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Answer and explain 6 discussion questions related to weight Management, athletes and endurance Athletes.

1) Briefly describe each of the seven steps of the initial nutrition consultation interview
process. In your description, list each step, give a brief summary of each step, and the
primary reason each step is used in the consultation process.
2) Calculate the range of daily calorie needs using the WHO equation and the following
information:
•
Female ultra-runner
•
5’6″ tall; 128 pounds; 34 years old
•
In high level training (at least 3-4 hours per day) in preparation for a 100-mile event
in 6 weeks
Based on your calculation’s range of calories, select a calorie level that you think fits her
calorie needs. Justify why you selected the calorie level.
3) Describe the concept of “hitting the wall” or “bonking” as it relates to energy
(macronutrient) utilization in exercise. List the macronutrients that are the primary fuel
sources during exercise and describe what occurs to cause fatigue during long duration
exercise.
4) Case: Max is a 16-year-old tennis player. His mother, Linda, calls you to schedule an
appointment for Max. he wants to gain 10-20 pounds of weight but is having a hard time
putting on even an ounce. Max is currently 6′ tall and weighs 135 pounds. he is in his off
season and, therefore, is not doing any exercise. Linda is frustrated because Max is a picky
eater, which severely limits his food options. While Max has agreed to see a dietitian, he
has told his mom that he is most interested in knowing about some quick, easy, weight gain
options.
Question:
What advice and recommendations would you give to Max, based on the information
provided in the case study?
5) Case: Casey is a 37-year-old runner. He is training for his first marathon. He has heard
from his experienced running partners that he should eat a lot of pasta in the days before
the marathon. He wants to know how much pasta he should eat, and if there is anything
else he should focus on, nutritionally, in the days leading up to his race.
Questions:
– Describe for Casey how carbohydrate loading can benefit endurance athletes’ sport
performance.
– What other tips would you give Casey in preparation for his marathon?
6) Describe the warning signs, medical symptoms, and behaviors that may indicates an
athlete (male or female) is struggling with an eating disturbance/disorder.
CHAPTER 10
Nutrition Consultation with
Athletes
Key Questions Addressed
1. Why is nutrition consultation and communication
with athletes important?
2. How much do athletes know about sports
nutrition?
3. Who provides nutrition assessment and education
to athletes?
4. How does the consultation process with athletes
begin?
5. What is a diet history?
6. How are food records analyzed?
7. What are the steps for the initial consultation with
the athlete?
8. What are the steps for a follow-up consultation with
the athlete?
9. What should walk-in or short sessions with athletes
involve?
10. Are there any concerns about the confidentiality of
the health, nutrition, and exercise information
provided by the athlete?
You Are the Nutrition Coach
Jennifer is a freshman and plays shortstop on her college
softball team. Her coach thinks that she has the skill to be a
starter during her sophomore year. She is thin and has a hard
time hitting home runs, despite consistently hitting over .325
for the past three seasons of play in high school. Her coach
feels that if she were to gain some muscle mass and strength,
her home-run hitting would improve, thus securing the starting
position for next year. Jennifer agrees but is also concerned
about gaining too much weight. She decides to consult with
the sports dietitian at her college to develop a plan to gain
muscle mass and a small amount of weight.
Questions
What information would you like to have Jennifer bring to
the first consultation session?
How do you determine whether Jennifer is ready to make
the changes in dietary intake needed to produce weight
gain?
What type of follow-up and continued nutrition consultation
would you recommend for Jennifer?
Why is nutrition consultation and
communication with athletes
important?
Athletes need coaches to help them train to succeed in their
sport. They need athletic trainers to help them prevent and
rehabilitate injuries that may occur during sport activities.
Athletes are not expected to know how to prevent injuries or
train appropriately on their own. However, it is often assumed
that athletes know about nutrition and know how to eat for
improved sport performance. Similar to working with a coach
or trainer to improve sport-specific skills, gaining education or
seeking consultation about nutrition can help improve
athletes’ sport performance. Unfortunately, many athletes
have had limited nutrition education, gaining no more
knowledge than the information presented during K–12
classes. Some athletes are fortunate enough to have coaches
or parents who are knowledgeable about good nutrition and
how it affects sport performance. Often, access to a sports
dietitian with expertise specifically in sports nutrition is limited.
However, for all athletes, acquiring the knowledge and skills
that support good nutrition behaviors can help individuals
meet their sport-specific goals.
The role of sports nutrition in improving sport performance
has been well documented. The well-hydrated and wellnourished athlete who pays attention to dietary intake before,
during, and after workouts/competitions can gain a
competitive edge over opponents. Therefore, empowering
athletes with nutrition education is essential to any individual
or team athlete. Educational opportunities can be provided in
team sessions, in individual consultations, on the playing field,
and by giving athletes information about credible sports
nutrition resources. Written educational materials designed
specifically for a particular sports team or athlete can be
valuable resources initially and for future reference.
Communicating messages appropriately that meet the
athlete’s needs, goals, and lifestyle will help the athlete be
successful in making dietary changes. Regardless of the
format of the communication, it is important that athletes
receive accurate and timely nutrition information to improve
their sport performance.
© iofoto/Shutterstock
This chapter reviews why athletes need nutrition
education, who should provide nutrition assessments and
educational sessions, common information-gathering
methods, consultation, and sport-specific nutrition planning.
Information about, and examples of, nutrition analysis, the
recording of dietary history, how to provide successful
individual consultations, and how to develop interviewing skills
are provided. An example consultation using an athlete case
study near the end of the chapter can help the learner piece
all of the communication concepts together.
How much do athletes know
about sports nutrition?
Athletes who train, compete, and socialize together
often obtain their nutrition information from each
other. They also get nutrition information from
coaches, trainers, and college courses. However,
many athletes lack accurate and up-to-date
knowledge of the nutrition practices that can
enhance sport performance. Most athletes are aware
of general nutrition concepts for overall health, but
struggle with sport nutrition specifics.
A study conducted by Jonnalagadda et al.,1 on
the dietary practices, nutrition education, and
attitudes of freshman football players at an NCAA
Division I school reported the following:
Sixty-one percent of these athletes believed that
protein is the main source of energy for working
muscles.
Seventy-one percent disagreed that sports drinks
are better than water for replacing fluid losses.
Sixty-five percent believed that vitamin and
mineral supplements increased energy levels.
Another study of 330 athletes in various sports in
Division I schools found that athletes had poor
knowledge of the recommended percentage of total
calories for the macronutrients.2 Only 29% identified
the correct carbohydrate intake, 11.8% the correct fat
intake, and just 3% knew the correct protein intake.
A more recent study of the dietary practices of NCAA
Division I football players indicated that nutritional
knowledge is still poor.3 Regarding hydration, Nichols
et al., reported that athletes had adequate general
knowledge but lacked information on appropriate
behaviors for consuming sports drinks.4
The study of 330 Division I athletes also surveyed
athletes to determine whether, and where, athletes
received sports nutrition information.2 They found
that 55% had received nutrition information or
counseling in their college careers (60% of the
women and 49.5% of the men). Most of the
information was distributed by the strength and
conditioning coaches (21.9%), athletic trainers
(19.0%), or university classes (12.5%), and 10% of
the education was provided by dietitians. Similarly,
Burns et al., report that athletes in several different
sports at eight NCAA Division I universities received
their nutrition information primarily from athletic
trainers (39.8%) and strength coaches (23.7%).5
Coaches, athletic trainers, dietitians, and others
working closely with athletes all should work together
to provide accurate nutrition information to athletes.
A study of a Division I hockey team revealed that
many hockey players obtain their information from
their peers.6 In this study, the freshman players
observed the dietary intake of, and comments from,
the older players on the team and subsequently
modeled their eating style after these more
experienced players. Fortunately, the older players in
this study chose lower-fat, more nutrient-dense
foods. Even though these older players did not have
formal nutrition education, they passed healthful
eating and nutrition information on to the younger
players. This modeling behavior worked well in this
instance because the older players made food
choices that benefited their health and sport
performance. However, if misinformation is passed
along by more senior members of the team, the
entire team could be making food choices that are
not optimal for sport performance. Some form of
traditional education about sports nutrition practices
led by knowledgeable staff, followed with peer team
support and well-respected role models, will help
provide accurate information to sports teams and
individual athletes.
Who provides nutrition
assessment and education
to athletes?
Athletes can benefit from nutrition education from a
variety of sports professionals. Coaches have a
significant influence on athletes and can affect their
knowledge of nutrition and encourage healthy
nutrition behaviors. Athletic trainers often have the
most contact with athletes, especially an athlete who
is injured or needs regular taping, ice, or other daily
treatments pre- and postpractice. Strength and
conditioning coaches also have regular contact with
athletes and work with them to improve sport
performance with proper training regimens.
Registered and licensed dietitians (RDs and LDs)
can provide an in-depth assessment of an athlete’s
current nutrition status; calculate specific calorie,
macronutrient, and micronutrient goals; aid in meal
planning/cooking tips; generate proper hydration
schedules; and address specific health-related
nutrition questions/concerns, thus making RDs and
LDs valuable resources for athletes. The
involvement of an RD or LD is also essential to the
athlete with medical complications such as diabetes,
anemia, weight control issues, or an eating disorder.
All of these professionals can, and should,
provide basic nutrition information to athletes;
however, the extent to which information and
recommendations are disseminated will vary based
upon each person’s qualifications. Coaches, athletic
trainers, and strength/conditioning coaches typically
have a high credibility rating with athletes, making
them valuable nutrition educators for players.
