Stitch Fix Outfits Review and Tips for Your Best Fix

It is normal for teens to show interest in a vegetarian lifestyle. This article is to help you learn more about vegetarian protein choices for teen athletes.

For more nutrition tips for teen athletes, check out our posts The Best Carbohydrates for Teen Athletes and Is Prime Hydration Drink Healthy.

Protein is often the center of the nutrition conversation with athletes. While everyone needs protein, teen athletes may need more in order to support their training AND growth. Protein is imperative for building and repairing muscle, producing hormones, replacing red blood cells, supporting immune function, and more. Since the body does not store protein, like it does carbohydrates and fat, eating protein daily is necessary to support all these critical jobs in the body. 

The term “protein” is often associated with animal products, but plants provide protein too. If your teen is interested in becoming a vegetarian athlete, it can most certainly be done well but does require some education. Whether your athlete is a vegetarian, a vegan, or is simply craving a plant-based meal, look to incorporate protein-packed plants.

Questions to Start a Conversation

A helpful first step to creating a protein-packed, vegetarian friendly meal or lifestyle is to decide which type of vegetarian your athlete is. Have an open conversation with your teen. Listen to why they are interested in this new way of eating and what is the most important components to them. Here are questions you can ask to learn more about your teen’s desires:

1. What has led you to make the decision to eat in a vegetarian style?
2. What foods are you thinking of eliminating and why is that important to you?
3. What foods are interested in including more of now?
4. How can I support you with this new endeavor?

Types of Vegetarians

The term “vegetarian” can mean a lot of different things and can also be a very flexible lifestyle.  Here are the 5 classic definitions of vegetarians:

• Flexitarian – Someone who chooses less animal products but may enjoy them occasionally. Nothing is necessarily off-limits but plant foods are emphasized over animal based foods.
• Lacto-ovo vegetarian – A vegetarian that consumes milk, dairy products, eggs, grains, fruits, vegetables, nuts and needs but abstains from meat, fish, and poultry.
• Lacto-vegetarian – A vegetarian that consumes milk, dairy products, grains, fruit, vegetables, nuts and seeds, but abstains from meat, fish, and poultry. This vegetarian does may or may not eat eggs.
• Pescatarian – A vegetarian who abstains from animal products but does include seafood.
• Vegan – A vegetarian that abstains from animal products entirely, including eggs, milk and dairy products, gelatin, and foods with ingredients from animals.

Choosing Plant based Proteins

Once your athlete has decided his/her vegetarian style, identify quality foods that are protein rich, and seek opportunities to include them. Include a variety of plant protein foods because not all plant proteins are created equal. Each plant protein has a unique amount of protein and provides unique amino acids (building blocks of protein).

Add peanut butter to a smoothie, boiled eggs to a salad, black beans to spaghetti sauce, tofu to stir-fry, or cottage cheese to a fruit snack. When choosing a nut milk to replace tradition milk, be sure to read the food labels. Many nut milks are actually low in protein. Choose a brand with low sugar and at least 8 grams of protein per cup or 8 oz.

Use the chart below to help choose more plant-proteins.   

Written by: Jenna Braddock, MSH, RDN, CSSD and Alyssa Fernandez, Dietetic Intern

Teen athletes find themselves pushing the limits of their body all year round without proper recovery time. Here's 5 Reasons for More Recovery Days.

For more tips for teen athletes, try this post on Omega-3 Supplements and Protein Powder for Teen Athletes.

Go Hard or Go Home!

Pain is Weakness Leaving the Body.

Sports provides an awesome opportunity for teens to learn hard work, persistence, and tolerance for uncomfortable situations. But with the way youth sports are going these days, athletes might find themselves constantly pushing the limits of their body all year round without proper recovery time.

Rest and recovery days are essential to improve overall fitness (aerobic, strength, and power), performance, mentality, technique, and efficiency. If you do not take a rest every once in a while during intensive training weeks you are more prone to overtraining syndrome. That sounds serious, and it is!

Overtraining syndrome is excessive training, characterized by long-lasting fatigue and worsening of competitive performance with further attempts to improve physical conditions. It may show signs and symptoms such as underperformance, altered moods, loss of appetite, recurrent infection, chronic fatigue, unintended weight loss, loss of menstrual cycle and/or muscle weakness. Overtraining and underperformance may occur from other stressors such as stress, poor nutrition, and illness. Heavy training and poor recovery can cause decreased immune functions, putting the athlete at increased risk for infection and illness. To avoid overtraining it is recommended to take recovery or rest days.(1)

5 Reasons for More Recovery Days

#1 – Prevent Mental Burnout

Stress is an inevitable part of life as a teen athlete. Whether it’s a tough game, passing exams, balancing workload, building new relationships, or meeting school deadlines, stress is always around us. Constantly feeling stressed can lead to burnout, which is a real thing. Athletic burnout happens when you feel physically and psychologically exhausted from the demands of training and competing. It can produce a reduced sense of accomplishment in sports or school and lead to sport devaluation and depreciation. Rest days are crucial to balance stress because it provides an athlete time to take a step back and relax the mind and body. (2)

If your athlete is showing signs of burnout it’s important to assess just how full their schedule is. It may be time to take something off their plate and allow true rest time on weekends or weeknights.

If you are an athlete feeling stressed or burnt out, please talk about it to your friends, family, and coaches. Many schools offer counseling services as well.

#2 – Balance Hormones

Our immune system consists of leukocytes. Leukocytes (or white blood cells) help the body to fight off disease and infection. When we work out, the function of these cells may be decreased by repeated intense prolonged exercise. This can leave our body in an inflamed state which consequently reduces immune system activity. Rest days help to create more leukocytes and regulate the overall immune system. (1)

#3 – Protect the Immune System

Our immune system consists of leukocytes. Leukocytes (or white blood cells) help the body to fight off disease and infection. When we work out, the function of these cells may be decreased by repeated intense prolonged exercise. This can leave our body in an inflamed state which consequently reduces immune system activity. Rest days help to create more leukocytes and regulate the overall immune system. (1)

#4 – Muscle Repair

Workouts put our body is in a muscle break down mode, or a catabolic state. Exercise creates microscopic tears in the muscle fibers. In order to repair and gain new muscle the body needs to be in a resting state, or anabolic state. Rest days encourage muscle healing and recovery, causing muscle building. If your athlete is desiring to build muscle and strength, rest days are imperative to do so. (3)

#5 – Initiates Parasympathetic Nervous System

Rest days help initiate the parasympathetic nervous system. This system activates digestion, slows heart rate, decreases blood pressure, and stimulates other metabolic processes that help us to relax. This system plays a major role in maintaining mental and physical health. If your athlete is constantly training and stressing their body, this system does not trigger near enough. An irritable athlete cannot perform at their best on the field, at school, or in the family. (4)

How Much Recovery Time Does Your Athlete Need?

There is no ‘one size fits all’ when it comes to rest days. Rest time is highly individualized and depends greatly on your training level and exercise prescription. Research has shown that athletes need more rest time when they are starting a new training regimen (like at the beginning of a season). Also, the higher the intensity, the more time needed for muscle recovery. No matter what your workout agenda is, it is always important to listen to your body. If you see signs and symptoms of overtraining (listed above) then you need more recovery time, period. (5,6)

It can be difficult to convince yourself or your athlete that rest days are needed. Many teen athlete are drawn to continue training on the weekends or adding a second workout in a day. However, if your athlete is feeling constantly tired, overly sore, irritable, or mentally drained, more rest time is needed.  Start by adding 1-2 complete rest days into their training regime but you may need even more depending on how intense training is.

As a family, you can decide together to take rest days, saying “no” to extra activities that don’t support rest and recovery. Write it into your calendar or agenda and follow through with it.

So what do you do on a rest day? Here are a few ideas to help you out:

What to do on a Recovery Day

1. Take a nap, or sleep in if you can. Some shut eye can go a long way and help make up for lost sleep during the week.
2. Nutrition is essential to replenish the body after tough workouts. Eat three balanced meals, some snacks, and drink plenty of water.
3. Practice stretching, low intensity yoga, or foam rolling to release lactic acid and stretch muscles and tendons.
4. RICE – rest, ice, compress, and elevate – any hurting body parts.   
5. Decrease screen time – instead read a book, daydream (yes, daydream!), journal, go on a walk, and meet up with friends.
6. Do something fun! Happiness increases your happy hormones (endorphins) and help to reduce anxiety, boost self esteem, and decrease pain.

Written by Dietetic Intern Sigourney McGovern and Coach Jenna Braddock.

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963240/
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772382/
3. https://www.ncbi.nlm.nih.gov/pubmed/12617692
4. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0025455/
5. https://www.ncbi.nlm.nih.gov/pubmed/20625191
6. https://www.nccpt.com/store/products/download.php?id=324 

Omega-3 is one of the many key nutrients that is essential in sports nutrition because it can help with inflammation and soreness. Here are my recommendations for Omega-3 supplements in teen athletes as a registered dietitian nutritionist.

For more nutrition tips for teen athletes, check out our posts on Preventing Muscle Cramps in Teen Athletes and Is Prime Drink Healthy.

It is well known that exhaustive or unfamiliar exercise can lead to muscle fatigue, delayed-onset muscle soreness, and a decreased performance. Nutrition before and after exercise is essential to promote muscle repair and replenish fuel sources, giving athletes an advantage.

