2. nutrition assessment and body composition

what is NCP?

A systematic, problem-solving method that registered dietitians use to critically assess and make decisions to address nutrition-related problems and provide safe and effective quality nutrition care

what is the most important part of the NCP

nutrition assessment

steps in nutrition assessment

• Nutrition Assessment

• Nutrition Diagnosis

• Nutrition Intervention

• Nutrition Monitoring and Evaluation

how does one initiate the nutrition assessment and why?

• initiated by referral or screening

• There can be many different reasons for referral

  • Under fueling, over fueling, post-surgery care, cramping

nutrition assessment

• format

• where information comes from

• Face-to-face (in-person or virtual) with athlete

• Additional info from athletic trainers, coaches, family

reasons for referral to sport dietitian

1. Lack of energy

2. Changes in body weight → both major and minor weight loss and gain

3. Persistent injuries (seen a lot with underfueling)

4. Abnormal biochemical data indicating possible nutrition etiology

5. Self-referral

   1. This is totally different to the other referral types due to motivational differences

nutrition assessment components

ABCDE

• Anthropometrics including weight history

• Biochemical (blood and urine)

• Clinical including nutrition-focused exam

• Dietary assessment - most difficult but most important

• Exercise/Energy Expenditure

what are biochem test

Measurement of nutrient and metabolite levels in the blood and urine

standard panel (biochem) includes what (4)

• Complete blood count

• Comprehensive metabolic panel with lipids

• Endocrine markers

• Urinary analysis

when should specific nutrients be assess

if deficiency is indicated

what are the potential deficiencies in athletes (3 main categories)

• oxygen carrying nutrients

• bone-building nutrients

• hydration status

oxygen carrying nutrients of risk include what

iron, folic, vit b12

bone-building nutrients nutrients of risk

vit D and calcium

hydration status importance (like for biochem exams)

• Can negatively impact performance

• Can also alter the result of key biochemical tests

• Include plasma osmolality, urine osmolality and urine specific gravity to ensure your athlete is not dehydrated during the testing

purpose of nutrition focused exam

To uncover any medical condition or physiological factor that may interfere with food intake, digestion, and metabolism

what issues can be found by nutrition focused exam

• Recent or chronic illnesses, recent or persistent injuries

• Anxiety and/or depression

• GI issues

• Physical signs of malnutrition

  • Muscle wasting, dry and brittle finger nails, bony protrusions, clubbed fingers

what is the most important skills for sport RDN to develop

dietary assessment

accurate dietary assessment allows the sports RDN to:

• Accurately screen + diagnose nutrition-related issues

• Highlight nutrient timing issues that hinder performance or recovery

• Optimize fueling and hydration to fully address the issue and/or help the athlete achieve athletic goals

what are the dietary recall tools (4)

• 24-hour Dietary Recall

• Food Frequency Questionnaire (FFQ)

• Diet History (combo of 24-h recall + FFQ)

• 3-day Food Records or Diet Logs

what are important things to consider for nutrition assessment (6)

• Weight history (how has weight changed)

• Fluid and electrolytes (enough water, electrolytes?)

• Dietary supplements and medications

• Environment, access to food, cooking facilities and competency

• Knowledge, beliefs, and attitudes

• Eating behaviors

24 hour recall

• what is it

• who does it

The athlete is asked to describe all foods and beverages consumed during the previous 24 hours,

• form is filled out by the dietitian

strengths (3) and limitations (3) of 24hr recall

• Strengths: quick and easy, low burden

• Limitations:

  • Memory and recall bias

  • Previous day may not be representative of typical diet or typical training day

  • Snacks and beverages, condiments, cooking oils + seasonings

24 hr tips to make it better (3)

• Experience is key

• Build rapport to improve accuracy of the information

• Multiple Pass Method & Probing

  • Food preparation

  • Portion sizes

  • Snacks and beverages

what is the multiple pass method

• Research-based, multiple-pass technique employs 5 steps designed to enhance complete and accurate food recall and reduce respondent burden

• 5 STEP METHOD

  • Quick list

  • Forgotten foods

  • Time and occasion

  • Detail cycle

  • Final probe

food frequency questionnaire (FFQ)

• what is

• strengths and weaknesses

• Commonly used for assessing intake of nutrients and specific foods in groups of people; Contain a predetermined food list with or without portion sizes; How frequently certain foods are consumed

• Strengths: chronic intake of specific foods, screening tool, food preferences

• Weaknesses: Recall bias, not suitable for usual energy intake and macros

diet history is a combination of what

24-hour recall + FFQ

diet history

• usage

• time

• Preferred technique of choice by most dietitians in clinical practice

• Fast (20 – 30 min)

diet history advantages (3)

• Gives good insight on social, behavioral and cultural influences on food choices

• gives you baseline of athlete nutrition and cooking literacy

• Valuable for assessing nutrient timing before, during, and after exercise

diet history con

It is NOT accurate for quantitative assessment of total energy or macronutrient intake

what are 3-day records

• Weighed or estimated records filled out by the athlete

• Usually 3 – 7 days

strengths of 3-day records

Does not rely on memory, potential to provide detailed info, better reflection of

typical dietary intake

major limitations for diet records (5)

• underestimation of energy and intake

• underreporting (around 50%)

• user error (portions, condiments, snacks, oils)

• athlete with weight focuses underreport

• reporting of socially desirable foods

how to make food records better (3)

• give instructions!!!

