SPORTS MEDICINE COLLABORATION; BIOCHEMICAL ASSESSMENT BEYOND

IRON AND VIT DKaty Meassick, MA, RD, CSSD, LD/N, ATC

Director of Sports NutritionFlorida State University Athletics

Successful Collaboration: Where do RDs fit?■ Stakeholders:– Certified Athletic Trainers– Team Physicians: Gen Med & Orthopedic Surgeons– Strength and Conditioning Coach– Team/Position Coach– Athlete and Parent– Administration– Registered Dietitian?

■ Sports medicine departments have been successful long before RDs became a necessity

■ Approaching new territory as a new RD in a program should be a delicate process to ensure overall success

One Team Goal: treating the “whole” athlete■ Approaching a long-standing Sports Medicine team as an incoming RD is

intimidating■ You want to show your knowledge and how your knowledge can be impactful without

rocking the boat too much■ Find out when clinic hours are, ask to be present and introduce yourself to the Team

Physician

■ See if the Sports Med Staff meets on a regular basis – ask to attend monthly, so you can get familiar of their protocols and policies and see how you can contribute

– Don’t be intrusive, provide impactful input as needed, and be sure to always provide an opinion when asked

■ Ultimately, you want nutrition to become a forethought rather than an afterthought and be integrated into current protocols

– Maximizing immunity during travel to fight off colds, rather than treating them with medicine afterwards

Understanding Roles■ Historically ATCs and S/C coaches have been the ones to provide nutritional

guidance and possible interventions

■ The addition of an RD can help these staff members focus on their main goals, the successful integration of an RD can do just that

– ATCs can be more efficient in their time with manual therapy, rehabilitation or even just having more time to focus on paperwork

– Showing the ATCs that post-practice therapy may be more successful if the athlete has properly replenished and refueled

■ Be available and be seen but don’t be intrusive, especially if you are in another staff member’s domain. Staff members will start to notice your presence and send athletes your way when asked a nutrition question, usually your presence will spark, “oh, I had a question for you” or “hey, I was thinking the other day…”

■ You want to show you can help promote ideal outcomes in any situation without being that “one more thing” the athlete has to do

Carving out your lane… while gaining trust

■ ATCs have the highest level of contact with the athletes, you want to gain their trust and provide them with credibility so they start to incorporate nutrition into their inventions and encourage the athletes to meet with you.

■ Show what you can provide, try to over-deliver, don’t over-promise

■ Trust can be gained by showing investment– Actions are loud

■ Show you understand the culture

■ Show you can adapt to change– Work well under stress

■ Show you aren't there to take anyone’s job– You're there to complement the initiatives

Critical Thinking Attitudes

Attitude Application

Confidence When you are confident, the athlete/coach/ATC is more trusting of your competence

Thinking Independently Consider all viewpoints, base your decision on your own conclusions about the issue

Fairness Listen to both sides, weigh all the facts

Responsibility & Authority Ask for help when you need it, follow established Standards of Practice / Protocols

Risk taking If you have a reason to question others’ judgment, do so - tactfully

Discipline Be thorough at all times, follow protocols, be prepared

Perseverance Be determined to find the most effective solution, don’t settle for quick solutions

Creativity Look for different options when outcomes are not as expected

Curiosity Ask “why?” find out as much as you can before making a judgment

Integrity Question and test your personal knowledge and beliefs. Be willing to admit inconsistencies

Humility Admit your limitations. Be willing to rethink a situation and seek additional knowledge.

Source: R. Paul(1993). The art of designing instruction. In J. Willsen & A. Blinker (Eds.), Critical Thinking: how to prepare students for a rapidly changing world. Santa Rosa, CA: Foundation for Critical Thinking.

Continue input, bring in a new point-of-view■ Dietitians can provide a wealth of knowledge in many areas, as well as, tailored

medical nutrition therapy that other providers in the athletic setting cannot.

■ Where does the role start and stop? The role will continue to evolve as you do as practitioner and continue to provide valuable input and bring in that point-of-view the ATC may not have, you may bring the creativity the team has been looking for

■ RDs can provide practical information/interventions for the athlete such as: providing healthy breakfast options; designing daily menus; planning meals for the team while on the road; providing individualized recovery protein shakes after training sessions and games; one-on-one nutrition consultations; providing individualized supplement recommendations; regular body comp testing; blood testing and analysis; and hydration testing

■ Be impactful with both the athletes and your sports medicine team, provide interventions that complement current standards of practice

BIOCHEMICAL ASSESSMENTBlood work beyond Ferritin and Vitamin D

When is it appropriate to ask for labs?■ Asking for blood work can be tedious and expensive, some athletes may not want to

give blood■ Don’t insist on labs for every case, show you can instill/motivate change through

nutritional interventions■ Give practical interventions a try and tailor as necessary to provide the scenario for

an ideal outcome

■ Some athletes are tested for other reasons, outside of your recommendations, be sure to be on the receiving end of the results, to help provide the additional set of eyes

■ Blood work may be necessary when interventions (both sports med and nutritional) may not be providing the preferred outcome

– Athlete compliance must be assessed■ Labs may be beneficial to show successful interventions– Diet change = nutrient deficiency improvement– DE monitoring or reinforcement

Biochemical assessment data: Review

■ Used to assess body stores

■ Altered by lack of nutrients, medications, metabolic changes during illness or stress

■ Interpret results carefully

■ Fluid status distorts results

■ “Stressed” states (injury, infection, surgery) effects results

■ Use reference values established by individual lab

Common Lab Tests: Functional Assays

Basic Metabolic Panel (Chem-7)■ Fluid and electrolyte status– Na+, K+, Cl--, Bicarbonate