Unfortunately, many teens and their parents aren’t thinking about omega-3’s for sports performance. Here is what you need to know about this essential nutrient and your teen athlete.  

What is Omega-3?

Omega-3 is an umbrella term used for essential fatty acids: ALA, EPA, and DHA. During digestion of fats our body breaks it down into fatty acids. Fatty acids have important functions in our body, like storing energy. ALA is an essential fatty acid, meaning we need to eat them in our diet because our body cannot synthesize it on its own. The body is able to convert ALA to EPA and DHA, but the process is slow and not very ineffective. This is why getting sources of all the omega-3’s from the diet is so critical

In a global survey it was found that the Americans had very low blood levels of omega-3 fatty acids. Regardless of athleticism level it is recommended everyone should be consuming 500 mg/day of omega-3 fatty acids a day.

Roles of Omega-3

Omega-3 has many critical functions in the human body. Some of the most well-known roles are (1): 

• Cognitive Development
• Decreases Inflammation
• Eye Function
• Prevents Blood Clots
• Improves Attention and Responsiveness
• Improves Bone and Joint Health

While all of these roles are certainly important for teen athletes, the ability of omega-3’s to reduce inflammation is of particular interest in sports. Inflammation is a common by-product of a hard workout, practice, or game. We all know what it looks like to have too much inflammation (i.e. an injury with swelling) but even small amounts of inflammation could prevent optimal recovery.

Omega-3 and Sports

Sports nutrition focuses on two omega-3 fatty acids, DHA and EPA. This is because EPA and DHA is readily utilized by the body and can aid recovery. While ALA is not as heavily studied nor as absorbable as EPA and DHA.

The interest in omega-3 for athletes is because of the anti-inflammatory and antioxidant effect. These potential outcomes may improve tissue restoration and improve adaptation to the physical stress of training, from the muscle to even neural development. Specifically, EPA and DHA has shown favorable effects after workouts to reduce exercise triggered inflammation and muscle soreness. Also, during workouts omega-3 fatty acids improves blood flow, opening airways, and increasing flow of oxygen and nutrients into the muscle. These are all powerful reasons to focus on omega-3 intake for athletes. (2,3,4)

Benefits

Research has shown the potential benefits of omega-3 in sports as:

• Muscle metabolism and tissue recovery
• Improve functional performance
• Relieve inflammation
• Reduce sports related asthma
• Recovery from injury or traumatic brain injury
• Training adaptation
• Decrease muscle loss

Omega-3 Dosing for Athletes

Even though omega-3 has been found to be very beneficial in sports, the doses, concentration, and duration of omega-3 supplementation has not been specified. Although one study found that general guidelines for athletes should include about 1 to 2 grams per day of EPA and DHA, it is still unclear if supplementation should be pursued by all athletes.  

Talk with your pediatrician or dietitian to confirm actual dosing of a supplement for your teen. A good starting place may be around 1000 mg of total omega-3’s a day, containing a mix of both EPA and DHA.

A safe approach is to always start with food first. Think about how often your athlete is consuming food sources of omega-3’s like fatty fish, nuts, seeds, and plant-based oils.  The benefit to this approach is that not only is your athlete getting omega-3, but that food also provides a ton of nutrients and vitamins that a supplement alone may not. (5) 

Tips for increasing omega-3:

• Swap to a DHA/EPA fortified milk.
• Swap to omega-3 fortified peanut butter (affiliate link) or margarine.
• Try granola bars that have chia, hemp, or flax seeds in them. This will provide a boost of omega-3. 
• At home try cooking with flaxseed oil, cod liver oil, or canola oil.
  • These oils have greater omega-3 content and are a good oil alternative. 
• Swap out meat for seafood 1-2 times a week (salmon, mackerel, sardines, tuna, and other seafood).
  • Recommend 6-8 ounces of fish per week or 3-4 ounces a serving.
• When shopping choose grass-fed beef and omega-3 fortified eggs. (6,7,8)
  • These are more expensive options, and are not the only way to increase omega-3 consumption.
• Eat 1 oz of nuts a day like almonds or walnuts.
• Top yogurt, cereals, smoothies, and salads with 1-2 tablespoon of chia seeds, ground flaxseed, or walnuts.

Omega-3 Tips

If an omega-3 supplement is best for you or your athlete here are some tips:

• Take supplement with food or close to mealtime to promote optimal absorption of omega-3 fatty acids.
• Remember that more is not better. Stick to recommended guidelines or health practitioner recommendations for the amount of daily omega-3 mg needed.
• Taking the supplement with a high fat food may boost absorption, such as avocado, peanut butter, and nuts.
• Check for freshness by smelling for rancidity, refrigerate to keep fresh.
• If your athlete experiences unpleasant burping after taking their supplement, try storing it in the freezer and taking it frozen. You can also buy supplements that reduce this side effect.
• When shopping look for:
  • The dose amount (mg)
  • Amount of EPA and DHA: read ingredients  
  • Form of omega-3: fish oil, krill oil, algae, etc. 
  • USP, NSF, Informed Sport or Informed Choice certifications on supplements, which are governing bodies that certify for purity.

Takeaways

Omega-3 is important for overall health and may particularly be beneficial for athletes. Research has shown that omega-3 may positively impact athletic performance by relieving muscle soreness and decreasing inflammation. To get the full benefits of omega-3 athletes should first eat foods like fatty fish, plant-based oils, nuts, seeds, and algae. If your athlete does not eat these food regularly, then you might consider a supplement.

Omega-3 supplements can be found over the counters in the medicine section at your local grocery store. You can also purchase it online through reputable companies like Nordic Naturals and Brain Armor.  The recommended amount of omega-3 for the American diet is 500 mg per day, but in sports nutrition research there is no set dose amount. A dose of around 1000 mg may be a good starting place for a supplement, but it is important to first consult your pediatrician or dietitian.

WRITTEN BY DIETETIC INTERN SIGOURNEY MCGOVERN AND COACH JENNA BRADDOCK.

References

1. https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/
2. GLIGOR Șerban, GLIGOR R. The potential role of omega-3 fatty acids supplements in increasing athletic performance. Timisoara Physical Education & Rehabilitation Journal. 2016;9(16):25-34.
3. Jakše B. Potential Benefits of Consuming Omega-3 Fatty Acids for Artistic Gymnasts. Možne Koristi Uživanja Omega 3 Maščobnih Kislin Pri Orodni Telovadbi. Science of Gymnastics Journal. 2017;9(2):127-152.
4. Atashak S, Sharafi H, Azarbayjani MA, Stannard SR, Goli MA, Haghighi MM. Effect of Omega-3 Supplementation on the Blood Levels of Oxidative Stress, Muscle Damage and Inflammation Markers After Acute Resistance Exercise in Young Athletes. Kinesiology. 2013;45(1):22-26.
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2846864/https://www.ncbi.nlm.nih.gov/pubmed/21673178https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5434201/
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2846864/
7. https://www.ncbi.nlm.nih.gov/pubmed/21673178
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5434201/

Including Cognitive Behavior Therapy, a psychological recovery piece, within injury recovery therapy creates a positive, whole-body healing environment. Here's what we mean:

For more tips for teen athletes, check out our posts on Signs and Symptoms of Iron Deficiency and The Best Carbohydrates for Teen Athletes.

Injuries On the Rise

The multi-sport athlete is becoming a thing of the past.  Competitive seasons are becoming longer and our young athletes are practicing all year long for one sport. Because of this, evidence shows injuries are on the rise.

I was not resistant to this trend as a child.  I held my first tennis racquet at 3 years old and I was hooked.  My mother was a professional tennis player and, as my coach, we spent the majority of my childhood on the tennis court together, developing the fundamentals and skills of the sport.  Weekends were rarely a time for relaxation, as we were constantly traveling the state for tournaments.

As I rose in the junior rankings, my confidence evolved and I felt that my success on the court began to define me.  I thought my mom and I were unstoppable, until I hit my first speed bump as a young tennis player. During a tournament in south Florida, I sprinted for a short ball, sliding to stop myself before reaching the net.  My front foot hit a shallow patch of clay and my ankle turned over. I couldn’t bear weight on my left leg as the pain and inflammation began to set it. The tournament was over for me. I had to withdraw, forfeiting the match so I could tend to my injured ankle.  

More Than a Sprain

A sprained ankle can be detrimental to a tennis player, as stability in the ankles are key to handling the dynamic footwork and speed the sport requires. Fortunately, the sprain was minor and my ankle healed soon enough. The pain and swelling had subsided and I was ready to return to the court with my mom.

We worked on ground strokes initially, regaining the timing of the forehand and backhand.  When I felt comfortable, my mom began to hit me some short balls. I rushed forward to meet the ball before the second bounce and hesitated.  Let’s try again. My mom hit another one and, once again, I hesitated. I was worried my ankle would give out on me as I stepped into the ball.

I didn’t understand.  

My ankle didn’t hurt, but my mind was stopping me from doing what needed to be done.  I became extremely frustrated as the next few training sessions went similarly. The mental block I had affected my performance considerably, as I became more  and more timid to chase down balls on the slippery clay. My mental and physical game suffered. A minor ankle sprain turned into weeks and months of missing tournaments and there was no concrete reason why.  