• review the food record entries with the athletes

• 2 weekdays and 1 weekend

what are 4 challenges od dietary assessment of athletes (4) - think of their training

• Periodized training cycles

• Training days versus competition days

• Major dietary changes (make weight or carb load)

• Nutrient timing

which is the best assessment tool in practice

food records (3-7 days) but expect 20-50% innacuracy

what would one usually do in practice (timeline)

• baseline visit

• follow-up

• Baseline visit → Diet history (24-hour recall and FFQ) USOC Form

  • Give them a food record and ask them to keep track of diet for minimum of 3 days (7 is better). Keep a record of exercise training logs including intensity and duration during same timeline.

• Follow-up visit → review food records and training logs with athlete

what must you do after your athlete has done their 3-day food record

Enter all of those foods and drinks into a nutrient analysis database

nutrient analysis potential error (6)

• Actual food composition are just estimates of nutrient composition

• Missing foods from the database

• No serving size given

• Serving sizes are difficult to standardize

• Different countries of origin

• Nutrition facts label

detailed nutrition assessment timeline

• initial visit (what to determine, look for- 7)

• time between

• follow up (when, what to do- 3)

why do we use anthropometrics (what do we determine)

• body comp

• height

• weight

• BMI

BMI issues

not a suitable assessment for body comp in athletes

what are better ways to assess body comp in athletes

• direct

cadaver

what are better ways to assess body comp in athletes

• indirect (5)

• Skinfold thickness

• Bioelectrical impedance analysis

• Underwater weighing

• BODPOD

• Dual energy X-ray absorptiometry (DXA)

skinfold thickness

• accuracy

• strength

• limitations

• Within 3 – 4 % of underwater weighing when individual is trained

• Strengths: cheap, fast, fairly accurate

• Limitations: training required for precision, unsuitable for quantifying absolute fat

bioelectrical impedance analysis (BIA)

• what is it

• strength

• weakness

• Measures the resistance to flow of electrical current passing through the body; based upon the idea that fat is more resistance than lean mass

• Strengths: cheap, fast, portable

• Limitations: greatly influenced by hydration status, moderate-to-high error versus DXA

underwater weighing

• what is it

• strength

• weakness

• Historical gold standard for assessing body composition via body density in humans

• Body density (fat and fat-free mass)

• Strengths: Very precise

• Weaknesses: Time insensitive, impractical, less accessible

air displacement plethysmography

• what is it

• accuracy

• strength

• weakness

• Measures body volume by measuring the amount of air displaced

• Comparable to underwater weighing (within 2 – 3%)

• Strengths: good accuracy, fast

• Limitations: claustrophobia, expensive

dual energy x-ray absorptiometry (DEXA)

• what is it

• what does it measure

• strength

• weakness

• Considered practical gold standard

• Measures 3 compartments: lean mass, fat mass, bone mass

• Strengths: Very precise, regional measurements, subject comfort

• Limitations: small amount of radiation, expensive, tall and broad athletes

body comp assessments ranking based on accuracy and practically

1. DXA

2. BODPOD

3. Underwater weighing

4. Skinfold thickness

5. BIA

body comp assessments based on cost and portability ranking (5)

1. Skinfold thickness

2. BIA

3. BODPOD

4. DXA

5. Underwater weighing

how often should one asses body comp

every 2-3 months

why do we want 2-3 month between body comp assessment

1. Main reason is variability of measurements (1-2 % error for body fat or fat-free mass)

2. Body composition changes typically take time

3. Too frequent measures can create bad dietary practices (fasting, etc.)

why do we measure body comp in athletes (3)

1. Address concerns about the health of an athlete

2. To determine contributions to performance

3.  To best prepare an individual for a sport-specific performance

too high body fat and health risk (4)

 increased risk of cardiovascular disease, diabetes, hypertension, and some cancers

too low body fat and health risk (2)

loss of menstrual cycles and impaired bone development which can lead to osteopenia and osteoporosis later in life

essential body fat in men

2-5%

essential fat in woman

10-13%

why would we track changes in muscle mass (2)

Loss of lean tissue over time can impair performance

when track changes in fat and muscle mass

during the season

why should one monitor the effectiveness of diet and exercise training programs (2)

• Athlete on a specific diet (weight gain or weight loss) led to favorable changes

• Athlete on a specific diet and they gained muscle and increased strength

sports that have strong relationship between physique and performance (6)

• Swimming (limb length, low fat)

• Track and field (depends on the event)

• Rowing (low body fat %, greater total muscle mass)

• Track cycling (leg muscle volume)

• Gymnastics (low body %)

• Diving (low body %)

sports with weight classes and cutoffs that greatly impact performance (5)

• Boxing

• Wrestling

• Mixed martial arts

• Horse jockeys

• Formula one racing

sports that vary in desired body size/comp differing on position (6)

• Baseball

• Softball

• Basketball

• Football

• Tennis

• Golf

nutrition assessment timeline

when you have all information from assessment, what must one do

Provide a written plan to both athlete and coach detailing results, interpretation, follow-up, plan, and next steps

nutrition diagnosis for athletes

• No standardized list of diagnoses for athletes

  • Use scientific literature to document diagnosis

• Describe the cause and factors contributing to the nutritional problem in the athlete

• Provide clinical signs and symptoms of the problem

• Develop a diagnostic statement of the situation

nutrition intervention for athletes (overall)

• Prioritize and provide nutrition diagnoses to athlete

• Develop educational materials for athlete that are evidence-based

• The plan → provide suggested meal plan, food monitoring system or log, educate athlete how to self-monitor and make appropriate food choices

nutrition monitoring and evaluation for athletes (what to focus on)

• Compare before and after values to assess changes (good and bad)

• Provide the athlete with written verbal feedback

• Document progress towards goals

• Do we need to reassess strategy if it’s not working?

• Determine whether to continue or discontinue