Guillermo is a 32-year-old former college athlete who has been competing in long-distance triathlon and marathon events for the past year. He complains of low energy as training and racing duration increases and is plagued by gut issues—gas and bloating after meals, nausea, and vomiting during races. He also suffers from sleep issues, waking up frequently during the night. He works full time at a stressful job as manager of an electrical contracting firm and trains in swimming, cycling, and running 10 to 12 hours/week.
Assessment
His height is 5ft 9 in and his weight is 174 lb. His body composition analysis as measured by the RD using the ISAK method was 6.8% (10.4 lb body fat, 164 lb [74kg] FFM). He is satisfied with his body fat percentage but would like to reduce his weight if possible to lighten up for the running portion of his events.
Urine specific gravity was assessed to determine hydration status on three visits: 1.035, 1.025, and 1.030 Cholesterol levels were 250, HDL 50, LDL 170, triglycerides 160; all other values were within normal limits. Using the Cunningham method to calculate REE:
500 1 (22 x FFM [Kg]) 500 1 (22 3 74) 5 2128 REE
Day off training: Activity factor 1.2, 5 approx. 2553 calories 1-2 hours steady state training: Activity factor 1.4 5 approx. 2979 calories 3-4 hours steady state training: Using Activity factor 1.6 5 approx.3404 calories 4-6 hours training steady state: Using 1.73 Activity factor5 approximately 4581 calories
Current Diet
Breakfast 1 hour before workout 12 oz coffee with 1 oz coffee creamer 3 eggs fried with onions, 2 slices bacon, 2 slices ham 1 spiced apple bran muffin Analysis: 570 calories, 30 grams fat (49%), 40 grams carbs (28%) 570 mg cholesterol Workout: 2000-yard swim,2-hour bicycle ride, 4-mile run During swim portion of workout (less than 1 hour): nothing During cycle portion of workout: 2 hours 2 electrolyte pills every 20 minutes on bike—total 12 pills Each pill contains: 40 mg Na—480 mg sodium 3 16 oz bottles fluid:
• 1 3170 cal, 32 g cho, 10 g pro
• 1 bottle high carbohydrate, hypertonic sports drink with maltodextrin270 cal, 54 g carb, 7 g sugar and protein, 220 mg Na, 25 mg caffeine
• Water 1 gel pack every 30 minutes5 6 packs Double latte with caffeine 110 cal, 27g carbs, 200 mg Na
During run portion of workout (less than 1 hour): nothing Total workout fuel: 1100 calories, 248 g carbohydrates (124 g/hr cycling, 900 mg Na) Immediately after workout: nothing Breakfast Coffee with half-and-half 1 plain bagel, cream cheese, jelly Banana 12 ounces milk Snack: none Lunch 2-6 oz chicken breasts grilled with skin, 2 cups white rice, 1 cup black beans, ½ cup fried plantains Snack: high-protein sports bar Dinner 1 onion soup with melted cheese 12 oz grilled steak 1 c yellow rice Sautéed mushrooms Dietary Analysis 3041 calories, 216 g protein (2.77 g/Kg) (28%), 249 g carbohydrates (3.15 g/kg)(33%), 13.5% saturated fat, 1172 mg cholesterol, 5634 mg Na RDA: 64% potassium, 85% Ca and folate, 26% C, 30% E, 13% K, dietary fluid intake5 9 cups Assessment Gut/Energy Antagonists Whole food portion of diet appears to be: Low in calories: 3041 calories (4141 with sport fuel) vs. 4581 calories required Carbohydrates: 249 g carbohydrates (3.15 g/kg) (33%) (497 g sport fuel), vs. a minimum of 5 to 7 g/kg 5 395-553 g
High in fat (38% total cal), saturated fat and cholesterol 1172 mg and sodium 5634 mg Low in antioxidants Excessive in fat pre-workout breakfast Excessive in sport fuel carbohydrates and sodium for 2-hour bike portion of ride Excessive in mealtime calories and protein Questionable whether athlete can tolerate FODMAPs foods, i.e., onions, beans, mushrooms, cream cheese, dairy (lactose), sport fuel sources of HFCS, and gluten
Intervention Increase meal frequency and calories while modifying fat, sat fat, and cholesterol Increase plant-based tolerable sources of protein and complex carbohydrates Modify amounts of animal protein at mealtime to 4 to 5 oz (30 to 35 g Improve leafy green vegetable intake via juicing if whole food veggies not desired or tolerate Improve intake of antioxidant rich fruits and fruit juices without added sugar
Recommendations Probiotic, EAA to heal and strengthen gut; enzymes before meals Adjust sport fuel intake, decrease electrolyte pills, reduce and modify carbohydrate-containing liquids and source, switch to waxy maize if maltodextrin or HFCS contributing to issue Meditation or yoga on day off from training and/or prayer or meditation 5 to 10 minutes a day for relaxation Melatonin and/or theanine for sleep issues, restlessness
Further Biochemical Evaluation and Testing Hydrogen/methane breath testing, gut dysbiosis Spectracell to determine extent of vitamin or mineral deficiency, assimilation, and absorption Upper/lower GI series if elimination diet, FODMAPs diet, and adjustments in eating/sport fuel do not resolve problems during training and racing Follow-up lipid profile after 9 to 12 weeks on modified fat, saturated fat, and cholesterol diet
Nutrition Care Questions
1. Calculate calorie and macronutrient needs using Cunningham Formula and guidelines provided in chapter
2. Assess what eating/lifestyle behaviors may be affecting this athlete’s energy levels, i.e., sleep, stress, portion sizes at meal time
3. Calculate training/race day/recovery fuel formulas for preworkout, workout calories, carbohydrates, and sodium
4. List issues that appear to be a valid reason to initiate FODMAPs and elimination diet.
5. Provide a list and justification for supplementation based on the dietary information and performance enhancement information from this chapter.