Fear of Re-Injury and Return to Sport

Returning to competitive sport following an injury can be a daunting task, especially for our young athletes.  In most cases with these young athletes, their first encounter with injury will be the toughest not only physically, but mentally.  

The mindset of invincibility of a young athlete has its pros and cons.  

On one hand, it can facilitate immense progress in their discipline, as growth is uninhibited by fear and doubt.  On the other hand, it can build a false sense of invulnerability to injury and when injury occurs, as it inevitably will, that foundation of invulnerability is broken and can leave the athlete feeling exposed and unsure of their future in their sport.

Reality will set in: the body they have relied on for success, achievement, and victory has failed them.  This realization is debilitating in many young athletes, as they naturally become more susceptible to breaks, sprains, and strains. Because of this, the road to injury recovery may be a bumpy one.

Psychological Factors

Psychological factors inhibit the mental and physical healing process and “When I return to play…” can unfortunately become “If I return to play…”.  

Approximately 47% of athletes do not return to sport following injury and, out of this 47%, only 36% do not return due to lasting physical impairments.1  

The assumption can be made that the remaining 64% are not returning to play due to a psychological barrier or fear of re-injury.  

This fear of re-injury not only has psychological effects, but widespread physical ramifications including decreased muscular endurance and activation, altered muscle recruitment strategies, increasing likelihood of re-injury, decreased dynamic joint stability and range of motion, and delayed and improper tissue healing.2  

As important as physical rehabilitation can be, the current model of rehabilitation focuses primarily on physical markers with minimal emphasis placed on psychological recovery. 

By including Cognitive Behavior Therapy, a psychological recovery piece, within therapy, a positive, whole-body healing environment can be created.  

What is Cognitive Behavioral Therapy?

Cognitive behavioral therapy, most commonly referred to as CBT, is a form of psychotherapy that uses specific principles to modify negative emotions, behavior, and thoughts.

This form of psychotherapy differs from conventional, Freudian psychotherapy in that it does not attempt to identify the root of negative emotions, but simply replace these negative emotions with positive ones.

Utilization of CBT is heavily researched in athletes and has been proven to enhance performance across the board.  Unfortunately the efficacy of CBT’s impact on fear of re-injury and return to sport is limited. Therefore, there are minimal recommendations for the implementation of CBT in the rehabilitation of our athletes.  In my practice, I attempt to find a standardized method of CBT through trial and error, and have found beneficial results in my young athletes. Let’s get to the specifics, shall we?

How to use CBT

Mental Practice

Mental practice involves the cognitive rehearsal of a task, typically used if an individual is unable to physically perform a task.  With my athletes, I used mental practice prior to every new exercised performed.

I would have my athlete visualize exactly how the exercise should be performed, with an external focus rather than an internal focus.

For example, if the athlete was performing a box jump, they would simply visualize jumping from point A to point B, rather than focusing on the anatomical structures required to perform the box jump.  This external focus solely on the outcome of the task been proven to increase performance while decreasing the emphasis placed on the physical strain of the exercise.3  

Early on in the athlete’s rehabilitation, mental practice should be performed for 1 minute and slowly reduced in 15 minute increments, decreasing the reliance as the athlete progresses.

Positive Self-Talk

Negative thoughts flood the mind while recovering from injury and can be detrimental to progress. Replacing these negative thoughts is key to the athletes future performance. A professional golfer would never approach a putt thinking, “I’m going to miss this.”  In their mind, they have accepted failure and the outcome will reflect that. This needs to be replaced with, “I am going to make this putt.”

Positive self-talk in athletes has actually been correlated with decreased anxiety, improved concentration and focus, and better performance in sport.4  So how can we transfer this practice of positive self-talk to our injured athletes? Positive self-talk can begin with a simple, general mantra:

Mantra

“I can do this.” The athlete should repeat this mantra whenever a new exercise or task is introduced. Their perspective on the task with change as they become mentally resilient to the possibility of hesitancy and failure.  As the athlete progresses, their mantra can change, becoming more specific to their sport and the task at hand. Whatever they choose, it should be something they fully believe is achievable in order to bridge the gap between the perception of failure and success.

Graded Exposure

Release of the athlete back into their sport should be gradual, as to not overwhelm the athlete with challenging tasks outside of their capabilities.  This graded exposure allows the athlete to build confidence in a progressive manner.

By breaking the sport down into components, variables can be manipulated and controlled, giving the athlete a sense of regulation over their environment.  The components should increase in difficulty as the athlete builds confidence, with the goal of simulating the competitive environment and all variables anticipated just before the return to sport. As a coach or parent, be mindful of this and return an athlete back to play gradually.

Faded Feedback

We are constantly giving feedback to our young athletes.  Feedback in the developing athlete is of utmost importance, but in the injured athlete, reliance on this feedback can be an issue.  Movement will change with injury and normalizing movement though the rehabilitation process is always a priority.

In our young athletes, coaching and feedback will help build confidence in their movement as they begin to redevelop skills.  In the beginning stages of returning to sport, feedback can be provided the majority of the time following an exercise or drill as the athlete will be very reliant on an outside perspective.   But, as the athlete progresses, feedback should be given less and less. This faded feedback will give the athlete confidence that they no longer need validation for their performance.

Final Thoughts

So, what’s the common theme here?  

Confidence.  

Regaining confidence in our injured, young athletes should be a huge factor in their speedy and safe return to sport.  The answer to this universal issue is the incorporation of mental exercises into rehabilitation.  There needs to be change in the rehabilitation of these athletes, shifting from a heavy emphasis on just physical recovery to also including psychological recovery. Just like the body, the mind will adapt to consistent, progressive, and specific overload and can be highly effective with the use of CBT.  I believe this additional training will increase the effectiveness of rehabilitation and have our young athletes return to sport mentally stronger than before their injury.

As a parent or coach you can work with your athlete on building confidence by implementing the techniques listed above.

Written by: Ray King

Ray King is a 3rd year student in the Doctorate of Physical Therapy Program at the University of North Florida.  He graduated from the University of Florida in 2016 with a degree in Applied Physiology and Kinesiology, with the specialization in Exercise Physiology. Ray played competitive golf and tennis throughout his youth, before transitioning to compete in CrossFit and Olympic Weightlifting after graduating high school in 2012.  He’s currently Co-Owner and Fitness Consultant for The Anabolic Agenda, an online company that strives to guide clients in meeting nutrition and performance goals.

Special thanks to Dr. Sherry Pinkstaff, PhD, PT, DPT, for support in this topic.

References

1.     Kvist, J., Ek, A., Sporrstedt, K., & Good, L. (2005). Fear of re-injury: A hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 13(5), 393–397. http://doi.org/10.1007/s00167-004-0591-8
2.     Hsu, C., Meierbachtol, A., George, S. Z., & Chmielewski, T. L. (2016). Fear of Reinjury in Athletes. Sports Health: A Multidisciplinary Approach, 9(2), 162-167. doi:10.1177/1941738116666813.
3.     Marchant, David C; Greig, Matt; Scott, Catherine. Attentional Focusing Instructions Influence Force Production and Muscular Activity During Isokinetic Elbow Flexions. The Journal of Strength & Conditioning Research: November 2009 – Volume 23 – Issue 8 – p 2358-2366, DOI: 10.1519/JSC.0b013e3181b8d1e5
4.     Raalte, J. L., & Vincent, A. (2017). Self-Talk in Sport and Performance. Oxford Research Encyclopedia of Psychology. doi:10.1093/acrefore/9780190236557.013.157

Iron deficiency anemia is a real concern for many young athletes, but it can be tricky to identify at first. Here is the story of how a female pole vaulter came to recognize the signs and symptoms of iron deficiency anemia and how she recovered from it. Knowing this information can help prevent your teen athlete from missing play due this common health issue.

For more nutrition tips for teen athletes, check out Meal Planning for Teen Athletes.

Of my many memories of my four years as a collegiate pole vaulter, I will never forget the day during my freshman year that I passed out on the football field during a sprint workout. The experience is still very real to me- the taste of the rubber turf, the horrible abdominal cramps, the shame of walking back to the athletic training room, workout incomplete. At the time, the athletic trainers and I had attributed this incident to not being hydrated or conditioned enough.

To ensure that it would never happen again I did what any ambitious athlete would do: I trained harder.

Intent on not repeating the experience on the turf that year prior, I had practiced some of the harder workouts over the summer and started to grow accustomed to the uncomfortable cramping feeling that seemed to show up at the end of any intense running workout.  I felt as prepared as any athlete could be for fall conditioning (i.e kind of, but not really) until our coach told us we’d be doubling up practices in order to cut down the time spent on getting back into shape. One week into conditioning, the cramping started getting worse, and I began feeling out of breath quicker than I normally would. One workout which consisted of ‘ladder’ style sprints up a 400m hill, left me so exhausted that I went home after practice at 5pm and slept until the next morning.

My performance the rest of that week declined quickly. By the end of the week, I remember barely being able to run the warm up lap without feeling fatigued. In a circuit training workout, I had gotten so light-headed and fatigued during sit ups that my eyes were rolling back in my head every time I sat back up. The cramping was getting worse with each work out. At this point, my teammates were also concerned. They noticed the change in my performance – from top three to last.  

I was also now sleeping any chance I got. While I was upset about my performance at practice, the need to sleep allowed me to not focus on it.

