen delivery to exercising muscles,  sufficient iron stores (best known as ferritin) are definitely essential to providing peak athletic environments.  There is little doubt that low red cell counts, also known as anemia, can torpedo both endurance and strength performance for many athletes.

Thus, should you seek out increased food and even supplement based sources of iron?

Well, the answer isn't so straight forward and depends on your current "group" of red cell counts and iron stores:

• Group 1: If you have low red cell counts with smaller red cell sizes and low iron stores, experience and science strongly suggest a need and benefit for supplemental iron intake
• Group 2: If you have normal red cell counts and normal iron stores, the prevailing thought is that supplemental iron intake is not needed and may actually have risks (organ damage, higher risk of liver cancer) that outweigh any benefits to your performance.
• Group 3: If you have normal or low normal red cell counts and low iron stores,  this is where things get real interesting as scientific studies and the sports medicine and performance communities do not have clear agreement.
  • Please click here for my thoughts on the growing trend towards medically supervised iron supplement programs in the non-anemic athlete with low iron stores. 

If that third category sounds a bit confusing, then let me add a bit more uncertainty to the picture.

• Athletic individuals have different oxygen transport and muscle function demands. Thus, what many of us consider as "normal" hemoglobin values for less active individuals may not be so acceptable for intense endurance or team sports athletes. Many athletes may strive for hemoglobin levels at least 2-3 points above the lowest range of normal.
• Hemoglobin or red cell counts can be lower in athletes due to increases in blood volume that allow for more efficient delivery of oxygen to working muscles. This is called pseudo-anemia where the red cell sizes and iron stores are both normal.
• Using ferritin to measure iron stores can be perplexing. Ferritin levels can be influenced by things like illness or even total body inflammation, so there are often cases where sick or over-trained and under-performing athletes mistakenly appear to be "doing better" with iron intake based solely on higher ferritin levels.
• If you "trust" ferritin, then deciding on acceptable levels is yet another concern. In many athletes, keeping levels in the 20-30 range is a challenge during period of heavier training or competition, with levels higher than that a true accomplishment.

So, how should you use this information to make sensible decisions for your health and athletic performance?

• Do not use any supplemental iron products (liquid iron, iron pills, ect) without appropriate medical evaluation and testing.
  • Those tests can include measurements of red cell counts (hemoglobin), total body iron, red cell iron saturation, ferritin, and possibly a test called soluble transferrin receptor which might be more accurate than ferritin in measure iron stores.
• If you are clearly in Group 1 or Group 2 from above, then your decision is probably more clearly defined.
• If like many people you are in Group 3, or even if you are in Group 1 or 2 and have questions, strong recommend scheduling a meeting with a sports medicine specialist who has additional experience, training and appreciation for the stresses and demands of higher level athletes to review your diet, training program and lab tests.  

What is Role of Iron Supplementation in Non-Anemic Endurance Athletes?

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It is relatively common to have young endurance athletes come into my office requesting lab work to check for anemia (low red cell counts) and iron stores in hopes of finding a relatively straight-forward treatment for fatigue or low performance. While the prevailing trends in the sports medicine literature are more in favor of iron supplementation,  I must also bear caution that iron treatments alone are not a "magic bullet" and that more specific review of training regime, diet, and sleep patterns is absolutely essential.

There is no doubt that endurance athletes are at particular risk for anemia, Potential exercise-related causes include iron losses through sweat, stool and urine along with breakdown of red cells with foot impact against the ground in running. Concerns about the role of chronic training-related inflammation reducing general body iron absorption and recycling and a diet deficient in adequate iron intake may also compound the issue.

We may also hold a higher expectation for red cell count numbers in endurance athletes, and this bias creates more findings of relative anemia. Red cell levels that are in the low normal range may be fine for the less active or couch potatoes of the world, but may not be as acceptable for a higher level runner, swimmer or cyclist.

Over the past 5-10 years, I have definitely seen a movement among athletes, coaches and sports medicine experts to be more apt to recommend iron supplementation for endurance athletes who have low iron stores but who are not be anemic (have low red cell counts). Prior to that time, the prevailing thought was to favor iron treatments only for those athletes who were both anemic and having lower iron stores.  The results of a recent meta-analysis in the British Journal of Sports Medicine lend additional support that iron supplementation for low iron stores without frank anemia can improve iron status and aerobic capacity.

Interesting points discussed in the article that may further influence treatment recommendations include:

• Selecting appropriate markers to measure iron status-  serum ferritin (measure of body iron stores) can vary from day-to-day and in combination with iron saturation studies, both tests may not be adequate to reflect whole body iron status. Use of soluble transferrin receptor studies may be more accurate, though variations in lab techniques may limit comparisons of findings over time.
• Higher doses of iron supplementation over a shorter period of time were suggested to be more effective than smaller doses over longer periods with effect on iron stores to be diminished with a treatment period over 80 days. 
• Optimal dosing amounts, protocols, and routes (oral versus injected) require more study.
• Female endurance athletes may respond differently to treatment, most likely due to menstrual cycle variations on hormonal levels that may influence iron absorption.

While this information adds significant value to the measurement and treatment of iron issues in endurance athletes, it is crucial to recognize that focusing on iron alone is grossly simplistic and insufficient when evaluating performance issues in endurance athletes.

A comprehensive review of diet may reveal insufficient overall caloric intake as high level athletes often suffer from relative energy availability issues where training related caloric demands may not be met by food intake. I have often found that lower calorie diets often have low intake high protein foods such as meat. poultry, fish, and dairy sources that not only reduce intake of high level, easily absorbed iron sources (red meat, red fish, dark poultry, veal) but also essential calcium (dairy) and the protein stores needed for muscle growth and recovery (especially if ingested within 30 minutes after exercise).

Diet choices that help reduce inflammation can not only aid in absorption of essential nutritional elements, but also minimize joint stiffness, muscle soreness, and reduction in mental sharpness, Less processed foods, lower carbohydrate diets, and diets rich in items such as berries and cherries, fish and fish oils, and spices such as tumeric and ginger are recommended as part of an anti-inflammatory diet.

Inadequate sleep can also lead to inadequate performance. Emerging evidence suggests that a minimum of 8.5 hours a day (can include a short nap of no more than an hour) can reduce risk of injury, illness, and may also contribute to enhanced academic and athletic performance. Sleep is part of the overall recovery process that must be integrated into a thoughtful training program that feature adequate rest days and alternating periods of heavier and easier training that may have to be individualized for each athlete.

Fatigue and under-performance are common concerns in the endurance athletes and human nature often leads us to find convenient remedies. Findings that support iron supplementation in non-anemic athletes give some evidence-based measures of optimism, but must be tempered with the reality that more comprehensive evaluation is necessary to provide optimal outcomes. Seeking counsel from a sports medicine expert versed in training and performance concerns of endurance athletes is a sensible and often very productive step in enhancing overall health.