However, most coaches, athletic trainers, and
strength/conditioning coaches do not have a college
degree in dietetics or nutrition certifications and
therefore, are qualified to educate athletes only on
information that is considered “public domain.” There
is a plethora of public domain information available
that is provided by government agencies and
research organizations geared toward sports
professionals working on improving the nutrition
status of athletes. Examples of public domain
information include the following:
MyPlate food guidance system—both print and
online information
Dietary Guidelines for Americans
Information in position papers published by major
nutrition and sport organizations such as the
American College of Sports Medicine, the
National Athletic Trainers Association, and the
Academy of Nutrition and Dietetics
Nutrition information found in textbooks and
scientific peer-reviewed journals
Food and nutrition information found on product
labels, websites, and printed brochures
The key for any individual working with athletes,
regardless of licensure and registration, is to provide
nutrition education to athletes using accurate,
scientifically based information. Without a license,
individuals can cross legal and ethical boundaries
when providing medical nutrition therapy. Currently,
46 states, Puerto Rico, and the District of Columbia
have statutory provisions regulating the dietetics
profession or associated titles such as “dietitian” and
“nutritionist”.7 The number of states that have
licensure laws will change as new legislation is
passed at the state level. These laws provide legal
definitions of what type of nutrition assessment and
education can be conducted by non-licensed
professionals and what cannot be provided unless
the individual is licensed. Most licensure laws for
dietitians are similar to other allied health
professionals, such as athletic trainers, physical
therapists, pharmacists, and nurses. The purpose of
licensure is to help the public find qualified and
trained professionals who have completed minimum
education requirements, maintain their education in a
timely manner, and have passed an exam that
verifies a high level of knowledge and proficiency in
their profession. Licensure protects the public
against fraudulent practices and also allows the state
to have regulatory authority over these professions.
In states where licensure is mandated for
dietitians, the term dietitian or nutritionist may be
licensed. That means that only a registered dietitian
who meets the qualifications set by the state to
obtain a license can use the term dietitian or
nutritionist in his or her title or practice. The states
also legislate which types of assessments or
education can be offered by licensed dietitians only.
In most cases, licensed, registered dietitians are the
only professionals allowed to provide nutrition
assessments and medical nutrition therapy to
individuals. This means that licensed and registered
dietitians are the only professionals allowed to
provide athletes with a full assessment of their
dietary intake, medical nutrition needs, and individual
recommendations based on those assessments.
When athletes need this type of assessment,
licensed and registered dietitians should be
consulted.
In this chapter, the majority of the information
related to nutrition consultations with athletes is
provided as examples of a registered and/or licensed
dietitian performing the assessment. Certainly, many
additional sports professionals will consult with
athletes about their nutrition needs and provide
some education regarding nutrition and sport
performance. The information in this chapter will be
valuable for individuals interested in obtaining the
registered dietitian (RD) credential as well as for
other professionals working with athletes in primary
roles who are not in the nutrition field but relate to
the overall health and physical performance of
athletes.
How does the consultation
process with athletes
begin?
Ideally, the athlete will document his or her personal
health history and dietary intake information prior to
the first nutrition education session. The information
gathered should include basic demographics,
including contact information, a health history
questionnaire, a list of current medications and
supplements, a food record, and a training or
exercise log. If this information is collected and
reviewed prior to the first visit, it can be evaluated
more thoroughly, and specific suggestions can be
generated during the first visit with the athlete. Each
of these pieces of information adds value to the
assessment and consultation process; collectively,
they provide sports nutrition professionals with the
information needed to develop a sound nutrition plan
for the athlete.
What is a diet history?
A diet history is the most comprehensive form of dietary
intake data collection. It is an interview process that reviews
recorded dietary intake, eating behaviors, recent and longterm habits of food consumption, and exercise patterns. A
skilled, trained interviewer is needed to take the diet history.
Most dietitians use a form of diet history interview in every
individual assessment with a new client. This process is time
consuming but well worth the effort.
A direct interviewing process can help the dietitian take a
diet history relatively quickly. In this process, a combination of
open- and close-ended questions can pace the interview
within the time allotted for the session. Using an initial health
history questionnaire and any food records completed, a set
of clarifying questions can be formulated prior to the first visit.
If the questionnaire and food records are brought in on the
day of the visit, the dietitian can quickly scan the information
and ask questions in the order of the questionnaire and food
record. The questions and format will vary for each athlete.
Most sessions are time limited, and the information must be
obtained as quickly and efficiently as possible to allow for
education, meal planning, and goal setting.
Assessing dietary adequacy should not only include
assessment of food intake data but also biochemical and
anthropometric parameters. Height, weight, body composition,
and body mass index should be compared with appropriate
standards. Laboratory assessments such as hemoglobin,
albumin, electrolytes, and any clinical diagnoses should also
be considered when making a complete dietary assessment.
Clinical observations of the athlete’s skin, hair, and nails can
provide information necessary to make accurate assessments
of usual dietary intake and adequacy. Dietary adequacy
should be assessed and diet plans formulated based on the
totality of the evidence, not on dietary intake data alone.8
Information about and examples of tools used in the diet
history are described in the following sections in this chapter.
What is a health history questionnaire?
The health history questionnaire asks a variety of questions
about current health, past medical history, and daily health
and wellness topics. These may have implications for nutrition
care and should be addressed as part of the sports nutrition
consultation. It is often assumed that athletes are healthy and
are not likely to have medical conditions. However, many
high-level athletes and recreational athletes do have
underlying medical issues that may affect nutrition status and
thus dietary recommendations. Information about chronic
diseases, current or past injuries, surgeries, and regular
medications helps nutrition professionals make a thorough
assessment of the athlete’s needs and subsequently develop
appropriate nutrition recommendations. A sample health and
nutrition history questionnaire is shown in FIGURE 10.1 .
Figure 10.1 Sample health and nutrition history questionnaire. Taking a
health and nutrition history in the first meeting with athletes helps the
dietitian determine any health concerns that should be addressed when
developing the nutrition plan.
Data from the Nutrition and Wellness Solutions, LLC,
www.nutritionwellnesssolutions.org
In addition to information about current medical conditions,
information about family history of major chronic illnesses
should also be obtained. Nutrition professionals need to look
at the athlete as a whole and make the best nutrition
recommendations possible for the athlete’s health and sport
performance. This may include providing assessment and
education on medical nutrition topics when the need arises.
For example, a college athlete states on his or her health
history that he or she has no chronic illnesses but has a
paternal and maternal history of diabetes. Nutrition education
for this athlete should focus on the athlete’s goals for sport
performance, as well as on information about diabetes
prevention.
A listing of medications is also valuable information to
obtain from athletes. Some medications may have drug–
nutrient interactions. Others may need to be taken with food
or on an empty stomach. This may affect the timing of meals
and snacks, thus affecting pre- and postexercise food intake.
Reviewing current medications can also provide the dietitian
with insight about medical conditions that the athlete may
have forgotten to disclose. For example, a diuretic on the
athlete’s medication list could suggest that he or she has
hypertension or some other cardiac condition. Inquiring about
the reasons for taking the diuretic and how often it is used will
clarify the effects the medication may have on hydration
status and medical nutrition management of the athlete.
Athletic trainers and coaches working daily with athletes also
need to be aware of medications in case of emergencies.
These professionals play a pivotal role in helping athletes
maintain their medication regimen and monitoring the effects
of these medications on sport performance. In addition,
athletic trainers, coaches, and the team physician should be
aware of the list of banned substances for athletes that may
be present in various medications.
Additional health and wellness information gathered in a
health history questionnaire provides more information about
the nutrient needs of the athlete. Routine questions about
smoking habits and consumption of alcohol should be
included on the health history questionnaire. Athletes are less
likely to smoke, but if they do, smoking may increase the need
for some nutrients, such as vitamin C. Alcohol consumption
can add extra calories with little nutrient value and may play a
role in the discussion about meeting the athlete’s goals.
Information about current exercise can be requested on a
health history questionnaire or within a more detailed exercise
log.
Many athletes seek the assistance of a dietitian because
they want to change their weight or body composition. Some
may desire weight gain, whereas others desire weight loss.
Others may just want to alter their body fat percentage without
a change in weight. Therefore, the dietitian should obtain
information on the athlete’s current height, weight, and body
composition and assess how the athlete feels about his or her
current weight before determining whether the desired weight
loss is appropriate. If an athlete states that he considers
himself overweight, but the anthropometric measurements
suggest otherwise, the dietitian knows to proceed with
caution. Athletes who are overly concerned about their weight
may be at risk for developing eating disorders or eating
behaviors that inhibit optimal sport performance. Information
about past and current dieting and weight-loss practices also
can be useful in the initial consultation session.
Why is an inquiry about supplement use
important?
Many athletes use one or more dietary supplements on a
regular basis. There are two main issues to explore regarding
an athlete’s use of supplements. First, a listing of all
supplements currently being used helps determine safety and
efficacy for the athlete. Some supplements may not be safe
for regular consumption, may not be proven effective, or could
be banned by several sports organizations. Sport nutrition
professionals need to know which supplements might fall into
these categories and share that information with the athletes.
The second question about supplements is to determine why
the athlete is taking each of the supplements. This can
provide clues about the athlete’s goals and his or her drive to
achieve these goals. If the athlete is taking three different
weight-gain and protein supplements several times each day,
this is a significant clue that the athlete has a strong desire to
build muscle mass. In addition, there may be myths about
certain supplements that need to be addressed with individual
athletes. Taking a thorough history of past and present
supplement use will help guide the discussion and education
necessary to help the athlete remain safe when consuming
supplements.
Many athletes take a multivitamin and mineral supplement
or single vitamins or minerals. Specifically asking about
vitamin and mineral supplement use may be necessary
because many athletes and the general population often do
not recognize vitamins and minerals as supplements.
Although taking a multivitamin/mineral supplement in most
cases is appropriate and for some athletes beneficial, taking
mega-doses of single vitamins or minerals may not be safe.
Follow-up questions to clarify the daily doses of vitamins and
minerals along with a review of food records will help
determine whether these supplements are necessary and
safe and whether doses can be decreased or discontinued.
What type of food intake information should
be obtained from the athlete?