I went to the athletic trainer, desperate to rid myself of the nauseating/cramping feeling. We talked about making sure I was getting enough sleep and the proper nutrition. He explained that cramping was commonly due to electrolyte imbalance, so he recommended hydrating with only Gatorade before practice.  He also recommended changing the timing of my meals.

In the following days neither seemed to help. I made it to the weekend, extremely frustrated and exhausted. My next method of attack would be my mentality. I would maintain a positive attitude no matter how terrible I felt, however; my optimism didn’t last long. Not making a single time during the next workout earned me an extra set of sprints. I didn’t even bother setting my watch because I knew there was no way I would be making the times.

Wanting to Quit

I was on the verge of quitting. I had tried adjusting my water intake, my food intake, maxing out electrolytes, prioritizing 8 hours of sleep, and even adjusting my mentality but I was still exhausted and performing poorly.

Three weeks into fall conditioning, my coach began to suspect something more severe was going on. I received the following text:   “Go to the nearest clinic and ask to get your iron ferritin level tested.” Desperate for an answer I scheduled an appointment for first thing the next day. At the clinic I explained to the physician my constant fatigue, lightheadedness, and abdominal cramping with exercise. I was walking to my coach’s office later that afternoon when I received a call back from the physician herself with my lab results:

Iron Ferritin: <5 ug/l

Hemoglobin: 8.5 mg/l

What is Iron Deficiency Anemia

Iron is a micronutrient that plays an integral role in physiologic functions such as oxygen transport and energy production (Alaunyte, 2015). Due to the combination of menstruation, increased iron loss through hemolysis (red blood cell rupture), and insufficient dietary iron intake female athletes are frequently affected by this condition (McClung, 2014).

The World Health Organization, and other sport organizations like the US Olympic Committee, use serum (blood) iron ferritin and hemoglobin levels to diagnose iron deficiency anemia. There are 3 stages of iron depletion:

Source: Kapinski, 2017

Signs & Symptoms of Iron Deficiency Anemia

The tricky part of identify this condition is that iron deficiency is asymptomatic in the first stage. As iron levels begin to drop, however, more symptoms arise due to impaired oxygen transport.

Stage 3 indicates that the body’s iron stores have been so depleted that it is no longer able to make new red blood cells, resulting in a decreased ability to transport oxygen throughout the body during rest – let alone during exercising when your body needs even more oxygen.

Other common symptoms of IDA are:

• gastrointestinal cramping
• extreme fatigue
• dizziness
• depressed thyroid function
• decreased ability to regulate body temperature (Suedekum, 2005) 

According to the National Institute of Health’s Office for Dietary Supplements, premenopausal female endurance athletes are at a high risk for IDA, especially those that have a restricted energy intake and heavy menstrual bleeding.

Recovering from Iron Deficiency Anemia

Since there are 3 different levels of iron deficiency, each athlete should consult a medical doctor and registered dietitian to determine the best course of treatment. In most cases, an iron supplement is prescribed. Iron supplements are easy to acquire over the counter but still use under the supervision of a medical doctor.

In addition to iron supplementation, rest from training may be required as well as additional dietary changes.

Due to the severity of my low iron level, I was prescribed an iron supplement and was instructed to stop all running for a minimum of 6 weeks to let my fragile red blood cell count increase. I was also advised to take oral iron supplements with orange juice and avoid drinking tea or coffee with meals. This curious combination stems from the ability of vitamin C to enhance iron absorption. Foods such as fruits, potatoes, and leafy greens have high levels of vitamin C which helps the body take in and store the iron we eat in our foods (WHO, 2001).  

Calcium

Conversely, the calcium found in milk products, as well as foods that contain tannins such as tea, coffee, cocoa and certain spices largely inhibit the body’s ability to absorb iron.  In addition to the high volume of endurance workouts, I had also been drinking iced tea or chocolate milk with almost every meal, thus inhibiting my body from absorbing what little iron I was ingesting.

After six weeks of no impact running, and avoiding tea or milk consumption during meals, I had my blood levels tested again.  My hemoglobin level had risen to 9.1 mg/l, and my iron ferritin was at 50 ug/L. I was told to take two more weeks off to let my hemoglobin rise further, and then was cleared to return to practice. As nervous as I was to run again, I had begun to feel exponentially better. My daily naps were no longer needed, and the weight training and cross training (biking/elliptical) no longer left me winded. My first practice back was a hill workout- I would never miss time on a workout for the rest of my collegiate career.

Educate Yourself

At the end of my anemia journey I was happy to finally have an explanation for the suffering I had gone through, but I couldn’t help but be angry and disappointed that I had not been educated earlier on the importance of iron.  I learned then that this was in part due to the fact that not all athletes are treated the same. While it is common for track athletes (sprinters and distance runners) to be educated on these issues, it is rare that field athletes (jumpers, pole vaulters, throwers) received the same education.  

Impacts

Iron deficiency anemia can have dramatic impacts on an athlete’s physical, emotional and mental health, and yet it is very easy to prevent, or at least catch very early. Education on the importance of a healthy, iron rich diet, especially among ALL female athletes is integral in preventing future cases of IDA and other common sport related issues such as the female athlete triad (a dangerous trio stemming from over-training, inadequate energy intake, and dysmenorrhea, or cessation of the menstrual cycle).

My mental health and self-esteem had also been greatly affected by this event. Had my coach not identified iron deficiency as a potential issue, I’m not sure I would have continued to participate in track and field. I had felt inadequate as an athlete, and my exhaustion often left me hopeless and upset.

Following my recovery, I gained a new outlook on sport performance and perseverance. Although we are often encouraged to push through the pain to get faster and stronger, pushing through my circumstances had left me in worse shape. Once my iron levels had returned to normal, my performance improved drastically and I was safely able to explore my mental and physical boundaries.

Proper iron intake should be priority for all coaches and sport medicine personnel- a simple educational session could be the difference between high level performance and running slow. 

Written By

Written by guest coach: Skylar Schoen is a 2nd year student in the Doctorate of Physical Therapy Program at University of North Florida. Originally from Batavia, IL, Skylar attended Grand Valley State University (Allendale, MI) and graduated in 2017 with a degree in Clinical Exercise Science, Pre-Physical Therapy Emphasis. While at GVSU, Skylar competed for Grand Valley’s Track and Field team as a DII collegiate Pole Vaulter. During her time as a collegiate athlete she made three appearances at the Division II National Track and Field Meets (Indoor & Outdoor).  Skylar moved to Jacksonville in 2017 and currently is an avid reader, surfer, yogi, and triathlete in training.

I’d like to thank my professor, Dr. Sherry Pinkstaff, and Jenna Braddock for allowing me this space and platform to share my experience with the sports world. I hope that this article encourages both athletes and coaches alike to consider iron deficiency and the importance of identification and prevention in helping promote the highest level of sport performance.

References

Iron Deficiency Anemia: Assessment, Prevention, and Control. World Health Organization. 2001

McClung JP, Gaffney-Stomberg E, Lee JJ. Female athletes: a population at risk of vitamin and mineral deficiencies affecting health and performance. J Trace Elem Med Biol. 2014;28:388–92.

Office of Dietary Supplements: National Institutes of Health. Dietary Supplement Fact Sheet: Iron. Accessed at: http://ods.od.nih.gov/factsheets/Iron-HealthProfessional/

Suedekum NA, Dimeff RJ. Iron and the athlete. Curr Sports Med Rep. 2005;4:199–202

World Health Organisation. Assessing the iron status of populations. Geneva, Switzerland: WHO Press; 2007

Whiting SJ, Barabash WA. Dietary reference intakes for the micronutrients: considerations for physical activity. Appl Physiol Nutr Metab. 2006;31:80–5

Alaunyte et al. Iron and the female athlete: a review of dietary treatment methods for improving iron status and exercise performance. Journal of the International Society of Sports Nutrition (2015) 12:38

Karpinski C, Rosenbloom C. Sports Nutrition: A Handbook for Professionals, 6th Edition. Academy of Nutrition and Dietetics. 2017.

RED-S, Relative Energy Deficiency in Sport is a debilitating syndrome for teen athletes. It often includes disordered eating and keeps an athlete from thriving and competing. Here’s what you need to know about RED-S and disordered eating in teen athletes.

This article is written by Karli Himmelreic, and edited by Jenna Braddock.

My Story with Disordered Eating as a Teen Athlete

Sunny, 80 degrees, with a slight October breeze from the river near our middle-school fields. Sounds like the perfect Florida afternoon for a cross country practice, huh? Usually, but that day for me it meant another hour of pushing my body to its limits, which was feeling increasingly more difficult lately. It meant another hour of feeling lightheaded and ignoring my growling stomach while I pushed myself through another tempo run. The breeze hit my skin, and I shivered with goose bumps. I was always cold now, so I shook it off and went on the run. I fought to make sure my foot landed on the ground with each step so that I wouldn’t collapse from hunger. Shakily, I walked back to the track, stretched, and talked with my friends.

