NHD EXTRA: NUTRITION MANAGEMENT
CASE STUDY: SPORTS NUTRITION Helen Phadnis Freelance Dietitian and Sports Nutritionist Helen’s practice is underpinned by over 10 years of previous clinical experience at a senior specialist level and five years in private practice. She provides workshops for local clubs and teams and runs clinics in Brighton and Hove. helen@nomnomn e rd.com http://www.nomn o mnerd.com/
The effects on body composition of a K2 summit attempt by an experienced climber Climbing at altitude puts additional energy demands on climbers, estimated at an extra 536kcal/d just for acclimatising to altitude,1 and 1,610kcal/d for climbing activities.2 Alongside these demands come welldocumented changes in taste perception and reduced appetite,3 making weight loss inevitable when climbing above 5,000m. K2 is the second highest mountain in the world, at 8,611 metres above sea level. It is known as the ‘Savage Mountain’ due to the extreme difficulty of ascent.
Matt is a 38-year-old experienced mountain climber planning a second attempt at reaching the summit of K2. Matt was seeking nutritional advice in an attempt to minimise weight loss experienced during his previous attempted summit of K2 two years prior. His trip had resulted in 17% weight loss from 100kg to 83kg. After initial basic dietary advice was provided, Matt requested an in-depth body composition assessment pre- and post- K2 expedition out of curiosity, to see the anthropometrical effects on his own body of climbing at altitude.
Identification of Nutritional Need 1. Assessment Medical diagnosis: Susceptibility to cold sores Anthropometric measurements: Body fat and lean mass measurements were taken via multiple frequency bioelectrical impedance, using Body Composition Monitor (BCM), Fresenius Medical Care (see Table 1). Skinfold thickness measurements were taken at seven sites using Harpenden Skinfold Calipers. Girth measurements were taken with a tape measure. Takei 5001 hand grip dynamometer was used to assess muscle strength. Seven-point Subjective Global Assessment scale was used to assess nutritional status. Dietary Intake Analysis Planned daily intake during climbing is documented in Figure 1. This was based on previous experience of what is possible to carry with regards to weight during a climb, as well as what is palatable. This would provide approximately 2,500kcal, 64g protein. From previous experience, in keeping with what is commonly reported in climbers at altitude, Matt knew he could tolerate carbohydrates in preference to fat when eating during a climb. Recommended Body Weight: BMI 18-25kg/m2 = 64-88kg Recommended body composition based on published elite sport climbers and high altitude climber anthropometry data4,5 is recorded in Table 1. Estimated energy needs: Using actual body weight (as client is not obese) BMR (Schofield) 11.5 (101.7) +873 = 2042 x 1.9 PAL = 3880kcal/d Nitrogen (Elia) 0.17 x 101.7 = x6.25 = 108g/d Based on ACSM Nutrition in Sport Position stand6 Very high carbohydrate needs (mod-high intensity exercise over >4-5 hours). Target 8-12g/kg/d = 813-1229g carbohydrate = 3,089-4,670kcal Protein = 1.2-2g/kg/d = 122-203g protein = 488-812kcal Total discounting fat = 3,577-5,482kcal/d Medications: None Supplements: Centrum multivitamin and mineral supplement.
64
www.NHDmag.com August / September 2016 - Issue 117
2. Identification of nutrition and dietetic diagnosis Diagnosis: Inevitable cachexia expected during planned K2 climb. Aims: To minimise negative effects of altitude on dietary intake and resultant muscle loss and fatigue during K2 climb. To assess body composition and compare to that documented for high altitude climbers. 3. Plan nutrition and dietetic intervention Nutrition Prescription: I. Prevent injury and illness during trip. a. Take probiotics e.g. Actimel daily for two weeks prior to trip to reduce likelihood of contracting diarrhoea. b. Probiotic tablet daily during trip. c. To take a broad spectrum multivitamin and mineral supplement daily during trip and pre-trip to reduce susceptibility to cold sores and upper respiratory tract infections. This will cover all micronutrient requirements when the effects of altitude cause a reduction total diet intake. d. Aim for adequate calories and protein during trip: supplement planned nutritional intake with Complan meal replacements and some medium Glycaemic Index snacks such as chocolate, fruit and nut bars. II. Optimise performance during climb. a. Match food intake to energy expenditure as far as is possible: i. Pack familiar palatable food to tempt into eating as much as possible: small frequent snacks to optimise intake. ii. Include high fat foods if possible: cheese, chocolate, fish in oil. III. Prevent loss of lean body mass during climb. a. As above. IV. Prevent dehydration a. Rehydration is more effective when there are some electrolytes and/or calories present: always drink when take food, preferably salty snacks. Aim for 4-5L when at altitude if possible. 