Any type of direct food recording provides valuable
information for the initial consultation. Reviewing the types
and amounts of food usually consumed, when and where
meals are consumed, and how they are prepared provides a
wealth of information to begin the evaluation of current intake.
This information will be used to formulate a nutrition plan for
the athlete. A variety of methods are available for collecting
food intake data. The most common is direct recording of food
intake using a food record. The athlete is asked to keep a 1-,
3-, or 7-day food record of all foods and beverages consumed
in the designated time period. Documentation of intake
throughout the day should be recorded as soon as possible
after consumption to obtain the most accurate information.
The recall method requires the athlete to remember all foods
and beverages consumed in a distinct period of time, usually
within the past day. This 24-hour dietary recall can be
obtained in the first session if food records are not available.
Another tool is a food frequency questionnaire that asks the
athlete to record how often common foods are eaten on a
daily, weekly, monthly, or even yearly basis. All of these tools
can be helpful to the dietitian and may be used separately or
collectively to obtain substantial information about the
athlete’s food intake. Each of these methods has advantages
and disadvantages.9, 10 The three methods are described in
more detail in the following sections.
How are food records used in nutrition
consultation?
The first step for nutritional assessment of the athlete is to
gather accurate information about food intake. The nutrition
plan developed later in the consultation will be based partly on
this initial information. The goal of any food recording is to
gain specific information about foods consumed by the
athlete. A food record kept prior to the first visit decreases the
reliance on memory to determine recent food intake.
The number of days an athlete should keep a food record
depends upon several variables. Many athletes will not take
the time nor see the need for recording food intake. A 1-day
food record gives a snapshot view of only 1 day of their eating
patterns. The athlete is asked to write down foods eaten in a
“typical” day. The athlete has to determine which day is
typical. This could be a weekday when practices are intense,
a school day, or a weekend day. Although this 1-day record
provides some dietary intake information, additional recorded
days will provide better information about usual dietary intake.
A 3-day food record provides more information about
foods eaten and consumption pattern differences throughout
a week than a 1-day record, but is not as time intensive as a
7-day log. A 3-day food record is most useful when 2
weekdays and 1 weekend day are recorded. Often,
individuals eat differently on weekdays than on the weekends.
Training schedules, access to meals, and time for meal
preparation may vary on different days of the week. In
general, a 3-day food record will provide an estimate of
nutrient intake that can be used to develop a nutrition plan.
This may not be an accurate reflection of long-term nutrient
intake, but it does provide a reliable assessment of short-term
patterns that is valuable for conducting an intake evaluation
and subsequent meal plans.
A sample completed food record is shown in FIGURE
10.2 . To help cue the athlete to record a thorough and
accurate food log, sections for the date, time of meals/snacks,
amount and type of food consumed, feelings or emotions
about food, and location should be included on the recording
form. Instructions on how to complete the food record should
be included for the athlete, such as a sample 1-day record
with examples of the amount of detail requested when
recording dietary intake. Instructions on determining the
amount of each food eaten, specific brands chosen,
restaurant names if dining out, and where the food was eaten
are necessary for cueing the athlete. If possible, the dietitian
should review the recording process on the phone prior to the
meeting or have the information available in detail on a
website that the athlete can access. This will help ensure the
most accurate food recording prior to the first session.
Figure 10.2 Sample 1-day food record. Completing a 1-, 3-, or 7-day
food record provides information on specific foods athletes eat each day.
Obtaining a complete and accurate food record from an
athlete can be a challenge. Athletes who are not accustomed
to keeping a food journal may forget to record every food
eaten each day. Even the most conscientious athletes may
forget to write down a snack or beverage consumed. The
accuracy of the food record is questionable in many cases.
Several studies have documented a high incidence of under-
reporting of food intake.11, 12 A number of studies also have
reported variations in nutrient intake based on the day of the
week13, 14 or appetite fluctuations, especially related to
physical activity or menstrual cycle changes.15, 16
Many factors affect day-to-day variations in dietary intake.9
Some athletes will eat the same thing for breakfast and lunch
every day of the week, and only have variety with the evening
meal and snacks. Other athletes have wide variations in meal
intake daily. The day of the week is almost certain to affect
intake based upon individual training and competition
schedules. Food intake during the competitive season versus
the off-season may influence dietary differences. The season
of the year could also have an effect. Less food may be
consumed in hot, humid months and more during cold winter
months. Athletes may have changes in appetite based on
their training schedule. During intense training, athletes may
not eat as much as in less intense training times. Therefore, a
food record ideally covers at least 3 days, combining
weekdays and weekends, as well as capturing heavy and light
training days.
How is a 24-hour dietary recall used in a
nutrition consultation?
Even when documented food records are obtained from the
athlete, a 24-hour dietary recall can be a valuable tool. The
purpose of the dietary recall is to get a complete and detailed
picture of what the athlete consumed over the last 24 hours.
In many cases, asking the athlete for a recall of a “typical” day
of food intake will also provide information to help with the
evaluation of an athlete’s usual intake. The athlete can
document all foods eaten in the past 24 hours on a blank 1day food record. This organizes the information, making
review and evaluation easy. The dietitian can then prompt the
athlete by asking questions about specific types of foods or
beverages consumed, condiments on food, and clarification of
portion sizes. Using food models can visually aid individuals in
correctly estimating the portion size of foods/beverages
consumed. Clarifying questions such as, “Did you have
anything to drink with that meal?” or, “Did you put anything on
your sandwich in addition to the turkey and cheese?” prompt
the athlete to be more specific about all foods consumed. A
24-hour recall is not going to provide a truly accurate picture
of what an athlete eats on a regular basis, but it does provide
information about general eating habits.
Gaining the Performance Edge
Completing food records provides substantial information
for the assessment of the athlete’s dietary intake. A 3-day
food record is recommended when assessing dietary
intake. It provides enough information to learn about
typical intake patterns without being time intensive for
busy athletes.
How is a food frequency questionnaire used
in a nutrition consultation?
Food frequency questionnaires (FFQs) look at intake over a
longer period of time than food records and dietary recalls.
The FFQ puts foods into broad categories and asks the client
to record intake over time. For example, an FFQ may ask,
“How often do you consume dairy products?” The responses
may be daily, weekly, or monthly, and the athlete is asked to
write in the number of servings typically consumed in those
three time periods. A sample portion of a food frequency
questionnaire is shown in FIGURE 10.3 . Many FFQs have
been developed to assess a specific population’s intake of a
certain type of food or designed by organizations for research
purposes, such as the National Cancer Institute Diet History
Questionnaire.17 Other FFQs provide a more general view of
dietary intake and are best for the information needed to
assess athletes’ usual intake over time. When selecting a
food frequency questionnaire, consider an instrument that is
already validated, provides information on either a group or an
individual’s needs, and is appropriate for the population being
assessed.18 FFQs provide information about long-term dietary
patterns, which is an advantage as compared to food record
data. However, assessing FFQs is time consuming, they can
be costly to administer and evaluate, and they may not
provide information specific to the athletic population. If the
athlete has time to complete food records and an FFQ, and
the dietitian has time to evaluate both tools, using them in
combination is valuable. With less available time, food record
data is more beneficial in assessing an athlete’s dietary
intake.
Figure 10.3 Sample food frequency questionnaire. A food frequency
questionnaire captures long-term dietary patterns of intake.
How is an exercise/training log used in a
nutrition consultation?
Documentation of how much exercise is completed daily and
weekly is essential to any sports dietitian’s assessment and
nutritional plan.19 The training log is a valuable tool in
determining energy expenditure and thus energy needs. It
also provides information on the time spent training and
competing that may influence food preparation and
consumption patterns. Information about the type, duration,
and intensity of training provides an even more accurate
picture of caloric expenditure.
A sample exercise log is shown in FIGURE 10.4 . As with
food records, a specific form requesting information regarding
daily/weekly exercise and a sample of how the log should be
completed will help athletes complete the record in the detail
desired. Detailed energy expenditure logs that record all
activity within a 24-hour period are available; however, these
are extremely cumbersome to complete with accuracy and
are very time consuming. An exercise log that reveals actual
duration, intensity, and type of exercise provides adequate
information for developing a nutrition plan that includes
nutrition needs for energy expenditure.
Figure 10.4 Sample exercise log. Keeping track of the time, amount, and
intensity level of exercise helps determine energy expenditure.
Which clinical assessments should be
conducted in the initial consultation
session?
Access to laboratory data and other medical documentation is
extremely helpful when consulting with athletes who present
with various medical conditions. Nutrition consultations
requiring the interpretations of laboratory assessments are
regarded as medical nutrition therapy and should be
completed by registered and licensed dietitians. Laboratory
assessment can help to determine an athlete’s nutrition
status, which will affect the development of a nutrition plan.
For example, female athletes, especially long-distance
runners, have a tendency to develop iron deficiency during
their training and competitive careers. Athletes’ laboratory
reports of total iron, hemoglobin, serum ferritin, and
hematocrit levels can help the dietitian evaluate iron status
and thus provide education on ways to improve dietary iron
intake if needed. Common laboratory reports often requested
by dietitians include electrolyte levels, albumin, prealbumin,
total protein, and potentially any clinical laboratory report
related to a current disease condition. Dietitians will need
detailed glucose monitoring values for athletes with diabetes
and lipid levels for athletes with known heart disease or
dyslipidemia.
Gaining the Performance Edge
The initial information gathering for the first session can be
extensive or minimal. The amount of time available prior to
the first visit and the athlete’s interest in, and ability to
keep, food records and to complete an exercise log will all
be factors the dietitian will consider when asking the
athlete to collect information before the first visit.
Other health/sports professionals may use laboratory or
diagnostic data to evaluate and educate athletes regarding
nutrition status. For example, athletic trainers may request
radiology reports for athletes with potential stress fractures
and MRI reports for any soft or hard tissue injuries. When
stress fractures are determined, the athletic trainer and
physician may discuss medical as well as nutritional treatment
to help the athlete heal. This is an opportunity to talk with the
athlete about regular calcium and vitamin D intake and decide
whether supplementation would be a helpful adjunct to
treatment. The dietitian, physician, and athletic trainers or
physical therapists work together as a team to develop the
best nutrition and healthcare plan for the athlete based, in
part, on the clinical medical information available.