While navigating some stressful family dynamics at home, trying to be a good oldest child, and having a perfectionist-seeking attitude towards school work, I sought comfort in the one thing I felt that I could control in my busy and hectic life: that being control over how much, or rather, how little I ate. — 

Effects On My Body

It did not take long for weight to shrink off of my already small frame. My skin turned yellowish, I developed a strange fuzz (called lanugo [6]) on my arms, my hair was falling out, my nails were flaking apart; all of my clothes were too big. I was so awfully fatigued, but I had trouble sleeping because I was so hungry. I was a straight-A student, but found it increasingly difficult to focus, particularly while fighting thoughts about the next meal I would allow myself, and how many calories it would be.  In short, my body was shutting down, and I was miserable, despite the constant support and concern of my loved ones. 

At the young age of eleven, I was diagnosed with an eating disorder called Anorexia Nervosa. This is a mental health disorder, characterized by weight loss and/or difficulty maintaining or refusal to maintain a healthy body weight, along with an intense fear of gaining weight, often accompanied by preoccupation with food and/or exercise and severe calorie restriction, among other symptoms [1]. In addition to this, my recreational activities as a runner and athlete also gave me another diagnosis, called “female athlete triad” [8]. 

I realize that this is a heavy history, but this is also a success story so stick with me. I share all of this to bring to light the fact that eating disorders can happen to anyone, at any age. It is my hope that through sharing my story, explaining these conditions, and providing some resources for parents and their children that together we can foster healthy minds and healthy bodies for our female athletes of all ages. 

Female Athlete Triad now called Relative Energy Deficiency in Sport (RED-S)

The Female Athlete Triad is defined as any combination of the following: low energy availability (with or without a clinical eating disorder), menstrual dysfunction, and low bone mineral density (BMD). While this is still a relevant term, it’s been discovered that some of these symptoms can also occur in men and are just as dangerous. Therefore, in 2014, the International Olympic Committee created a more gender-encompassing diagnosis, Relative Energy Deficiency in Sport (RED-S). In women, these diagnoses may be used interchangeably. 

What is RED-S

The Triad, now RED-S is a vicious and inter-related cycle that can have severe long-term health consequences [3,6].  It is considered a syndrome with impaired physiological function that is caused by low available energy and includes, but is not limited to these symptoms: 

• Impaired metabolic rate 
• Impaired menstrual function  
• Impaired bone health 
• Poor immunity 
• Inadequate protein synthesis
• Impaired cardiovascular health[10] 

If any of these symptoms are observed in an athlete the American College of Sports Medicine Position Stand on Female Athlete Triad states that it is “IMPERATIVE that if one of these syndromes/conditions are recognized, then the rest be screened for”, as these conditions so commonly occur together [4].

If your athlete is experiencing fatigue but none of the other symptoms, it could be iron deficiency anemia. Read more in this post, The Signs & Symptoms of Iron Deficiency Anemia.

Low Energy Availability

The root cause of RED-S is most commonly attributed to an athlete not eating enough energy/fuel/food to support the amount of energy needed expended by activity and basic body functions. 

To simplify this problem into an equation: energy out (significantly) > energy in.  

This may not make sense at first glance, as an athlete may seem like he or she is eating. But keep in mind that calories are needed to not just fuel athletic activities, but also daily activities like going to school, and baseline functions like digestion and keeping your heart beating.

Low energy availability can occur unintentionally where the athlete is not aware or does not have the time or resources to consume the amount of food that their body needs for them to keep up with their daily activities, including sports. However, it often occurs more “intentionally” through disordered eating practices[2]. An athlete could be intentionally restricting certain foods, food groups, or overall calories or it could be more severe as in the case of anorexia. 

Why is not eating enough such a problem for athletes?

It is because low energy availability is the catalyst for the pathophysiology of the rest of the syndrome of RED-S! [2, 10] Inadequate essential nutrients translates into inadequate essential building blocks for hormones and body structures, such as bones and muscle tissue. Acutely, this negatively affects athletic performance and recovery, as well as interrupts all other body systems and the athlete’s ability to concentrate. 

Without enough calories – and sufficient distribution of those calories from our basic macronutrients (carbohydrates, proteins, AND fat), the body will not be able to produce all its hormones, nor be able carry out other vital functions. To preserve energy, the body will often “shut down” non-essential functions that require energy in the form of calories, such as reproductive health. For a young female athlete, this can have a severe impact on her menstrual cycles, or delay that start of her first menstrual cycle (termed “menarche”), which can in turn have major impacts on her bone and reproductive health in the long run. [7]

Calcium

Calcium is a vital mineral in the body, as it is required for muscle contraction, including cardiac muscle of the heart, in addition to bone health and other essential functions. Low energy availability deprives the body of this high-esteemed electrolyte and will acutely “strip” bones of their vital calcium and vitamin D, in order to maintain these careful balances in the bloodstream required for homeostasis [7]. This is also related to menstrual dysregulation because the female sex hormone estrogen is a mediator in the balance of bone building (osteoblastic) and bone break-down (osteoclastic) activity. Thus, lower levels of estrogen not only affect the menstrual cycle, but also interrupt this bone metabolic balance, leading to excessive bone breakdown [2]. Long-term, this translates into earlier risk of osteopenia or osteoporosis, and a heightened risk of stress fractures [2,7].

Determining if Your Athlete has RED-S

Diagnosing RED-S is done by a medical professional. Unfortunately your pediatrician may not be aware of, or comfortable with this condition if they don’t work with athletes regularly. Sports medicine practitioners are usually well equipped in quickly recognizing RED-S. Physical Therapists, Athletic Trainers, and Registered Dietitians certified in sports nutrition are usually educated on RED-S (but cannot legally diagnose) and may encourage an athlete to seek medical care. Regardless of who your preferred practitioner is, if you suspect your child is experiencing one or more symptoms of RED-S, do not stop until you find a provider experienced in treating it. 

Treatment of RED-S

The first step most practitioners will prescribe for treatment of RED-S is suspension of training for and playing in sports (AKA “rest”).This is a necessary step for quickly reducing the amount of energy the body is expending.

Typically “rest” means “don’t do anything beyond walking around” but is best determined by your doctor and/or Physical Therapist. Athletes are often unhappy about this step, but I assure you it is necessary. 

The next step is usually to significantly increase calorie intake. This is where working with a Registered Dietitian Nutritionist is very valuable. They can help you and your athlete determine how to add energy and nutrition to most quickly help you recover. They also may recommend supplementing with things like calcium, vitamin D or omega-3 fatty acids, but make sure you seek personalized recommendations before beginning a new regimen. 

After these important first steps, it’s a bit of a waiting game to see how the body responds. The goal is to increase weight (if needed), strengthen impaired physiological functions, and allow any injuries to heal. Working with a Physical Therapist during this time may also be beneficial. 

Returning to play should be done with great caution and under the influence of your medical doctor. A RED-S risk assessment model is used to categorize athletes as red/high risk, yellow/moderate risk or green light/low risk and is a guide for when an athlete is probably ready to return to training. This assessment tool can be found on page 5 of this RED-S article. 

RED-S Warning Signs for Parents & Coaches of Athletes

In reflecting on my experiences, I also want to summarize and share some helpful tips to parents, athletes, and coaches to look out for in regard to RED-S and disordered eating:

• Pay attention to how your child talks about and acts around food as they are warning signs:
  • Are they barely eating and/or picking at meals? 
  • Restricting certain foods or food groups without a medical reason? 
  • Are they hiding food?
  • Rushing to the bathroom immediately after meals? 
  • Saying they need to exercise to “burn it off”?
  • Preoccupation with food or exercise 
• Other obvious, physical warning signs: [1]
  • Intolerance to cold and incessant coldness, even when it is warm outside 
  • Development of lanugo, or fine hair on the skin
  • Sudden loss in weight
  • Excessive bagginess of clothes
  • Loss of menstrual cycle or absence of menarche in a female 16 or older
  • Decline in athletic performance, in combination with the above signs
• Subtle signs that may be noticed overtime or in conversation with a medical professional:
  • Monitor your child’s growth chart and attend pediatrician check-ups regularly!
    • A sudden decline in a child’s growth chart without any other medical cause can indicate a chronic nutritional deficiency (CDC, 10).
  • Be alert and aware of chronic injuries, particularly those associated with the triad, such as recurrent stress fractures that heal poorly.

Tips for Parent Involvement

• Prepare to practice your patience muscle. If your athlete is dealing with disordered eating patterns, they take time and a lot of work to improve. 
• Be a loving guide in your child/athlete’s food intake – check in with them in a non-hovering way and encourage well-rounded habits
  • Make lunches together so you are able to observe choices. You’re child may not be in a good place to make these decisions alone. 
  • Discuss options of healthy foods your athlete would enjoy and try to make them available. Focus on finding an enjoyable source of calcium each day as well as satisfying sources of fat. 
• Enlist a Registered Dietitian Nutritionist (RDN) who is a Certified Specialist in Sports Dietetics (CSSD) as quickly as possible to help your child get on a more nourished eating path.
  • We offer a dietitian created online course on How To Gain Weight, which is appropriate for some athletes in this situation, but not all.
• Check in with your child’s doctor regularly and privately if needed.
  • Look at growth charts and trends [10].
  • Be mindful of the conversations you have with your pediatrician in your child’s presence. They might not all be appropriate for their ears. 

