Training Talk: What Female Athletes Need to Know About Fueling Their Bodies

At the 10th Annual Sanford Sports Medicine Symposium last weekend, I spoke about nutrition's role in injury prevention and recovery. One of the main topics of the presentation was low energy availability in athletes. Energy availability is the amount of calories left over for the body to use for normal physiological functions (heart beating, walking around, lungs breathing, thermoregulation, growth, etc.) after accounting for calories burned during training or exercise.

Food intake - Energy Expended During Exercise = Energy Availability

Athletes who have heavy training schedules can be living in a chronic state of low energy availability, where every calorie they eat at meals is burned off during exercise, leaving little to no calories for the body to perform those regular bodily functions.

When calorie intake doesn't match energy expenditure, this low energy availability can not only have negative effects on training and athletic performance, but can put athletes at risk for other health problems.

For female athletes, this low energy availability can lead to other health issues, such as low bone mineral density and menstrual function disorders in what is called the Female Athlete Triad. Physically active girls and women can experience any one of the 3 components, which are interrelated and occur along a spectrum of healthy to unhealthy (see picture below).

Source: 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad.
De Souza MJ, et al. Br J Sports Med 2014;48:289

Female athletes won't always know the signs of female athlete triad because they won't necessarily lose weight if they have low energy availability (many athletes have a stable weight despite not meeting their calorie needs)...but they might notice if  they're training hard and lose their menstrual period. An estimated 20% of active women has missed 3 or more consecutive menstrual periods, called amenorrhea. This can lead to a loss of calcium from bones, a much higher incidence of stress fractures and poor bone health...but some athletes might believe that losing their period is just a normal part of hard training.

Regardless of body fat and weight, athletes' low energy availabliy can trigger amenorrhea, and appropriate treatment depends on why the athlete is under-fueling.

• Unintentional fueling due to low appetite from heavy training, or they may have a hard time fitting in meals and snacks around a heavy training schedule. 
• Some athletes are caught up in the diet culture of their sport (or society in general), trying to lose weight, with the goal of being better at their sport. They may take this too far and develop disordered eating habits, restricting intake of foods such as carbohydrates or animal protein, which can cause under-fueling and nutrient deficiencies. 
• Some athletes' restrictive eating patterns and disordered eating can lead to eating disorders, which puts athletes at a greater risk for health problems, and requires a different approach to recovery. 

Treatment of female athlete triad requires correcting the energy imbalance - increasing calorie intake and resting from exercise. 

Female athletes are often surprised when they find out how many calories they need to be eating to fuel their bodies, and how few they are currently eating. Very active individuals usually need at least 3 meals and several snacks per day. To get a better idea of current intake, athletes can track their food using popular apps, such as MyFitnessPal or tools like the SuperTracker.

Although these tools give athletes an idea of what they're doing now, working with a registered dietitian can take the guess work out of meal planning and give them more guidance to how many calories they really need to support training, and which foods they should be focusing on to really optimize their workouts and recover properly.

The total calories aren't the only thing that matter - girls and women can be deficient in several key nutrients:

• Vitamin D: spend more time outdoors, fortified breakfast cereal, milk, fatty fish like salmon, egg yolks or a vitamin
• Calcium: dairy such as milk, cheese, yogurt
• Iron: it's important to get screened for iron status, as many women, especially endurance athletes, tend to have low iron
• Healthy fats: focus on eating plenty of nuts (including peanut/almond butter!), seeds (flax, hemp, chia), olive oil, avocados, salmon
• Adequate protein: 20-25 grams per meal, 10-15 grams per snack in the form of lean protein (chicken, fish, lean beef), nuts, yogurt, milk, beans, peas and soy
• Energy-enhancing carbohydrates: the amount of carbs an athlete needs depends on their weight and what kind of sport they're in, but because carbs are our muscles' main fuel source, eating plenty of fruit, vegetables, whole grains, and potatoes is necessary to perform well and recover adequately. 