How are food records analyzed?
Once the data are collected from the athlete, clarification of the
food record will help ensure that the most accurate information
is obtained for analysis. In the initial consultation, clarifying
questions can be asked to help learn more about actual food
intake. Often, the food consumption information is incomplete.
The most frequently omitted items on a food record include:
Actual portion sizes
Condiments used
Restaurant or name brand of item
Method of food preparation
Beverages consumed with meals or snacks
Snacks between meals
A sample food record with clarifying questions is shown in
FIGURE 10.5 . Clarification questions such as those listed in
Figure 10.5 help jog the athlete’s memory without making
judgments about the foods eaten or trying to lead the athlete to
add or omit foods during the discussion. The question, “What
else did you eat at lunch on Wednesday?” might sound
judgmental to the athlete. The athlete may feel that the dietitian
does not believe the information provided on Wednesday’s food
record. Similarly, asking, “Did you have any juice with
breakfast?” could lead the athlete to say yes if he or she feels
that is the answer the dietitian wants to hear. Asking the
question, “Did you have something to drink with breakfast?”
helps clarify the meal without suggesting a particular beverage
or making any judgments about the intake.
Figure 10.5 Sample food record and clarifying questions. Food recording
provides valuable information when developing nutrition plans for athletes.
The accuracy of the recording process can be improved by providing a
sample record and asking clarifying questions about the foods eaten.
Information from the food record is most often entered into a
nutrient analysis software program. Many software databases
are available to calculate the content of the diet to estimate
macronutrient and micronutrient values. Some nutrient analysis
products are available on the Internet and offer free access to
any user. All of these programs perform the mathematical
calculations and comparisons to the food database, saving
significant time. Books of nutrient composition tables are also
available to research a specific food item that may not be
available in nutrient databases.
TABLE 10.1 provides a list of software, websites, and
books that provide nutrient analysis information. Most
computerized nutrient analysis packages come with a standard
nutrient database included with the software. Occasionally, the
purchaser has the option of selecting which database to include
in the software package. The database is used to compare the
food data input from the dietary records with estimated nutrient
intake. The most common database used in software packages
is the U.S. Department of Agriculture (USDA) Database for
Standard Reference. This database is appropriate for the
analysis of diets of people in the United States and reflects
typical foods consumed. It is regularly updated with new foods
and uses the most current Dietary Reference Intake (DRI)
tables. The database used is important when selecting software
or websites to assess the nutrient content of food record data.
The database should be updated regularly, and updates should
be included in any software package contract. The nutrient
information is only as good as the database used to calculate
the nutrient composition. The U.S. food supply is highly fortified
and also contains highly processed foods. This is not the case
in many other countries. Using an appropriate database
matched for the athlete’s typical intake will provide a more
accurate reflection of nutrient intake.
Table 10-1
Resources for Dietary Analysis
Resource
Contact information
Comments
My Food
Record
www.myfoodrecord.com
Web-based
analysis tool,
free to all
Internet
users; will
save
personal data
and allows
users to add
more days;
includes an
energy
calculator
USDA
https://www.ars.usda.gov/northeast- Large database
Database
area /beltsville-md-bhnrc/beltsvilleof foods
for
human-nutrition-researchconsumed in
Standard
center/nutrient-datathe United
Reference laboratory/docs/usda-nationalStates;
nutrient-database-for-standardupdated
reference/
regularly;
often the
database
used by
computerized
nutrient
analysis
software
Resource
Contact information
Comments
Nutritionist
Pro
www.nutritionistpro.com
Accurate, upto-date food
and nutrient
data for
complete
analysis on
over 51,000
foods and
ingredients,
including
brand-name,
fast foods,
ethnic foods,
and enteral
products
FitDay
www.fitday.com
Web-based
analysis tool,
free to all
Internet
users but
requires
setting up a
free user
account
NutriBase
www.dietsoftware.com
Commercially
available
nutrition
analysis
program for
professional
or personal
use
Resource
Contact information
Comments
Cronometer www.cronometer.com
Web-based
analysis tool,
free to all
Internet
users
Bowes and Lippincott Williams and Wilkins
Church’s
Publishers (www .shop.lww.com)
Food
Values of
Portions
Commonly
Used,
19th ed.
Well-organized
book of many
common foods
listed in
standard
portion sizes.
Includes brand
names and
some
restaurant
items. Gives
macro- and
micronutrient
values.
Excellent for
determining
nutrient content
of a specific
food
Gaining the Performance Edge
Assessing athletes’ intake using computer analysis provides
detailed information about the various nutrients consumed
in the diet. Athletes tend to consume sports foods and
beverages that typically are not included in standard nutrient
databases. Software purchased to analyze the diets of
athletes should include the option of adding these foods to
the database to produce an accurate dietary analysis for all
foods and beverages consumed.
Food for Thought 10.1
Dietary Intake Methods and Obtaining
Accurate Data
Describe the advantages and disadvantages of various
dietary intake methods, and review a food record for
accuracy.
New food products enter the marketplace daily, and no one
database can keep up with the changing food market. Sports
nutrition products are increasing in popularity, and new sports
drinks, bars, supplements, and foods are marketed regularly to
athletes. Many of these items are not in standard databases.
These foods could make up a substantial portion of an athlete’s
intake and need to be accounted for in the nutrient analysis.
Many software and online analysis databases allow users to
add new foods to their own nutrient analysis database.
Information from the food label can be added to the database
for each new item. Not all micronutrients are required to be
listed on the supplement label, so many of them will not be
available for the data analysis. There will, however, be calorie,
macronutrient, cholesterol, and fiber information on the label of
sports-related items or other foods that are not in the database.
When working with athletes, nutrition professionals should be
prepared to add new foods to the nutrient analysis database to
provide the most accurate nutrient analysis.
How do you compare dietary intake to
nutrition recommendations?
An athlete’s diet can be compared with national standards to
help determine nutritional adequacy in a number of different
ways. Three common ways are to compare intake to the DRIs,
to the MyPlate food guidance system, or to the Dietary
Guidelines for Americans. In addition, published data on
nutrition intake specific to athletes can be used to compare the
intake of similar athletes. There are advantages and
disadvantages to all of these methods of assessment, and
several can be used together to provide the best assessment of
dietary intake.
How can the DRIs be used to assess athletes’
nutritional adequacy?
Most frequently, the dietary information obtained from the
dietary assessment is compared with the DRI standards. The
DRIs include Recommended Dietary Allowance (RDA),
Adequate Intake (AI), Estimated Average Requirement (EAR),
and Tolerable Upper Intake Level (UL). Most computerized
dietary analysis software uses the RDA or AI data for
comparing intake to dietary standards. If the RDA or AI of the
athlete’s intake is met, the dietitian can determine with
confidence that the athlete is consuming adequate amounts of
the nutrient. When a UL is available, the dietitian should
compare that number to each nutrient and determine whether
too much of any nutrient is being consumed. Using the
appropriate DRI values that are available for each nutrient and
comparing these with the established RDA or AI are essential
to any accurate dietary intake assessment.
How can the MyPlate food guidance system
be used to assess athletes’ nutritional
adequacy?
A quick and easy way to assess overall adequacy of dietary
records is to use the MyPlate food guidance system. This can
be an excellent, easy guide to help the dietitian and athlete
compare the number of servings from each food group
consumed with the number recommended. If an athlete is
consuming the minimum number of servings in all of the food
groups on the plate, there is relatively good assurance that the
dietary intake will meet minimum recommendations for most
nutrients. This does not ensure that an athlete will obtain
adequate calories but may help determine generally healthful
food intake with adequate micronutrients. The MyPlate system
is an excellent tool for any professional trying to quickly assess
an athlete’s dietary intake. However, it is not the best tool for a
detailed analysis of current dietary intake.
TABLE 10.2 provides a sample comparison of an athlete’s
1-day food intake to the recommended servings from MyPlate.
In the example, the athlete’s intake meets or exceeds the
minimum number of daily servings for all MyPlate categories,
based on a meal plan of 2,200 calories per day. Although
meeting the minimum number of servings will provide adequate
vitamins and minerals, it may not be enough total calories to
meet the athlete’s energy requirements. Additional assessment
of energy intake is discussed later in this section.
Table 10.2
Comparing Athletes’ 1–Day Food Intake to the MyPlate
Food Guidance System (2,200 calorie plan)
Can the Dietary Guidelines for Americans be
used to assess athletes’ nutritional
adequacy?
The Dietary Guidelines for Americans are a set of general goals
for food intake and dietary comparison developed by the USDA
and the Department of Health and Human Services (HHS).
They are intended to help educate Americans about healthful
food consumption patterns to reduce the development of
chronic diseases such as hypertension, diabetes,
cardiovascular disease, obesity, and alcoholism. These are
very general guidelines for the average American and are tools
that all individuals can use to decipher how their diets match up
to healthy guidelines. However, athletes expend more energy
and may need or tolerate higher levels of some of the nutrients
than the guidelines suggest as an average intake for
Americans. This public domain information is valuable for
anyone working with athletes on a nutrition plan for general
health. Although useful, comparing athletes’ intakes to the
Dietary Guidelines alone is the least useful method for helping
to determine the best nutrition plan for individual athletes.
How is energy and macronutrient intake
assessed?