More Tips

• Ask your child how they are feeling and handling stress. Encourage them to talk about their feelings about their body and mind, and don’t be afraid to seek help if they are struggling. 
• Build your athlete emotionally as best you can and in a way they receive.
  • Spend quality time together where you are not distracted by your device. Good conversations with teenagers happen when you least expect them. 
  • Let your child know you are on their side and here to help them. 
  • Encourage them to continue making the choice to fuel their body, even when it’s hard or not what they want to do. 
• USE YOUR VOICE. Parents, please do not be afraid to have this conversation with your athletes; and don’t let it go just because they “look healthy” to you. 
• Encourage your child to be an active participant in their health and growth, but also encourage them to find joy in their body’s capabilities- with less emphasis on how it looks as they develop. 

**If you or someone you know is concerned about disordered eating, use this screening tool to learn more: https://www.nationaleatingdisorders.org/screening-tool 

My Recovery Experience

To help you understand how this all works, I’ll share a little more on how RED-S affected me:

Because my body was so severely deprived of essential nutrients as an eleven-year-old, I had a delayed menarche, and struggled to maintain a regular menstrual cycle for years. My childhood and adolescent growth was also stunted, signified by an overall reduction in my estimated height based on my previous growth charts [10]. 

Eventually, I grew and achieved a healthy weight for my height, but I continued to train my body on metabolically compromised bones. This resulted in stress fractures and nagging injuries that kept me out of numerous competitions, including my senior state level cross country meets. 

Unfortunately, I struggled with my eating disorder for almost 10 years, experiencing a very scary relapse with anorexia and anxiety in college. I was experiencing the same symptoms as before, but this time with abnormalities in my heart rate and rhythm. I had to be frequently monitored by my doctors, almost causing me to take a medical leave from college. During my junior year of college, almost 9 years after my diagnosis of anorexia, my body was in a state of very poor health, and this is when I decided to seek treatment with a more definitive approach.

Inadequate Nutrient Intake

For me, the primary factor in all of this was inadequate nutrient intake, which resulted in complications of all the components of the triad. However, this situation can be prevented, and these adverse health effects avoided. Proper treatment for this can result in high success rates, particularly with a multi-disciplinary approach, especially when combined with support and from the athletes’ families and coaches [3].

I am incredibly grateful for the dedicated and high-quality care I received in both my adolescent and college-aged years. Without my team of health-care professionals and the support of my family, I would not be where I am today – finishing up my Doctorate degree in Physical Therapy, able to healthfully train for marathons, and getting ready to marry the most wonderful man.  

Karli Himmelreic is currently finishing her Doctor of Physical Therapy Degree at the University of North Florida and is passionate about helping adults and children with disabilities. She received her Bachelor’s of Science in Exercise Physiology from Florida State University. In her free time, you can catch her doing something outside – running, reading, or spending time with her fiancé and her family. She would like to thank both Jenna Braddock and her UNF professor, Dr. Sherry Pinkstaff, for assisting her in writing this piece and providing a platform to share her story.

References

1. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia 
2. Brown, K. A., Dewoolkar, A. V., Baker, N., & Dodich, C. (2017). The female athlete triad: Special considerations for adolescent female athletes. Translational Pediatrics, 6(3), 144–149. https://doi.org/10.21037/tp.2017.04.04 
3. Thein-Nissenbaum, J., & Hammer, E. (2017). Treatment strategies for the female athlete triad in the adolescent athlete: current perspectives. Open Access Journal of Sports Medicine, Volume 8, 85–95. https://doi.org/10.2147/oajsm.s100026 
4. Carol, L. M. D., D, B. P., Mimi, M. D., D, A. P., & D, J. P. (1997). ACSM Position Stand: The Female Athlete Triad, 29(5). 
5. https://www.nationaleatingdisorders.org/screening-tool 
6. https://www.nationaleatingdisorders.org/health-consequences 
7. Drabkin, A., Rothman, M. S., Wassenaar, E., Mascolo, M., & Mehler, P. S. (2017). Assessment and clinical management of bone disease in adults with eating disorders: A review. Journal of Eating Disorders, 5(1), 1–9. https://doi.org/10.1186/s40337-017-0172-0 
8. https://www.eatingdisorderhope.com/information/eating-disorder/dangers-of-female-athlete-triad-syndrome 
9. Joy, E., De Souza, M. J., Nattiv, A., Misra, M., Williams, N. I., Mallinson, R. J., … Borgen, J. S. (2014). 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return To Play of the Female Athlete Triad. Current Sports Medicine Reports, 13(4), 219–231. https://doi.org/10.1249/jsr.0000000000000077 
10. https://www.cdc.gov/growthcharts/cdc_charts.htm 
11. Mountjoy, M et al. (2014). The IOC consensus statement: beyond the Female Athlete Triad –Relative Energy Deficiency in Sport (RED-S). British Journal Sports Medicine. 48, 491-497.

You’ve probably seen the Prime Hydration drink lining the shelves at your local grocery store or even in student’s lunch boxes at school. The Prime brand, created by athletes and social media stars KSI and Logan Paul, is promoted primarily to children, teenagers, and young people who participate in exercise and athletic sports. As a registered dietitian, I want to take a deep dive into what this relatively new beverage is made of. The big question is, is Prime hydration healthy? 

For more nutrition tips for teen athletes, check out Creatine for Teen Athletes.

What Do Sports Drinks Do?

Athletes turn to sports drinks to help with hydration and improve athletic performance. These formulas are designed to hydrate and restore electrolytes and carbohydrates that are lost during exercise. When we look for a helpful sports drink we are typically looking for 3 things: electrolytes, BCAAs, and Carbohydrates. Electrolytes such as sodium, potassium, chloride, magnesium, calcium, and phosphate serve to replenish what is lost through sweating. To slow fatigue and improve muscle function, amino acids are often included. Finally, carbohydrates are present to help sustain energy and prevent bonking. Let’s see if Prime’s products meet these standards.

Prime Energy vs Prime Hydration

There are two main beverages: Prime Energy and Prime Hydration. Prime Energy drink contains 200 mg of caffeine whereas Prime Hydration does not contain caffeine. The intention of Prime Energy is to mimic an energy drink with high amounts of caffeine while Prime Hydration is intended to be consumed after intense exercise. The American Academy of Pediatrics suggests that children and teenagers avoid energy drinks with a high caffeine content, therefore Prime Hydration might be a healthier option. However, there is suspicion still with the beverage. 

Prime Hydration Ingredients

The Prime Hydration beverage ingredients list includes: filtered water, coconut water from concentrate, citric acid, dipotassium phosphate, trimagnesium citrate, natural flavor, sucralose, L-isoleucine, L-leucine, L-valine, D-alpha tocopheryl acetate (vitamin E), acesulfame potassium, retinyl palmitate (vitamin A), pyridoxine hydrochloride (vitamin B6), and cyanocobalamin (vitamin B-12). These ingredients can be found on the Prime website. 

Branch Chain Amino Acids

Prime Hydration contains isoleucine, leucine, valine, also known as branched chain amino acids (BCAA’s). They promote protein synthesis, enhance athletic performance, and help with muscle mass and growth. One 500 mL bottle of Prime hydration contains 250 mg of BCAA’s and the recommended daily allowance (RDA) is about 4-20 grams per day. Labeling on the bottle of BCAA’s indicates that it will play a role in muscle function, but 250 mg of BCAAs is just not an adequate amount. This beverage is not a reliable source of BCAA’s. Dietary protein such as meat, poultry, fish, and beans will provide athletes with adequate BCAA intake daily. Prime Hydration drinks are likely not making a big difference here.

Sweeteners & Carbohydrate Content 

This beverage is sugar free and contains artificial sweeteners such as sucralose and acesulfame potassium. The safety of artificial sweeteners is a highly controversial topic with nutrition experts ranging in their opinions on what you should consume and who should consume them. Recent studies have found that consistent sucralose and acesulfame potassium consumption may be interfering with insulin and glucose homeostasis by disrupting the balance of gut microbiome. The World Health Organization recently advised the public to not consume non-sugar sweeteners due to evidence of increased risks of type 2 diabetes, cardiovascular disease, and mortality in adults. There is also research to suggest that it is safe to consume them.

Personally, I would caution parents against giving children artificial sweeteners more than occasionally. The occasional intake of artificial sweeteners likely has zero impact on health or well-being, but if it is something that you’re trying to decide if you should drink on a regular basis, you may want to be cautious about that.

The recommended intake of sports beverages depends on exercise duration and intensity. Research suggests that as little as 20 grams of carbohydrates per hour is beneficial for athletes’ sports performance. The American College of Sports Medicine suggests that athletes should consume 30-60 grams of carbohydrates per hour during exercise. When looking for a beverage to support athletes during exercise and performance, we are wanting a product containing a combination of multiple different carbohydrates.

There are 6 grams of carbohydrates in one bottle of Prime Hydration. This is a small amount of carbohydrates to consume during exercise. So really, Prime Hydration offers little to no energy during exercise. There are no carbohydrates found within sucralose and acesulfame potassium, so where are these 6 grams coming from? It can be assumed that they are coming from the coconut water. 

Coconut Water

Coconut water can be a natural alternative for such popular sports drinks because it has similar hydrating effects. Additionally, it is high in potassium and contains magnesium, chloride, antioxidants (arginine and vitamin C) and various carbohydrates (sucrose, glucose, and fructose). During exercise, it has been shown to maintain and improve hydration and reduce oxidative stress from exercise.