When speaking with female athletes, it's important to emphasize that food is fuel!

It's a good thing to eat when you're hungry and to enjoy food.  Eating more food doesn't necessarily equate to weight gain, and many times, it can actually lead to improved sport performance. If an athlete or parent of an athlete suspects they are having any of the issues discussed, they should talk to their doctor. There are other causes for amenorrhea, so it's important to consult with your doctor to rule out other causes! A Registered Dietitian can help athletes fuel their bodies properly to avoid issues related to female athlete triad and under-fueling for their sport.

NPR || To Thrive, Female Athletes Need a Lot More Food

The Informed Appetite || Drink Milk, or Don't. But Maybe Read This First (#Science!)

New York Times || After 'The Biggest Loser,' Their Bodies Fought to Regain Weight

Yeah...Imma Eat That || The Hunger and Fullness Scale (AKA How to Stop Dieting)

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Apps to Help You Make It A Healthy Holiday & Beyond!

As the holidays approach and the celebrations begin, one of these apps could potentially be your new bff!  It is so important to be mindful of what you are eating and that is easily lost during the holidays at the buffets, cocktail hours, pass around hors d'oeuvres, the office food fest and the actual holidays. Here are 2 great smart phone apps that will EASILY let you keep track of all your

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The Biology Behind the Size of Your Behind

The new year always seems to bring the desire to "get in shape" - A poorly defined objective wave that can mean many things to many different people. But with obesity rates in the country more than 30%, it is reasonable to assume that fat loss is (or should be) a priority for many of us.Unfortunately, it's not as easy as shopping and reality shows have you believe. This does not happen in a week,

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How To Enjoy a Healthier Halloween

Because Halloween is fast-approaching and the grocery store has an entire aisle dedicated to giant bags of candy, this post is going to be all about enjoying a healthier Halloween. Whether your family celebrates Halloween or not, you can't miss the candy fest in the grocery stores during this time of year. Although Halloween is only one night a year, the giant bag of candy may linger around the house for much longer.

I've gathered some healthier  Halloween tips to help your young athlete enjoy a healthier Halloween (without ruining all the fun).

1. Focus on other seasonal activities.

Kids and adults alike may associate this time of year with candy, and kids are usually thinking about candy a LOT, but there are many local seasonal events, like pumpkin picking and carving, apple picking, hay rides, corn mazes, haunted houses...the list goes on. 

2. Cook a healthier meal to enjoy before trick-or-treating/before eating candy.

We all know how good a candy bar tastes when you allow yourself to get super hungry...but it's usually pretty hard to stop at just one piece because candy may have a lot of calories, but doesn't fill us up and doesn't contain the nutrients our bodies really crave at meal time. What about something seasonal, like pumpkin chili? 

Choose a meal with plenty of filling vegetables, whole grains and a little bit of protein and encourage kids to drink a glass of water with dinner to hold them over during the night and to prevent them from choosing handfuls of sweet treats as a dinner substitute. 

3. Choose your candy wisely.

Even those bite-sized treats can pack a huge calorie punch, especially if you're grabbing for several pieces a day, and it's those extra 100-200 calories each day in addition to your normal calories that result in weight gain over time. One peanut butter cup is ~100 calories and those mini chocolate bars are usually around 40-50 calories each. Chocolate candies have more fat and usually more calories than fruity candies.

If you're passing out candy at your house, make sure you're choosing the miniature options or some of the non-candy options listed below.

4. Set some limits.

As far as HOW MUCH candy to eat, in an ideal world, kids, teens and adults would eat a piece or two and forget about it. This isn't always the case...but over-restricting the candy jar can often times make the candy more desirable and kids can develop tendencies to obsess over/sneak/hoard the candy.

Don't give the candy so much attention and eating the candy won't become such a big deal.