Energy intake can be determined by using food record analysis
data. The total calories consumed for each day or series of
days is listed on the food record analysis report. This
information can then be compared with the athlete’s estimated
energy needs. In most cases, estimating athletes’ energy
needs is done using one of several prediction equations. One
of the equations is listed in TABLE 10.3 , where resting energy
expenditure (REE) indicates the basic energy needs of the
body, and this number is multiplied by an activity factor that
reflects the energetic demands of the sport and/or level of
training. The dietitian can calculate energy needs for individual
athletes by using the athlete’s body weight and gender and age
category and selecting an appropriate activity factor. Activity
factors are on the low end for athletes training for less time and
at lower intensity levels and are on the high end if they are
highly competitive, training hard for many hours each day.
Table 10.3
Resting Energy Expenditure (REE) Calculations and
Activity Factors
Gender and age
(years)
Equation (BW in
kilograms)*
Activity
factor
Males, 10 to 18 years REE = (17.5 × BW) + 651
1.6–2.4
Males, 18 to 30 years REE = (15.3 × BW) + 679
1.6–2.4
Males, 30 to 60 years REE = (11.6 × BW) + 879
1.6–2.4
Females, 10 to 18
years
REE = (12.2 × BW) + 749
1.6–2.4
Females, 18 to 30
years
REE = (14.7 × BW) + 496
1.6–2.4
Females, 30 to 60
years
REE = (8.7 × BW) + 829
1.6–2.4
*BW, body weight.
Data from World Health Organization. Energy and Protein
Requirements, Report of a Joint FAO/WHO/UNU Expert
Consultation. Technical Report Series 724. Geneva, Switzerland:
World Health Organization; 1985:206.
The dietitian should then compare the estimated energy
expenditure to the dietary intake. In some cases, dietary intake
may be below recommended energy needs based upon the
energy expenditure calculations. If this is the case, the athlete
and the dietitian can discuss ways to increase caloric intake.
When energy intake is higher than calculated energy
expenditure, additional discussion about weight changes may
be helpful. If the athlete has not lost or gained weight recently
and his or her diet has been consistent over time, the dietary
energy intake is probably meeting energy demands. The goals
of the athlete must be considered when determining the
appropriateness of energy intake versus energy expenditure. If
the athlete desires weight loss, a calorie deficit is appropriate.
When the athlete wants to gain weight, additional calorie
consumption above calculated energy needs should be
encouraged. FIGURE 10.6 provides an example of a dietary
analysis report of an athlete’s 1-day food record. Note that the
calories, macronutrients, and micronutrients are displayed in
absolute numbers (e.g., grams, milligrams) as well as a
percentage of the established dietary recommendations.
Figure 10.6 Dietary analysis report. Many computer programs are
available that provide detailed dietary analyses of food records.
If calorie intake needs to be altered, the absolute value
and/or the relative contribution of the macronutrients compared
with total calories may require adjustment. Carbohydrate intake
should be assessed first because it is the macronutrient that
should be consumed in the highest percentage of calories for
the athlete’s diet.20 Whether working with a team sport,
strength, or endurance training athlete, carbohydrates are
going to be used as fuel during exercise. The recommended
range of intake of carbohydrates for athletes is 3 to 12 grams
per kilogram body weight. The amount of carbohydrate required
will depend upon a variety of factors including an athlete’s
training volume, exercise intensity, and performance goals.
Information from the analysis of the grams of carbohydrate
intake should be compared with the calculated needs and
adjusted to meet the athlete’s requirements.
Protein intake is assessed after carbohydrate intake and
needs are established. Protein intake should be compared with
overall calorie intake as well as to fat and carbohydrate intake
to provide a well-rounded picture of the athlete’s diet. The
recommended range of protein intake for athletes is 1.2 to 2.0
grams per kilogram body weight. Protein needs will vary based
upon factors such as training intensity and duration, desire of
the athlete to lose or gain weight, dietary protein quality, and
age. Comparing protein intake from dietary assessment data to
the protein range appropriate for athletes will help the dietitian
determine the optimal protein needs for the individual athlete
and adjust the dietary intake recommendations accordingly.
Fat is the last macronutrient to be compared with overall
calorie intake and to have its levels assessed. Once the
carbohydrate and protein needs are established, the rest of the
calories should be derived from fat intake. A minimum of 20%
of calories should come from fat in the athlete’s diet, especially
for athletes performing long-duration, low-to-moderate intensity
workouts.21,22 A range of 20 to 35% of calories consumed as
fat is safe and adequate for most athletes. This range allows for
plenty of flexibility in fat intake based on the other
macronutrient needs for each athlete.
How is vitamin and mineral intake assessed?
Most computer programs compare the vitamin and mineral
intake to the RDA/AI values. This provides information on how
an athlete’s vitamin and mineral intake compares with the
recommendations for the general population. The RDA and AI
are designed to prevent nutrient deficiencies for men and
women in various age categories and are not targeted
specifically for physical activity needs. For example, the
calcium recommendation for a 30-year-old female athlete is
1,000 milligrams and for a 15-year-old female is 1,300
milligrams, regardless of activity level. Similarly, a female
athlete in childbearing years may have higher iron needs than a
male athlete or a female athlete who is postmenopausal.
There are no specifically designed standards for vitamin and
mineral intakes of athletes. When assessing an athlete’s
vitamin and mineral intake, use the correct gender and age
categories. A large number of research studies have assessed
both intake and nutrient needs of athletes. Some comparison
with these studies may be appropriate. However, comparisons
with these studies should be made only when the athlete is in
the same gender and age group and has an equivalent
exercise level as the subjects in the published study.
Gaining the Performance Edge
Comparing an athlete’s dietary intake to estimated calorie
and macronutrient requirements as well as to established
RDAs or AIs provides information on the adequacy of the
athlete’s daily diet. Using this information in combination
with other dietary assessment methods can help the
dietitian accurately assess dietary intake and the athlete’s
needs.
What are the steps for the initial
consultation with the athlete?
The initial consultation with an athlete is designed to gather
information, assess dietary intake, develop goals, provide
nutrition education based upon these goals, and develop a
nutritional plan. A review of why the athlete has sought nutrition
education and what goal(s) he or she has regarding nutrition
and sport performance is the first step in the consultation
process. Information from food and exercise records are then
assessed and compared with appropriate standards. Education
on ways to improve intake is completed and goals are set to
help monitor progress. This process is completed in the general
format listed in Fortifying Your Nutrition Knowledge.
However, each initial consultation will be different from the next.
The dietitian must remain flexible in the consultation session
and be willing to complete these steps in a different order based
on how the interview progresses.
Fortifying Your Nutrition Knowledge
Steps for the Initial Consultation Interview
Not every initial consultation with an athlete will follow these
particular steps in order. The dietitian must be flexible in
gathering information and providing education and guidance
based upon the athlete’s needs and goals. The following
steps will help guide dietitians in providing an efficient and
effective consultation with an athlete:
Establish rapport.
Clarify the athlete’s reasons for the nutrition
consultation.
Complete the nutrition assessment (anthropometrics,
food record analysis, exercise assessment).
Assess readiness for change.
Determine nutrition goals.
Provide education related to goals.
Summarize and set a follow-up visit date and time.
How is rapport established with an athlete?
The key to any good interview is establishing rapport early in
the session. Coaches, strength and conditioning staff, and
athletic trainers may already have established rapport with the
athlete. A consultant dietitian may not know the athlete well and
might need to spend more time initially on rapport building.
Addressing the athlete by name and asking a few general
questions about the sport, the athlete’s position on the team, or
his or her specialty in the sport can set the athlete at ease with
the process of the interview. When a dietitian knows about the
sport and can converse about the type of play, positions, and
typical workouts and competitions, the athlete feels that he or
she is understood. This helps establish a personal relationship
with the athlete in a supportive environment.
Projecting a positive demeanor and body language helps
put the athlete at ease. Communication experts and social
scientists believe that the image a person projects accounts for
more than half of the total message conveyed to another
individual at a first meeting.23 Nonverbal communication,
including tone of voice, eye contact, facial expressions, posture,
and physical environment, contributes to the ability to
communicate with clients. A simple nod and cordial greeting
can set the stage for effective communication. Conversely, a
sour facial expression, lack of eye contact, and a physical
barrier, such as a desk between the client and interviewer, can
immediately put the athlete on the defensive.
The setup of the physical space where the consultation
occurs can be arranged to help the athlete feel at ease. Sitting
behind a desk while the athlete is in a chair on the other side of
the desk places the consultant in a position of power over the
athlete. A better situation is to sit next to the athlete, with a table
or part of a desk nearby on which to place papers or
educational materials. There should be a comfortable distance
between the athlete and the nutrition educator. Sometimes,
education and assessment are conducted on the playing field or
in the athletic training room. Providing a comfortable
environment that is quiet and conducive to communication can
be achieved in even the most cramped or open spaces. Simply
paying attention to the details of the environment and creating a
comfortable, nonthreatening space between the athlete and the
professional can provide an excellent opportunity for
communication.
How can you determine the reasons for a
requested consultation?
After establishing rapport, clarification of the purpose of the visit
and the athlete’s goals will define what type of additional
information the dietitian needs to elicit from the athlete. Asking
specific questions about the athlete’s goals will help clarify what
is necessary to improve nutrition, weight, and health or sport
performance status. It also helps the dietitian to determine the
nutrition plan and education required to assist the athlete. Some
questions to determine the nutrition goals of the athlete may
include:
What would you like to improve regarding your daily diet?
What has motivated you to seek nutrition advice?
How are your daily energy levels and recovery from training sessions?
Do you want to change your weight or body composition?
What are your sport performance goals?
How do you think nutrition can help you achieve these goals?
Once the athlete verbalizes initial reasons for requesting the
consultation and specific nutrition/performance-related goals,
the nutrition assessment part of the consultation can take place.
How is the nutrition assessment conducted?
The majority of this section regarding the assessment stage
provides a case study example of how a dietitian can interact
with an athlete. The concepts in this section can be applied by
all health professionals working with athletes to improve their
nutrition; however, the actual assessment and nutrition plan
development in this section are examples of nutrition
assessment and nutrition therapy, and thus should be
conducted by a registered and/or licensed dietitian.