4. Implement nutrition and dietetic intervention I talked Matt through the above nutrition prescription, alongside advice on basic principles of sports nutrition and how they could be applied on the trip as well as to his pre-expedition training. A key element when considering 10-15 hour climbs with no stop for a proper meal was aiming for 30-60g carbohydrate per hour to minimise fatigue. 5. Monitor and review See Table 1: Anthropometry I. Matt’s body mass index was above the healthy range before the trip. Abdominal circumference and sum of skinfolds were also high, indicating excess fat before the trip. After the trip, total fat stores fell by 8.0kg, the most significant loss being from abdominal stores, indicating healthy weight loss. II. Results from the body composition monitor show that a far larger proportion of weight lost was fat (about 8.0kg), compared to muscle (about 2.0kg). This is attributable both to Matt’s persistence with taking on board nutrition during the trip, and also due to the fact that he was exercising daily during the expedition. III. Subjective global assessment classed Matt as ‘at risk’ of malnutrition post-expedition. Also the rate at which he lost weight during the expedition was 12.5% loss body weight in three months. This is clinically significant for malnutrition. However on his return: a. Matt was unlikely to be deficient in vitamins and minerals due to daily supplementation during the trip and did not display any symptoms of micronutrient deficiency; b. daily exercise led to fat loss in preference to muscle loss. Body mass index within the healthy range for athletes; c. despite a lack of appetite, Matt was not suffering from any other adverse gastro-intestinal symptoms. IV. Muscle bulk was reduced post-trip and as a result Matt lost some power, as indicated by reduced handgrip strength. Matt was counselled on recovery snacks containing 20g protein along with carbohydrate to encourage regain of muscle stores. He was also encouraged to self-monitor his nutritional status via waist circumference measurements, aiming to minimise fat regain in this area. It was recommended that his multivitamin and mineral supplement was only necessary at times of intense training or life stress. 6. Evaluation Loss of both fat and muscle are inevitable whilst climbing at high altitude. This can be minimised by good planning and implementation of a calorie dense diet comprised of tried and tested meals, snacks and supplements. www.NHDmag.com August / September 2016 - Issue 117
65
NHD EXTRA: NUTRITION MANAGEMENT Table 1: Nutrition Assessment Data Reference range *Elite sport climbers5 # High altitude climbers4
Pre-trip
Post-trip
Height m
*1.72
1.884
1.884
Weight kg
*65.5 #69-85
101.7
88.5 on immediate return 92.5 at appointment
Body Mass Index (BMI)
WHO 18.5-25kg/m2
28.6 kg/m2
25kg/m2 on immediate return 26kg/m2 at appointment
% weight loss past 3 months
Stable = <5%
4%
9% (12.5% total)
Hydration L
Euhydrated = 0
-0.4 L
+1.2L
Body fat %
*6.8-12.7
26.4 7.3% (from skinfolds)
21.9 5.7 (from sfs)
Fat mass kg
*8.6 #4.9-13.1
7.4kg (from sfs) 36.6
5.3kg 27.5
Lean mass kg
#20.7-42.2
66.1
64.2
Subjective Global Assessment
Well nourished = 6-7, at risk = 4-5, Malnourished = 1-3
6
5
Hand Grip Strength
76-176
138
117
Triceps Circ (+-flex) cm SF mm
# 28-34 6.5-19
35.7, flex 36.4 7.2
33, flex 34.5 6.2
3.8
5.5
Biceps skinfold mm Chest skinfold
# 5-13.5
3.8
3.2
Abdomen Circumference skinfold
# 82-96 7-21
94 13.0
87.5 11.0
Subscapular skinfold
# 8-16
13.8
9.0
Suprailiac skinfold
# 8-21.5
7.2
4.95
Thigh Circumference skinfold
# 55-61 7-14
65.1 4.8
56.4 5.2
Calf Circumference skinfold
# 37-39
46.2 11.5
44.5 8.0
57.5
44.35
Sum of 6 skinfolds
Abdomen circ: <94cm = healthy, 94-102cm = increasing health risks, >102cm = high health risks.
66
www.NHDmag.com August / September 2016 - Issue 117
Figure 1: MGâ&#x20AC;&#x2122;s original planned dietary intake when climbing
Planned daily intake during climbing . . . This was based on previous experience of what is possible to carry with regards to weight during a climb, as well as what is palatable. References 1 Pulfrey SM and Jones PJH (1996). Energy expenditure and requirement while climbing above 6,000m. J Appl Physiol 81: 1306-1311 2 Westerterp KR, Saris WHM, Van Es M and Ten Hoor R (1986). Use of the doubly labeled water technique during sustained heavy exercise. J Appl Physiol 61: 2162-2167 3 Anonymous (1938). Nutrition panel of the food group. J Soc Chem Ind 57: 1230-1234 4 Reynolds RD, Lickteig JA, Howard MP and Deuster PA (1998). Intakes of high fat and high carbohydrate foods by humans increased with exposure to increasing altitude during an expedition to Mt Everest. The Journal of Nutrition pp50-55 5 Romero et al (2009). Body fat measurements in elite sport climbers: Comparison of skinfold thickness equations with dual energy X-ray absorptiometry Journal of Sports Sciences 27(5): 469-477 6 American College of Sports Medicine, Dietitians of Canada, the Academy of Nutrition and Dietetics (Feb 2006). joint Position Stand on Nutrition and Athletic Performance
dieteticJOBS.co.uk To place an ad or discuss your requirements please call
0845 450 2125 (local rate)
www.NHDmag.com August / September 2016 - Issue 117
67