A good tip for kids (and adults!) is to choose a couple favorite pieces of candy after trick-or-treating (2,3,4,5...whatever number you both set) to enjoy, and make sure to put the candy jar away and help kids practice moderation by only choosing 1 or 2 pieces as they please a day. It goes along with the "out of sight, out of mind." Put out a bowl of fruit, cut up some vegetables - have some healthy snacking options available that are more easily accessible than the candy. 

5. Pass out non-candy options.

I know this is a total "dietitian" tip, but hear me out! There was a research study that showed that kids between 3-14 years old were just as likely to choose non-candy (toy) options just as much as candy options on Halloween. 

Because almost ALL houses will be handing out candy on Halloween, passing out non-candy options will be something new for kids.

Non-food ideas ideas from The Teal Pumpkin Project.

This is a pretty cool project  - because a lot of Halloween candies contain allergens, this project promotes passing out non-food options for trick-or-treating to ensure kids with allergies can still enjoy trick-or-treating!

Some options include: glow sticks, stickers, temporary tattoos, small toys like slinkies, bouncy balls, art supplies (crayons, paintbrushes, markers), noisemakers, bubbles, fancy erasers...the list goes on.

If you want to hand out some non-candy healthier food options, there's a lot of good individually-wrapped options in the stores:

Cereal bars, snack mix, single-serve cereal boxes, microwave popcorn or little bags of popcorn, snack-size bags of Goldfish or animal crackers, pretzels, boxes of raisins/dried fruit, sugar-free gum...

You might also like:

Greatist || 20 Healthier Halloween Candy Choices

Greatist || 16 Healthier Halloween Candy Recipes to Make at Home (Fun for older kids!)

Food Allergy Research & Education || Teal Pumpkin Project

Nutrition 411 || 8 Halloween Tips for Trick or Treat Night

Eat Right || Enjoy a Healthy and Happy Halloween

Real Simple || 4 Nutritionist-Approved Tips for a Healthier Halloween

FDA || Halloween Food Safety Tips for Parents

Contact the Sanford Sports Nutritionist for answers to your food and nutrition questions, additional tips, tricks, recipes and menu-planning ideas!

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"How Dieting Makes the Lean Fatter" (Article Review)

In athletics, there is much focus on body fat percentage and weight. Whether it's to lose weight, gain weight or maintain weight everyone puts a lot of emphasis on these numbers, especially in the weight sensitive sports (wrestling, gymnastics, etc.). Many athletes restrict their diet to lose weight so they can possibly run faster, jump higher or push harder but do they really need to lose weight? Are they doing more harm than good? Are they losing the weight the right way?
A recent review published in Obesity Reviews found that lean people that restricted eating (dieting) to lose weight ended up not only gaining back the weight, but actually gaining more fat and weight compared to where they started. Interestingly, the leaner the person the more effect it had on fat and weight gain. Moreover, a single episode of dieting or more in adolescents increased the risk of becoming overweight by 3-5 times by the time they reached young adulthood when compared to non-dieters. So, if someone was dieting or "weight cycling", the leaner they were the more odds they had of gaining weight and possibly becoming overweight or obese. Gaining more fat and weight compared to what was initially lost is defined as "fat overshooting".

Taken from leanmansystem.com

The article notes that as the energy intake decreases (semi-starvation) and there is loss of fat mass (FM), there is also a loss of fat free mass (FFM = muscle, water and bone). When re-feeding occurs and weight is gained back, it takes more time to regain FFM compared to FM. This in turn causes what we call hyperphagia (abnormal increase in appetite to help reach previous levels of FFM). However, at that point FM is back to where it was before weight loss. By the time FFM is completely restored, FM has increased significantly. The leaner the individual is initially, the higher the fat overshooting will be (more FM). Higher FM is a result no one would want from "weight loss".

This article is a wake up call to those who are trying to lose weight when they shouldn't or to individuals that are over restricting their intake, especially if they are at a normal weight. Dieting or weight cycling can be detrimental not only to your body composition but also to your health. If weight loss is needed or if you are considering it, consult with a sports registered dietitian or a medical professional.