Jennifer’s Case Study
Jennifer is a freshman and plays shortstop on her college
softball team. Her coach thinks that she has the skill to be a
starter in her sophomore year. She is thin and has a hard
time hitting home runs, despite consistently hitting over
0.325 for the past three seasons of play in high school. Her
coach feels that if she were to gain some muscle mass and
strength her home-run hitting would improve, thus securing
the starting position next year. Jennifer agrees, and she has
started to eat more calories in an attempt to gain weight, but
she is concerned about gaining too much body fat. She is
fast around the bases, and her defensive quickness is a
huge asset to her team. She decides to consult with the
sports dietitian at her college to develop a plan to gain
muscle mass and a small amount of weight.
Specific Information from Jennifer’s Initial
Diet History
Height: 5´9˝
Weight: 142 lbs
Body mass index: 21
Body fat: 18%
Usual body weight: 140–144 lbs
Recent weight change: None
Jennifer’s 1-day food record is shown in FIGURE 10.7 .
Figure 10.7 Jennifer’s 1–day food record. This 1-day food record was
analyzed by dietary analysis software. An abbreviated summary of the
analysis highlights the categories in which Jennifer is either meeting her
needs or falling short of recommendations.
Jennifer works out with the softball team 6 days per
week. This includes playing time at practices, three aerobic
conditioning sessions per week, and morning strength
training three times per week. She burns a lot of energy in
these workouts and gets very hungry after practice. She has
started to increase her food intake but does not like meat
and is concerned she may not be getting enough protein in
her diet.
At the first appointment, Jennifer shares her concern
about wanting to gain more power and strength without
losing speed. After analyzing her food record and assessing
current intake, the dietitian works to develop goals and
objectives to achieve muscle mass gains. Jennifer states
that her outcome goal is to add approximately 5 pounds of
muscle mass in the next 3 months.
Three short-term goals were developed to help her
achieve her long-term goal of gaining muscle mass. First,
she needs to eat an additional 300 to 500 calories daily for
weight gain. Second, she should include a minimum of two
servings of high-quality protein daily to allow for protein to
be used for development of additional muscle mass. Third,
because her calcium intake was low, she needs to consume
a minimum of two milk/alternative servings per day. Jennifer
will measure her progress toward these goals by keeping a
food record for 3 days each week for the next 2 weeks. She
will weigh herself once per week, and body composition
analysis will be performed once each month for the next 3
months.
Education is provided to help Jennifer meet her goals.
The dietitian gives Jennifer handouts on ways to increase
calorie intake with nutrient-dense foods, including meat,
beans, and other protein foods. Information about grocery
shopping and meal and snack selection as well as foods to
choose that are higher in calcium is also provided.
At the end of the first consultation, the dietitian
summarizes the goals developed and the education related
to achieving those goals. She asks Jennifer to restate the
goals and how she plans to take action to meet the goals.
Jennifer verbalizes a list of foods she is prepared to
purchase the next time she goes grocery shopping.
The dietitian offers to meet with Jennifer again in the
future to provide support and additional education and to
monitor progress toward her goals. Jennifer decides she
would like to meet again in approximately 2 weeks. She
plans to bring her food records to the follow-up consultation
as well as a list of additional questions or concerns that may
arise over the next 2 weeks. They mutually decide on a date
and time, and the consultation is ended.
Which anthropometric data need to be
collected?
An important part of developing a nutrition plan for athletes is to
analyze their current nutrition intake and compare it with weight
and/or body composition data. Weight and body composition
data may not be readily available except in terms of a stated
height and weight. In an office setting, the dietitian can measure
the athlete’s height and weight in the first visit to establish an
accurate measurement rather than relying on stated
information. Body mass index (BMI) can be calculated from
height and weight; however, body composition must be
measured through specific assessment tools.
Dietitians are sometimes trained in body composition
assessment and can perform these measurements. In an office
or field setting, skinfold calipers or a bioelectrical impedance
analyzer is the easiest way to measure body composition. If a
dietitian has access to and is trained in using more elaborate
and accurate body composition analysis tools, such as the BOD
POD or underwater weighing, these methods are preferred.
Often, athletic trainers or strength and conditioning coaches are
skilled in body composition techniques. This is an excellent
opportunity for dietitians and other staff to collaborate in
assessing body composition and developing a plan for
improvement if needed. Comparing body weight over time is
necessary to determine whether energy intake is appropriate.
Asking probing questions about weight changes, training status,
energy level fluctuations, fatigue, or a drop in performance at
different times during the training and competitive season will
help the dietitian and the athlete determine whether intake is
consistently adequate to meet weight and training goals.
Jennifer’s Case Study
Jennifer’s BMI is 21, and she appears slight of build with
good muscular definition. Her BMI of 21 is in the normal
healthy range (18.5–24.9); however, considering her
musculature and high level of activity, an increase in BMI is
appropriate to meet her goal. Assessment of body
composition is indicated in Jennifer’s case. Her body fat
percentage was measured at 18%, which is considered
within the healthy range for athletic women. Because
Jennifer has not gained or lost more than 5 pounds in the
last 3 years, she is eating an appropriate number of calories
per day for weight maintenance. To gain weight, she will
need to add 300 to 500 calories per day.
How can an athlete’s food record be reviewed
and analyzed?
Ideally, the food record is obtained and analyzed before the
athlete arrives at the initial assessment appointment. The
dietitian can also ask questions about usual intake to determine
whether the foods listed on the food record are typical of the
athlete’s intake. If food record data are not provided in advance,
the dietitian can elicit a 24-hour recall or have the athlete
complete a brief 1-day food record at the very beginning of the
consultation. This is an opportunity to start immediately
interviewing the athlete and clarifying dietary intake information.
Once information from the food record or 24-hour recall is
clarified, analysis of the information should be completed
(covered in detail earlier in this chapter). This analysis can be
done using computer software or by the dietitian comparing the
information and making judgments based on clinical knowledge
and sport nutrition practice. Most often, a combination of
comparing foods consumed with set guidelines, such as
MyPlate; assessing food purchasing/preparation practices and
the time available for meal preparation and consumption; and
simply assessing the quality, quantity, and timing of food
consumed will all be a part of this analysis. The anthropometric,
dietary, and exercise assessments will be used to determine
whether energy needs are appropriate and will aid in creation of
the athlete’s nutrition plan.
Jennifer’s Case Study
One day of Jennifer’s 3-day food record is listed in
Figure 10.7. Jennifer’s food record contains only one
serving from the milk/alternative group. Clarifying whether
this is a typical amount of dairy product consumption daily
will help in assessing calcium and protein intake. For
example, Jennifer may state that she rarely has more than
one serving of milk each day, mainly on her cereal in the
morning. The dietitian should then further clarify whether this
is a food preference or a lactose intolerance problem.
Overall, Jennifer’s dietary intake is adequate in energy to
meet her estimated needs to maintain weight (approximately
2,300 calories daily). To gain weight, she will need to add
calories to her regular dietary intake. Her protein intake is
below recommendations at 1.1 grams per kilogram body
weight and 13% of her total caloric intake. To increase
muscle mass and weight, some of the additional calories
she needs to consume should come from additional protein
sources. Jennifer’s intake of vitamins and minerals
exceeded the RDAs/AIs except that for calcium. Her calcium
intake was less than the recommended AI, and thus needs
improvement.
© Larry St. Pierre/Shutterstock
How is energy expenditure assessed?
A review of when and how often the athlete exercises will
provide information on energy expenditure. A quick exercise
recall or review of an exercise log provides information on the
duration, intensity, and frequency of exercise sessions.
Additional questions should be asked about overall activity level
that does not include exercise sessions. For example, a college
athlete who drives to all classes will have a lower energy
expenditure than one who walks to all classes on campus.
Information about exercise and activity habits is then compared
with information obtained from dietary records and the
assessment of nutrient intake to determine whether calorie
intake should be increased, decreased, or maintained at the
current level.
Jennifer’s Case Study
Determining overall energy expenditure is necessary,
especially in Jennifer’s case because her goal is to gain
weight and muscle mass. Jennifer is a very active athlete on
and off the field. She usually walks to classes and drives
only to off-campus activities. She exercises 6 days per week
with the softball team at afternoon practices. They have
additional strength-training sessions three mornings each
week. When comparing her activity level to her energy
intake, and knowing that her weight has been stable for 3
years, the dietitian determines that she is consuming
enough calories to meet but not exceed her energy needs.
How can an athlete’s readiness for change be
assessed?
Assessing readiness to make nutrition and behavior changes is
an important part of any initial consultation. A variety of
methods are available to assess readiness for change.
Whichever method is chosen, it is essential to determine
whether the athlete realizes the need to make nutrition changes
and is ready to take action. Only an athlete with some level of
readiness will be able to make the changes needed to meet
goals. One such strategy for eliciting behavior change is
motivational interviewing. For more information on motivational
interviewing, see Fortifying Your Nutrition Knowledge.
Fortifying Your Nutrition Knowledge
Motivational Interviewing: A Tool for
Helping to Change Behavior
After performing a dietary analysis, one of the biggest
hurdles that sports nutritionists face is helping athletes adopt
new behaviors that can help them reach their personal and
sport performance goals. While athletes may have the best
of intentions to change their behaviors, actually practicing
and maintaining the new behaviors is another story. This is
where motivational interviewing can help. Motivational
interviewing is an athlete-driven, sport nutritionist-directed
consultation strategy for identifying potential barriers to
behavior change and how to deal with them. The sport
nutritionist merely guides the conversation while the athlete
actively reflects and develops ways of changing his or her
behavior. Motivational interviewing has been shown to be an
effective behavior change tool in situations ranging from
helping patients comply with a prescription medication
routine to helping people with extremely addictive habits.
For more information and current research findings
regarding the effectiveness of motivational interviewing,
refer to the following review articles:
1. Christie D, Channon S. The potential for motivational
interviewing to improve outcomes in the management
of diabetes and obesity in paediatric and adult
populations: a clinical review. Diabetes Obes Metab.