■ Kidney function– BUN, creatinine

■ Blood sugar levels– glucose

■ Response to medication and other therapies

■ Doesn’t include Ca2+ (Chem-8)

Comprehensive Metabolic Panel (Chem-20)■ All the chem-7 tests plus

■ Protein tests– Serum calcium, serum total protein,

serum albumin

■ Liver function assessment– ALT, AST, ALP, bilirubin

■ Calcium

■ CO2

Common Lab Tests

Complete Blood Count (CBC)■ WBC*

■ RBC*

■ Hgb/Hct*

■ MCV*

■ MCH / MCHC

■ RDW

■ Platelets

Additional Assays■ Urinalysis– Over 100 tests– USG, pH, Ketones, Protein, glucose

■ Stool sample– Digestive tract investigation– Nutrient malabsorption– Pancreas, liver function– Parasites, pinworms

■ Total Cholesterol, A1C

■ Lipid panel

■ Endocrine / hormonal panel

Possible Scenarios

■ Habitual Cramper (defensive lineman)– Corrected overall daily hydration intake– Provided hydration supplement (electrolyte packet of choice) prior/during workouts– Athlete “promises” they’re eating enough outside of team meals

■ After a couple of weeks of trying different interventions, additional puzzle pieces are needed

■ Labs are ordered to provide more info and create new interventions

■ What labs would you choose?

■ Comprehensive Metabolic Panel– Electrolyte balance– Fasting glucose (if they are compliant)– Protein panel – see initial look at nutritional status– Inconclusive? Maybe CRP, see inflammation status

Scenario: difficulty losing weight■ Female, basketball athlete– No current medical issues, on Depo shot for birth control

■ Goal of 20# weight loss in off-season

■ Work with Strength Coach to have coinciding plans to get to goal weight over summer months

■ Athlete reports compliance, turns in food journals, photos, exercise reports

■ Measure initial starting point via DXA scan

■ Pre-season physical revealed low Fe and Vit D, athlete is compliant with taking supplement, no other abnormalities shown, level was returned WNL in 3 months

■ 2 months of work, no significant change in weight, athlete shares frustration

We need more information!■ Knowing an athlete is working hard, it can be frustrating to all parties when the

outcome isn’t being reached

■ Athlete also reported she did not get new Depo shot for her birth control

■ A CMP was ordered to uncovered more information

■ Team Physician wanted to run Thyroid Panel

■ CMP revealed elevated liver enzymes, thyroid panel was normal

■ With the elevated liver enzymes, the sports med team suggested more rest in between exercise bouts and focus on both external and internal recovery post-workout

■ Next eight weeks showed body comp improvement

Scenario: “exhausted” swimmer■ Male swimmer – who “can’t finish a race”

■ Complains of cramping with 15 meters left

■ Mastered all recovery techniques: cold tub, normatec, post-practice smoothies, cherry juice

■ Complied with all hydration recommendations, even use of electrolyte packet

■ When nothing was working – labs were ordered– CMP, CBC, CRP, Fe, Creatine Kinase, and TSH– Everything was inconclusive

■ This is one instance where labs were not helpful

■ We investigated a little further

Potential  Trigger of  Over  Training  Syndrome

Increased  training  load  without  adequate  recovery

Monotony  of  training

Excessive  number  of  competitions

Sleep  disturbances

Stressors  including  personal  life  (family,  relationships)  and  occupational

Previous  illness

Altitude  exposure

Heat  injury  episode

Severe   “bonk”

Importance of labs outside Fe/Vit D

■ Can help provide additional information when intervention isn’t successful

■ Can help provide you with backing in decision making

■ Can help increase compliance with athlete

■ Helpful with screening and monitoring

■ Helpful assessing further health risks (CVD, bone density, anemia, etc.)

Limitations to blood work

■ One lab value can be helpful in screening or to confirm an assessment based on changing clinical, anthropometric or dietary status

■ Nutrition status changes relatively slowly – one lab value can’t really “diagnose”

■ Blood work is sensitive to so many environmental factors– Eating before, exercising before, cold/flu at time of test, etc.

■ Efficacy of all tests have not been proven

■ Not all tests/results are reliable

■ Physicians have final interpretation and say-so in blood work ordering, etc.**

Questions?

Thank You!

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■ Bernstein LH: Relationship of nutritional markers to length of hospital stay, Nutrition 11(suppl2):205, 1995.

■ Bron D et al: Biological basis of anemia, Semin Oncol 28(2; suppl 8):1, 2001.

■ Cardoso, Carlos, et al. "Bioaccessibility assessment methodologies and their consequences for the risk–benefit evaluation of food." Trends in Food Science & Technology 41.1 (2015): 5-23.

■ Chandra, Ranjit Kumar, and Paul M. Newberne. Nutrition, immunity, and infection: mechanisms of interactions. Springer Science & Business Media, 2012.

■ Haurani Fl. Interpretation of serum ferritin in anemia of chronic disease. Am J Hematol 69:296, 2002.

■ Lee RD, Nieman DC: Nutritional assessment, ed 3, St Louis, 2002, Mosby.

■ Nelms, Marcia, and Kathryn Sucher. Nutrition therapy and pathophysiology. Nelson Education, 2015.

■ Stipanuk, Martha H., and Marie A. Caudill. Biochemical, physiological, and molecular aspects of human nutrition. Elsevier Health Sciences, 2013.