Dulloo AG, Jacquet J, Montani JP, Schutz Y. How dieting makes the lean fatter: from a perspective of human body composition autoregulation through adipostats and proteinstats awaiting discovery. Obes Rev. 2015 Feb;16 Suppl 1:25-35      

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Paleo Diet for Athletes (Article Summary)

Not long ago I heard this great presentation from a fellow RD (Steve Hertzler PhD, RD) about the Paleo diet (caveman diet) for athletes. Since the Paleo diet has been such a popular topic in the past several years, I decided why not share the wealth of information with you. Here is a summary of his talk and article from SCAN's Pulse. He reviews and references The Paleo Diet for Athletes by Loren Cordain and Joe Freel as they paved the way for this diet in the past decade.

First lets try and define the paleo diet: It's typically defined as the diet that was available in the paleolithic era which was in the pre-agricultural period between 2.5 million to 10,000 years ago. However, different regions had different diets during those times which means there was no one paleolithic diet. Books on Paleo state that humans should not have dairy products nor grains/legumes, since they did not exist in that era, but have a diet rich with meat/fish, vegetables and fruits, low in starches and only natural sources of sugar. The theory is that our "human genome was developed based on this diet" and by sticking to it we decrease risk of multiple chronic diseases and improve human performance. However, some of the science shows otherwise; anthropologists have evidence that during that era there was more reliance on starches and tubers. Moreover, research shows that our guts have evolved and continue to evolve since 10,000 years ago allowing us to digest many foods not present during that era. Lastly, to replicate that exact diet is quite impossible since most of the foods we currently have (meats, produce, fats) are very different than what they had back then. 

Pros about the diet and book:  

• The diet promotes eating less refined carbohydrates and more fruits and vegetables
• Lean meats (including game) are recommended
• Adequate fish (containing omega 3) is highly encouraged
• Healthy fats are important
• Timing is important when it comes to performance
• For recovery, combination of carbs and protein is important post exercise

Cons about the diet and book:

• Elimination of several food groups (e.g. grain, dairy) leads to limited variety which in turn could cause defeciencies
• Interestingly, alcohol in moderation is permitted (I wonder what caveman drank alcohol?!)
• The book itself only addresses endurance athletes, not power nor strength athletes
• To date, there are not many studies on the Paleo diet in athletes. The studies that have been done were done on mainly obese and sick individuals (heart disease, diabetes) which have seen improvements in body composition and health markers (blood lipids, blood sugar). Athletes are very different than obese individuals
• In the book there are multiple exceptions to meet the high carbohydrate demands of the endurance athlete. If there are so many exceptions are they really eating Paleo?!
• "The diet is nutritionally inadequate, expensive and impractical". Studies show that the diet would lack calcium, Iron and fiber recommendations as well as cost 9.3% more annualy
• "Acid ash theory states that by eating a diet high in grains and dairy we produce a high acid load on the body and the body must remove calcium from the bone to buffer the load." The more the food is acidic the more we are supposed to see calcium in the urine. However, urine pH does not represent blood pH as it stays more or less the same. Moreover, there is no evidence indicating that high calcium levels in the urine mean that there is less calcium in the bone or a decrease in calcium balance
• Some of the research quoted by the authors for "avoiding certain foods such as potatoes, peanuts and canola oil are misinterpreted and taken out of context"
• The authors mention that the Paleo diet is the best. However, currently, the people that live the longest (to about 100 years of age) eat meat infrequently and their diet is based on grains or starch

In summary, the Paleo diet promotes certain healthy habits that are worth keeping such as limiting processed foods, eating fruits and vegetables, healthy fats and lean meats. However, by adding dairy, legumes and grains in your diet you can have a more complete varied and healthy nutrition plan to promote your activity.   

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