2014;16(5):381–387.
2. Thompson DR, Chair SY, Chan SW, Astin F,
Davidson PM, Ski CF. Motivational interviewing: a
useful approach to improving cardiovascular health?
J Clin Nurs. 2011;20(9–10):1236–1244.
The Transtheoretical Model, developed by Prochaska and
DiClemente, is a research-based model that approaches
behavior change as a process versus a distinct event.24 The
process involves a progression through a series of six stages
that ultimately leads to permanent lifestyle behavior change.
Each of these stages can be applied to helping athletes change
their eating patterns to improve overall health and maximize
athletic potential. The following overview of the Transtheoretical
Model briefly describes the six stages of behavior change and
how each stage can apply to working with athletes on changing
nutrition habits. The final part of each section highlights tips for
how to help athletes move progressively from stage to stage.
What are the characteristics of Stage 1:
Precontemplation?
An athlete is in the precontemplation stage if he or she states
no intention of making a change in the foreseeable future
(within the next 6 months). Most of the athletes in this stage are
merely uninformed or lack knowledge regarding the reasons
why making dietary changes can influence their overall health
and athletic performance. Unfortunately, these athletes are
generally categorized as resistant to change and unmotivated,
which may cause them to receive little attention from coaches,
athletic trainers, or dietitians. Providing a clear explanation of
why dietary changes are needed and the personal benefits they
will realize by making positive behavior changes is essential at
this stage. Educating athletes about the importance of proper
dietary habits in relation to their sport will help them move from
the precontemplation stage to the next stage, contemplation.
What are the characteristics of Stage 2:
Contemplation?
An athlete is in the contemplation stage if he or she has stated
the intention to make a specific dietary change within the next 6
months. Athletes in this stage are fully aware of the benefits of
making dietary changes but are also acutely aware of the
disadvantages of changing. Athletes in this stage know they
should make a change, but the barriers to achieving their goal
overshadow their ability to move forward. For many athletes,
the acknowledgment that their season is quickly approaching
causes them to initiate some action to improve their dietary
habits. Dietitians can help athletes move out of this stage and
into the preparation stage by discussing the pros and cons of
changing versus not changing their dietary habits and the
resulting effects on their athletic performance.
What are the characteristics of Stage 3:
Preparation?
An athlete is in the preparation stage if he or she has stated an
intention to change within the next month. These athletes have
taken steps to prepare for change (e.g., they have scheduled
an appointment to see a registered dietitian or bought a new
healthy eating cookbook). Once they have reached this stage,
the athletes are ready for traditional behavior change
programs/services.
As a dietitian, this is an exciting and important stage—
athletes are ready for change and open to professional
guidance. It is critical not to overwhelm a person in this stage
with too much information. Providing information on ways to
change dietary patterns, intake, and behaviors while
emphasizing how these changes will benefit the athlete is the
best educational method in this stage. Identifying one or two
small changes to focus on will build the athlete’s confidence in
his or her ability to make more changes and therefore, will help
move the athlete toward the action stage.
What are the characteristics of Stage 4:
Action?
An athlete is in the action stage if he or she has made specific,
overt modifications in dietary habits within the last 6 months.
The changes made must be significant enough to improve
athletic performance or reduce the risk of disease. These
athletes are not only ready for professional guidance but also
are actively putting the professional recommendations into
practice. Athletes in this phase are hungry for examples of easy
ways to make healthy eating a reality.
Individualization is a key component in this phase. The
calculation of individual energy and macronutrient
requirements, the development of an individualized daily meal
plan and exercise hydration schedule, and the provision of
quick, easy recipes are popular topics often requested by
clients. Athletes want to know not only why they need to make a
change but also how they can make the change so that
implementation happens with ease. Athletes require consistent
guidance by dietitians, who can provide the practical tools they
need to continue making positive dietary changes over several
months to reach the next stage, maintenance.
What are the characteristics of Stage 5:
Maintenance?
Athletes in the maintenance stage are actively working on
preventing a relapse. This phase mainly consists of working on
self-efficacy and the confidence that they will not resort to old
habits—a process that can last from 6 months up to several
years. Encouragement should be provided to make the
changes fit into the athlete’s lifestyle. It should be noted that
“relapse” is often thought to be an actual stage. However, in the
Transtheoretical Model, relapse is not a distinct stage; it is
instead a backward step to an earlier stage. If an athlete has
progressed to the action or maintenance stage, he or she
generally will not relapse all the way back to precontemplation.
The backward step usually falls somewhere between
contemplation and preparing to take another action. This stage
does not necessarily involve “change,” but it can involve finding
alternatives or additional ways to meet their goals.
What are the characteristics of Stage 6:
Termination?
Athletes who have reached the termination stage have zero
temptation of ever returning to old habits. These individuals
have established such a solid plan that no emotional state,
situation, or environment will cause them to resort to old habits.
There is controversy regarding whether most individuals ever
reach this stage. It appears that most people will remain in the
maintenance stage for a lifetime—constantly working to adjust,
adapt, and learn how to keep on track with healthy eating
patterns. Reaching termination is possible; however, dietitians
should realize that it is rare for individuals to fully reach
termination. Therefore, athletes should be supplied with a
constant stream of tools and resources to keep them at least in
the maintenance stage, with termination as an ultimate goal.
Jennifer’s Case Study
Jennifer is in the action stage. She asked for the nutrition
consultation because she realizes she needs guidance to
improve her nutrition. She has already started to make some
small changes to improve her nutrition intake for muscle
mass gains by eating more at some of her meals. Additional
education and tips for improving calorie and nutrient intake
should help her continue taking action to complete the
nutrition changes recommended.
How can appropriate nutrition goals be
established?
Athletes should set both short- and long-term nutrition and/or
weight goals. Athletes generally have a long-term goal in mind,
such as to gain muscle or lose body fat. This long-term goal is
the final outcome the athlete would like to achieve and is also
referred to as the outcome-oriented goal. Outcome-oriented
goals help guide the athlete and dietitian to develop a nutrition
plan, revise the plan as needed, and continue behavior change
to meet these goals. An outcome-oriented goal will be
measured throughout the educational process to determine the
effectiveness of the nutrition plan and the implementation of the
plan by the athlete. However, this long-term goal is difficult to
reach quickly, and therefore, several short-term goals may be
necessary to help guide the athlete to the final outcome.
A short-term or process-oriented goal is designed to help
the athlete achieve the outcome desired but with small steps.
Process-oriented goals may also be considered objectives.
These goals help provide interim steps and ways of measuring
success before the final outcome goal is achieved. Short-term
goals must be made difficult enough to be challenging, but also
be attainable in a short period of time. If goals are developed in
this manner, success is seen in small steps, and progress
toward the final goal is defined by the success of the short-term
goals.
Helping athletes set realistic, achievable goals is an
important part of the nutrition consultation. Both the athlete and
the dietitian should mutually decide upon goals. If goals are set
too high, or if expectations for how quickly goals should be met
are too aggressive, then meeting the goals will be difficult. The
athlete can help determine how many goals and what goals to
start with based upon his or her motivation and lifestyle. In
general, a maximum of three process-oriented goals should be
agreed upon initially. Nutrition professionals can gauge how
many goals to suggest based on assessment of readiness to
change as well as the interaction in the initial and follow-up
sessions. Once short-term goals are developed, the athlete and
dietitian should develop a plan for measuring and monitoring
progress toward goal achievement. The challenge with nutrition
goal setting is to develop goals that encourage small changes
in gradual, manageable, and measurable steps to reach the
ultimate (outcome) goal.
Gaining the Performance Edge
By understanding the stages of change, a dietitian can be
more effective in counseling, educating, and motivating
athletes to make healthy dietary changes by catering to their
individual needs and preparedness for change.
Jennifer’s Case Study
The dietitian recognizes that to gain weight and muscle
mass (Jennifer’s long-term, outcome-oriented goal), Jennifer
will need to increase total calories and protein in her diet.
Intake of other nutrients is adequate except for calcium.
Because calcium is essential to bone health, improving
calcium intake is another goal the dietitian shares with
Jennifer. They discuss how the long-term goal can be
achieved, and together they decide on the following shortterm (process-oriented) goals:
Goal 1: Eat an additional 300–500 calories per day,
focusing on nutrient-dense foods.
Goal 2: Eat a minimum of two servings in the protein
foods group each day.
Goal 3: Consume at least two servings of dairy products
each day.
Each of the short-term goals is focused on the ultimate
goal of gradual muscle gain without excessive weight gain.
Jennifer is already in the action stage of change and is likely
to succeed with three goals because her motivation level is
high.
To determine progress toward these three goals, Jennifer
will keep food records for at least 3 days of each week for
the next 2 weeks. To assess the overall outcome goal, an
accurate height, weight, and body composition analysis is
performed in the initial appointment. These measures can
be repeated at 1-month intervals to assess changes in body
weight and composition. Jennifer is asked to weigh herself
only once a week, at the same time each week, to help her
avoid becoming overly concerned about her weight. This will
allow a monitoring process and feedback mechanism for her
as well as for the dietitian.
How can appropriate nutrition education be
provided to an athlete?
Education about healthful eating is likely to be done throughout
the initial consultation process. There may be moments in the
conversation at the beginning of the session when education is
provided. If athletes share information that they have learned
that appears to be inaccurate, the dietitian can clarify that
information and provide accurate information at that time. Near
the end of the session, specific education should take place that
will help the athlete achieve his or her goals.
Dietitians should have a variety of sample meal patterns
ready in handout form to avoid the time-consuming process of
developing the plan in the first session. Having sample plans
available in a variety of calorie levels, for vegetarian and
nonvegetarian patterns, and for different age levels that can be
adapted for different athletes is extremely valuable for dietitians
and their athletes. Adjustments to these sample patterns can be
made quickly based on specific short- and long-term goals.