Electrolytes

We lose electrolytes when sweating, so athletes’ needs are increased. There are 834 mg of electrolytes in Prime hydration include potassium and magnesium. Compared to leading sports beverages, Prime Hydration has higher amounts of these electrolytes, however, it significantly lacks sodium, which is most important to replenish at higher levels.

Vitamin A

There are 900 mcg of Vitamin A in one bottle of Prime Hydration which is 100% of the RDA. The recommended intake for children and teenagers is between 600 and 900 mcg. Athletes are not depleted of this vitamin and they do not have higher needs for it. Vitamin A deficiencies are rare in the United States and most people get enough through food. Yellow, orange, and green leafy vegetables are all sources of beta-carotene.

Increased preformed Vitamin A (from supplements) can cause headaches, seizures, blurred vision, muscle aches, and coordination problems. However, consuming beta-carotene from food is harmless.

B6 and B12

The RDA for vitamin B6 is 1.3 milligrams and vitamin B12 is 2.4 micrograms and this beverage exceeds these levels. These B-Vitamins help utilize energy, metabolize amino acids, and aid in tissue repair. But are they helpful to an athlete’s success? Studies have shown that athletes do have higher dietary intake of B6 and B12, but you don’t necessarily need to get all of this from one beverage. There’s no guarantee this is actually benefiting a teen post-workout.

Benefits of Vitamin E

Vitamin E is also found in Prime Hydration. It prevents free radical damage to cell membranes, so it acts as an antioxidant. It can reduce oxidative stress after exercise. Athletes have lower levels  of vitamin E compared to other antioxidants. The Prime Hydration beverage contains the full daily amount for young athletes. 

Citric Acid

Prime Hydration contains citric acid, which is a preservative and flavoring agent and can cause tooth decay and erosion. Most sports drinks have a pH lower than 5.5, which leads to demineralization of enamel. When athletes are dehydrated due to physical activity, there is less salivary flow. Low salivary flow decreases the clearance of such acids and sugars from tooth surfaces, leading to poor dental health such as cavities and erosion. 

Is This Popular Drink a Good Choice for You?

The bottom line is that yes, Prime hydrates, because it’s made with water! It just has insufficient electrolytes to really replace and replenish compared to others. It also doesn’t contain any energy to replenish glucose stores. For these reasons, it’s not an ideal choice to drink during practice or sports. Designed to be a re-hydration or re-fueling drink, it even falls short in these areas. The brand and related beverages are very popular and have high demand, but it is not the best option for teens. So in my opinion, I’d recommend you hydrate and restore energy requirements first with plain water and food, then use sports beverages as a secondary source for nutrients.

Life as a teen athlete can be pretty full. Between classes and homework, practices, games and trying to have a social life, it can feel like there is little "down time". Find out why meal planning for teen athletes is so important.

Busy schedules are often the reason behind the biggest eating mistake teen athletes make, and for all these reasons, I can certainly understand. If it's not schedules that's the problem, it's not knowing what to do or not having the right resources.

What is this eating mistake I see many teen athletes making time and time again?

Eating Randomly.

Eating randomly throughout the day, as opposed to following a planned eating rhythm, can hinder any athlete from reaching their performance goals. I’ve seen it time and time again.

Most athletes just let food happen to them in a day and it could look like any of these excuses:

• I don’t have time to pack a lunch or snacks so I’ll just eat what’s available.
• I don’t have any food so I guess I won’t eat OR I’ll just eat this candy bar because that’s all that is available.
• I need more sleep in the morning and therefore I don’t have time to eat breakfast.
• My mom or dad forgot to make me breakfast or lunch.
• I don’t have enough time between classes.
• My school day starts so early.

…and I could go on.

Randomness is the killer to optimal performance. Do you practice randomly? Do you play games or compete randomly? No; that’s absurd.

Why is the same not true for your sports nutrition eating style? There should be some thought or planning put into to.

But wait a minute…Didn’t I just say that teen athletes have NO extra time?? How will you make time to plan your eating?

Instead of thinking about food planning as “one more thing” to do, think about it this way:

A small amount of planning can make execution exponentially easier. Think about the concept of a game plan. Even against a very challenging opponent, a game plan brings comfort in knowing how to execute.

Another way to think about it is this:

Nutrition Strategy

A solid nutrition strategy is your secret weapon. Seriously, how you feed yourself can make or break you in competition. It is a secret weapon against an opponent who does not pay attention to their eating strategy. It’s “the edge” that you NEED to succeed.

In other words, you can’t afford to not plan, at least a little, your eating. If you want to perform at your best, you have to think about your eating. It doesn’t need to be a crazy amount of effort, but it should be getting some energy.

Meal Planning for Teen Athletes

So, how do you go from eating randomly to eating on purpose for performance? Start with any of these simple steps:

• Make breakfast happen. Think about it the night before to make sure you have something to eat within an hour of waking up.
• Make your lunch. You can do it. Take the 10 minutes and make your own lunch. You might not need to do this every day but it must happen on days when your schedule it up in the air.
• Pack a snack. Bars are a great choice to throw in your backpack or gym bag.
• Bring a water bottle to school with you. Ensure you stay hydrated through the day by being purposeful with your fluids.

If you struggle with figuring out a good eating plan for yourself, we can help. Sign up for our performance course, Weight Gain Strategies, which is not just for “bulking up”. It walks you through setting up your own eating rhythm based on your personal schedule to determine the best way to eat. You’ll also learn about the right choices for meals, snacks, pre and post workout nutrition. It covers all your bases. Check it out HERE.

Jenna Braddock is a Registered Dietitian and Certified Specialist in Sports Dietetics. She has been working with athletes of all ages and levels since 2006 to reach their optimal performance through solid nutrition strategies.

Sitting the bench.

Not starting.

Being smaller or bigger than their teammates.

Losing playing time to a teammate.

Being injured and no longer contributing to their team.

All of these situations can lead a teen to feel down on themselves and experience jealousy in sports.

Jealousy can be a common issue in competitive team sports. Younger athletes can struggle with seeing a Coach’s bigger picture and internalize it as they are never going to be good enough. Since sports can help a young person develop confidence, dealing with jealousy is a priority to enable them to really benefit from their experience. 

At the root of this jealousy issue is an unhealthy comparison of athletic skills between athletes, often based in irrational thoughts and feelings.  It can intensify when a young athlete perceives there is unequal treatment on the part of a coach. Accepting that the treatment is not based on subjective favoritism, but different skill levels is challenging.  

Or perhaps your child has not hit a growth spurt yet like his or her teammates, giving them a disadvantage. You might observe their confidence dwindling as their performance cannot match their peers.

Walking alongside your teen athlete during one of these situations is not easy. It’s hard to see your child struggle! It can also be hard to find the right words to speak life into them and help them know their value as a person no matter their circumstances.

Here are suggested conversation starters you can use to help your young athlete build maturity and confidence despite what they perceive. You might try all of these or just one to begin to open the door of what’s going on deeper in their mind and heart.

Starter #1

How good or talented a teammate is does not mean that your athlete is not valuable. Talk to your teen about not allowing someone else’s performance to dictate how they feel about themself. That’s handing over a lot of power to another person that they do not deserve.

Starter #2

Ask open ended questions to your teen about why they think they are not playing as much, how important is it to them to improve a needed skill, how much control do they have over improving in an area, and how you as a parent can help them reach their goal. You don’t have to give them these answers as discovering them on their own tends to be more powerful. If you’re itching to give your teen advice, simply say “If you would like to talk more about that, I am happy to do that.” If the opportunity does come up to talk more, give them your full attention. 

Starter #3

Dig into your teen’s feelings about the situation by asking simple, open questions like “How did it make you feel when you didn’t get to play today.” Simply responding with, “I can understand those feelings,” may help your teen feel heard and understood. You don’t necessarily need to fix anything as a parent. This could lead to an opportunity to validate them as a person and the many strengths and talents they do possess.

Starter #4

This situation presents an opportunity to help your teen translate lessons from sports into other areas of life. Help them make these connections by comparing their circumstances to another time in their life (either factual or hypothetical). For instance, “Do you think there might be other times in your life where you will have to put in more work than someone else to achieve a goal?” Or, “You’ve invested a lot in this team and it seems like it means a lot to you. Have you gained or learned anything from the experience so far?” Certainly share an experience from your own life if you have one.   

Jealousy in Sports Takeaway

A coach or family member is the perfect person to help a teen athlete identify the trap of basing their self-worth in athletic performance by comparing them self with another athlete of differing skills.  

For more tips for teen athletes, check out Creatine for Teen Athletes + Creatine-Rich Food Sources.

Many teen athletes are interested in taking dietary supplements to help them be their best. In this article, you’ll learn about the benefits of creatine for teenagers. We’ll also discuss if creatine is safe for teens and the best creatine brands for teens.

As a former high school athlete who played soccer and ran cross-country, I had a natural tendency towards being very competitive. This meant I went to ALL the pre-season practices, conditioning/lifting workouts, and one-on-one training opportunities. If something could help me improve, I was there. 

This is a great mentality for improving physical performance. It wasn’t until later in life I discovered training could only take me so far without a solid nutrition plan for  muscle growth and recovery. Many young athletes also find themselves in this situation. They are willing to put the work in on the field or in the gym. But they may be seriously lacking a purposeful nutrition strategy to support that training. 