Jennifer’s Case Study
For Jennifer’s first goal, she is provided with a handout
describing healthy weight gain for athletes that includes
nutrient- and calorie-dense foods. This handout provides
examples of 300- to 500-calorie snacks and ideas for
higher-calorie beverages to consume with meals and
snacks. Encouraging Jennifer to consume nutrient-dense
foods to increase calories rather than consuming high-fat,
high-sugar snacks helps her increase nutrient intake.
Providing a handout about grocery shopping that includes
tips on purchasing a variety of protein foods, including
vegetarian, meat, and dairy sources, will help her purchase
the necessary protein foods, increasing the likelihood of
regular consumption. By focusing on obtaining extra calories
from protein-rich foods and dairy, she is learning how to
increase her total calorie intake, while focusing on her other
two goals of increasing protein and dairy in her diet.
Because Jennifer is not a consistent meat eater, she
needs some information on nonmeat protein sources to
meet her second goal. Using the MyPlate food guidance
system is a simple way to show her how to incorporate both
nonmeat and meat sources of protein into her daily diet.
To meet her third goal, Jennifer needs to consistently
consume two dairy/alternative servings daily. The MyPlate
food guidance system recommendation for dairy/alternative
intake is actually two to three servings per day. However,
because Jennifer is currently consuming only one
dairy/alternative serving daily, and has expressed difficulty
with dairy food consumption, setting a goal of increasing to
two servings of dairy daily is more realistic for her than
aiming for three servings. A list of dairy foods and
beverages, and creative ways to consume more dairy, will
help her meet this goal. For example, she currently
consumes milk only on cereal. The dietitian could suggest
milk as a beverage to consume at her evening meal. Or, if
the taste of milk is unappealing, then alternate dairy sources
such as plant-based milks, dairy or nondairy cheese or
yogurt, and foods made with these items could help her
meet this goal.
A sample meal plan for Jennifer is shown in TRAINING
TABLE 10.1 . The changes in the revised meal plan are
based on her food preferences gleaned from the
consultation.
TRAINING TABLE 10-1 Jennifer’s Sample
Meal Plan
Jennifer’s Initial 1Day Food Intake
Jennifer’s Revised Meal Plan
Cheerios cereal
Cheerios cereal
Milk, 1%
Milk, 1%
Bagel, plain
Bagel, plain
Peanut butter
Peanut butter
Orange juice
Calcium-fortified orange juice
Banana
Turkey sandwich
Whole wheat
bread
Turkey sandwich
Whole wheat bread
Turkey, 2 oz
Turkey, 5 oz
Lite mayo
Lite mayo
Sugar cookies
Sugar cookies
Lemonade
Lemonade
Apple
Spaghetti
Spaghetti
Spaghetti sauce,
premade in a jar
Spaghetti sauce, premade in a
jar plus 3 oz lean ground beef
Salad (lettuce,
tomato, pepper,
cucumber)
Salad (lettuce, tomato, pepper,
cucumber)
Jennifer’s Initial 1Day Food Intake
Jennifer’s Revised Meal Plan
Lite ranch dressing
Lite ranch dressing
Garlic bread
Garlic bread
Gatorade
Gatorade
Graham crackers
Graham crackers
Apple
Hot chocolate made with milk
Total Calories: 2278
Total Carbohydrate:
350 (61%)
Total Protein: 73 g
(13%)
Total Fat: 68 g (27%)
Total Calcium: 698 mg
Total Calories: 2777
Total Carbohydrate: 401 (58%)
Total Protein: 107 g (15%)
Total Fat: 83 g (27%)
Total Calcium: 1076 mg
How should a consultation be summarized
and closed?
As the initial consultation process comes to an end, a summary
of the goals and meal-planning ideas, education provided, and
questions from the athlete will provide a framework for further
sessions. The athlete should be given an opportunity to ask for
clarification or information on additional topics not covered in
the session. The athlete should be asked to state, in his or her
own words, how the suggested changes will be made based on
the information provided. This helps the athlete understand the
goals and how to implement them after leaving the consultation.
If the athlete is unsure of how to put the nutrition information
into practice, a review of the goals and education methods
should be done prior to the athlete’s departure.
It is helpful to provide the athlete with a brief written list of
the main objectives of the nutrition plan and how the plan can
be implemented. This can be written on the back of an
educational handout or on a separate form that the dietitian
creates. These goals and the educational plan to achieve them
can be shared with other sports professionals if the athlete
gives permission to do so. This improves continuity of care and
helps the athlete and the rest of the professionals work together
toward a common goal. At the closing of the interview, plans for
follow-up appointments should be discussed.
Jennifer’s Case Study
The dietitian summarizes Jennifer’s three goals and asks
how Jennifer plans to implement the dietary changes.
Jennifer appears to understand the goals and how to add
calories to her diet. She verbalizes protein sources she is
going to purchase when she goes grocery shopping. She
verbalizes concern about increasing dairy products, but
states she is going to try to purchase more dairy foods as
well. Jennifer states that she would like to meet again in 2 or
3 weeks. The appointment is set and appropriate closing
comments are shared.
What are the steps for a
follow-up consultation with
the athlete?
Providing the athlete with an opportunity to meet with
the dietitian after the initial assessment allows the
athlete to attempt some of the changes
recommended and then review these changes. This
process is critical to the athlete’s continued success
in accomplishing established short- and long-term
goals. Making permanent dietary changes can be
more challenging than most athletes initially
perceive. Athletes need guidance along the way to
help them meet their goals and provide a continued
resource for education, goal revision, and ultimate
success in behavior change. Accountability to
someone else for making recommended changes is
also a motivating factor in making and keeping
follow-up appointments.
Food for Thought 10.2
Initial Nutrition Consultation
Describe the steps of the initial nutrition
consultation process.
Follow-up visits may be dependent upon the
number, and difficulty, of the dietary changes for
each athlete. In some cases, a one-time visit is
enough to help the athlete move toward healthier
eating for optimal sport performance. In most cases,
at least one follow-up visit is recommended. Athletes
who present with eating disorders or disturbed eating
patterns will likely need several follow-up sessions.
Athletes presenting with weight concerns, trying to
either gain or lose weight, or those with medical
conditions will likely require a series of sessions.
The process for a follow-up appointment is similar
to the initial consultation but is usually much shorter.
Typical follow-up sessions are scheduled for
approximately half the amount of time as for an initial
consult. Less time is needed for the rapport-building
part of the session because the athlete and dietitian
already know each other. The beginning of the
follow-up visit often consists of a quick review of
goals and a review of any food records. A
comparison of the record to the stated goals helps
provide input to the athlete about progress made.
Assessment of how the athlete is feeling, energy
levels, and any subjective information about sport
performance should be discussed. Often, the
subjective information is the first progress an athlete
notices. The scale or body composition assessments
may not reveal a change in body weight or body
composition, but the athlete might recognize feeling
better or having more energy during practice and
competitions. Eliciting this subjective information is a
skill all dietitians working with athletes need because
it can be a strong motivating factor in continuing the
dietary changes that influence the attainment of
short- and long-term goals. Assessing weight, body
composition, and any laboratory or clinical
assessments may also occur during the follow-up
visit.
Based on all of the information obtained in the
follow-up session, revision of short- and long-term
goals can occur. If the athlete has mastered one or
more process-oriented goals, adding another goal
may be indicated. If the athlete is having difficulty
meeting some short-term goals, revision of goals
may be necessary.
The final step in the follow-up process is to
determine whether additional appointments are
indicated. Determining this may depend upon the
time the athlete has to keep appointments, finances
for appointments if nutrition consultations are not
covered by the team or by insurance, and the need
for additional sessions. Telephone consults may be
an easy alternative to having face-to-face contact.
Brief consultations and questions may be handled
through email; however, nothing confidential should
be shared through email. The dietitian and athlete
together can determine the best follow-up plan for
the athlete. Developing a plan for follow-up or
deciding to terminate additional appointments should
be clear to both the athlete and the dietitian in the
closing of the appointment.
Jennifer’s Case Study
Jennifer returns after 2 weeks for a follow-up
visit. She has brought in food records for 5 of the
past 14 days since the last visit. Upon review of
the records, the dietitian sees that Jennifer is
meeting two of her three goals consistently. Her
calorie intake is excellent, and she is consistently
consuming two or even three high-quality protein
sources each day. However, dairy intake is still
averaging only one serving per day. The dietitian
reviews dairy intake with Jennifer to determine
why this is a difficult goal to meet. Jennifer states
that she just does not like the taste of milk and
yogurt. The dietitian provides a handout with
dairy and nondairy sources of calcium to Jennifer.
Calcium-fortified orange juice, instant oatmeal,
and hot chocolate made with milk are options that
Jennifer states she will try to incorporate into her
diet for the next 2 weeks. They set another
follow-up appointment date for 2 weeks later and
continue with the three original goals set. At the
upcoming follow-up appointment, weight and
body composition assessments will be made to
determine progress toward the long-term weight
and muscle-gain goals.
What should walk-in or short
sessions with athletes
involve?
Often, a dietitian will meet with many athletes on a
walk-in or first-come, first-served basis. In these brief
sessions, completed food records and health history
questionnaires are generally not available. These
sessions, however, can be valuable for the athlete
despite the short time and limited availability of prior
information. This may be the only opportunity for an
athlete to speak with a nutrition professional, so
making the most out of the short time can
significantly help the athlete.
An excellent opportunity for brief sessions occurs
after a group nutrition session with a team. Athletes
may be encouraged to ask questions after the group
session is over. In this case, the athlete often has
one specific question that can be answered relatively
easily. The dietitian should be prepared for a variety
of questions from the athletes. These may include
questions about popular sports supplements or
dietary regimens seen in the media, clinical
questions related to health conditions, and questions
about specific nutrients in foods or how to obtain
certain nutrients from different foods. Answering
questions and…
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