We can find plenty of information on the internet about sports nutrition, but it’s not geared for teen athletes. This is particularly true for sports supplements and creatine may be the one teen athletes wonder the most about.  Perhaps you’ve even experienced your athlete come home from practice and say, “I want to take creatine, all my friends are taking it”. I’m sure almost immediately, a pang of doubt and uncertainty hits you. Maybe this is followed by a long list of questions about creatine and uncertainty regarding where to find answers. 

You’ve come to the right place. Off-Season Athlete exists to help teen athletes and their parents know what is safe and effective for improving athletic performance. Current research has revealed that anywhere from 15 – 40% of high school athletes use some form of creatine supplementation. Does this mean they should be?¹ Let’s pull back the curtain on creatine. Here are the facts from current research on creatine and its use in high school level athletes.

What is Creatine?

Creatine is a type of protein we naturally find in the human body. Creatine is stored in the muscles where your body uses it to generate energy during high-intensity exercise and heavy lifting. The energy from creatine stored in the muscles is called phosphocreatine. 

What Does Creatine Do?

Creatine plays a large role in many bodily processes, but especially in high-intensity exercise. When you supplement creatine it increases your stores of creatine, or phosphocreatine within the muscle. In other words, the energy stores within your muscles are increased. They are made more available for the body to use during exercise.¹

Foods that Contain Creatine

Your body can produce one-third of the creatine it needs through the liver and kidneys. We can obtain the other two-thirds through a well-balanced diet. Unlike other nutrients creatine does not have a recommended daily allowance (RDA). However, studies have revealed that the body needs about 1 – 3 g of creatine a day to maintain normal stores.²

I always suggest trying to meet nutritional needs through your diet first before turning to supplements. A balanced diet provides nutrients such as fiber and antioxidants that supplements tend to lack. We primarily fine creatine in red meat and seafood. For example, a pound of uncooked beef or salmon provides about 1 – 2 g of creatine.²

What are the Benefits of Creatine for Teenagers?

The benefits of creatine for adult athletes has been studied extensively. These studies suggest that creatine supplementation can improve exercise performance and training adaptations. Furthermore, the research indicates that creatine supplementation may enhance post-exercise recovery, injury prevention, and concussion and/or spinal cord neuroprotection.¹

Is Creatine Supplementation Safe for Teen Athletes?

The lack of literature surrounding the safety of creatine use in teenagers has led to many misconceptions. For example, one may reference that a con of creatine is the warning signs on product labels cautioning individuals younger than 18 years of age to not supplement creatine. However we should recognize that the warnings on labels are not evidence-based. They become more of a legal precaution related to the lack of knowledge on creatine and its side effects on younger populations. 

Fortunately, new research is emerging suggesting that creatine is not only safe for teens, but very beneficial as well. There have been recent articles suggesting that creatine supplement use is safe for teenage populations.

One study showed that supplemented creatine could potentially increase protection of the brain before a concussion. Creatine aids and alleviates symptoms associated with concussion recovery. Studies further suggest that teen athletes can benefit from creatine supplementation as it improves recovery, cognition, and fatigue.³

Remember more is not better when using supplements. Creatine could potentially have harmful effects if taken incorrectly or in conjunction with kidney damaging medications (nephrotoxic drugs). Types of these include aspirin, ibuprofen and naproxen (Aleve).⁴ Young people who take these medications regularly should talk to their medical professional before beginning a creatine routine to reduce the risk of adverse effects.

Furthermore, a recent study has shown that individuals with asthma may want to be especially careful if they choose to supplement with creatine, suggesting that unfavorable changes in airway inflammation were seen in adolescents who supplemented creatine.⁵

When to Take Creatine Supplements

If you scour the internet trying to find out the best time to supplement creatine you’ll find various different outlets giving you loads of different advice. The fact of the matter is that the evidence from research is conflicting. In my professional opinion, I suggest starting in the off-season if you’re beginning the use of creatine for the first time. 

Similar to a new prescription medication, you never know how your body is going to adapt and react to the introduction of a new nutritional supplement. In the chance that your body has a poor reaction to the supplement, you really do not want it to affect training or performance at any point during the season. 

In spite of that, it is also important to know that when starting to supplement creatine, particularly in the loading phase (a term I’ll delve into later on), creatine users may notice weight gain and/or bloating. This is common and is typically short term. However, it’s important to note that it may impair weight-related performance in sports such as cross-country, track, and wrestling.⁶

How Much Creatine Do You Take?

First and foremost, it is important to speak with a sports medicine doctor or sports dietitian. They will help discover if supplemented creatine would be appropriate and benefit your teen. These professionals can guide you in determining how much creatine your teen may need based on their diet and level of physical activity. 

To work with Jenna Braddock, a certified specialist in sports dietetics, on creating the right supplement plan for your teen athlete, visit her private practice page here. 

We supplement creatine using a loading dose and maintenance dose. The term “loading dose” can sound a bit intimidating. This is especially true when talking about sports nutrition supplements in athletes, let alone your teenage athletes.

The loading period is beneficial because it saturates the muscle to its upper limit of capacity with creatine to be used for muscle energy during training. We commonly use a loading dose of 0.3 grams per kilogram of body weight per day for 5 -7 days when starting creatine supplementation. Following the loading phase, the daily dose to maintain elevated creatine stores is 0.03 grams of creatine per kilogram of bodyweight.¹

You can also do a loading dose of 20g per day divided over 4 servings, so 5g per serving, for one week.

What Kind of Creatine Supplement Should You Buy for Teen Athletes?

The supplement market is constantly evolving. This makes it difficult to determine whether a product is of high quality, safe, and tested. We find creatine supplements in various stores at varying prices with a wide array of other ingredients. 

It is very important to consider brand, amount of creatine, and hidden harmful ingredients when thinking about choosing the best creatine supplements for your teen athlete. A checklist to use when identifying the right product is:

• Single Ingredient – The product only contains Creatine Monohydrate and nothing else. 
• Certified by Third Party – This ensures the product is pure and does not contain trace amounts of any other ingredients, including harmful or banned substances. Look for NSF Certified for Sport, Informed Choice, or USP certified. 
• Budget Appropriate – Some supplements can be pricey. It’s important to weigh the cost-benefit of using your money on the supplement or just more healthy food in general. Consider figuring the cost per serving of the supplement by dividing the total cost by the number of servings. If it is low and affordable for you, great! If it’s getting too close to the amount you would spend on a serving of food for a snack or meal, you may want to reconsider it. 

Brands of Creatine

Here are a couple of the best creatine brands for teens that meet the criteria appropriate for adolescent athletes. Please note, we are not saying your teen athlete should take these creatine supplements. It’s important to work directly with a Sports Dietitian to determine what is the best product. They will also help you determine dosing for each unique situation. 

These are affiliate links that will take you to FullScript.com where you can create a secure account to order trusted products.

Conclusion

If your athlete seems like a good candidate for creatine, please work with your sports medicine doctor and sports dietitian. Do this at least initially to create the right plan and monitor progress.

Hopefully this information has helped you feel more confident in engaging with your athlete on the topic of the benefits of creatine as you determine if it’s a good step for them.

Written By

Written By: Jenna Braddock, MSH, RD, CSSD, LD/N, ACSM-CPT & Jessie Melendez, University of North Florida Dietetic Intern

I moved to Jacksonville, Florida in the Fall of 2019 as a graduate student and dietetic intern at the University of North Florida (UNF). Prior to UNF, I completed my bachelors degree in Human Nutrition, Foods, and Exercise with a concentration in dietetics at Virginia Tech. Since starting my journey in the nutrition and dietetics field I have learned how to critically review research to find evidence-based answers. Through my internship I am able to apply my knowledge in nutrition to educate people of various backgrounds on healthy food choices that fit their lifestyle. When I’m not keeping busy with my classes and internship you can find me lounging at the beach or cruising on a bike ride. 

References

1. Jagim AR, Stecker RA, Harty PS, Erickson JL, Kerksick CM. Safety of Creatine Supplementation in Active Adolescents and Youth: A Brief Review. Front Nutr. 2018;5:115. doi:10.3389/fnut.2018.00115.
2. Kreider RB, Kalman DS, Antonio J, et al. International Society of Sports Nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport, and medicine. J Int Soc Sports Nutr. 2017;14:18. doi:10.1186/s12970-017-0173-z
3. Ainsley Dean PJ, Arikan G, Opitz B, Sterr A. Potential for use of creatine supplementation following mild traumatic brain injury. Concussion. 2017;2(2):CNC34. doi:10.2217/cnc-2016-0016.
4. Taner B, Aysim O, Abdulkadir U. The effects of the recommended dose of creatine monohydrate on kidney function. NDT Plus. 2011;4(1):23-24. doi:10.1093/ndtplus/sfq177
5. Simpson AJ, Horne S, Sharp P, et al. Effect of creatine supplementation on the airways of youth elite soccer players. Med Sci Sports Exerc. 2019;51(8): 1582 – 1590. doi: 10.1249/MSS.0000000000001979.
6. Naderi A, de Oliveira EP, Ziegenfuss TN, Willems MT. Timing, Optimal Dose and Intake Duration of Dietary Supplements with Evidence-Based Use in Sports Nutrition. J Exerc Nutrition Biochem. 2016;20(4):1-12. doi:10.20463/jenb.2016.0031