TrueSport: January 2022 - Clean Sport

Returning to sport from illness of any kind can be tricky, and with the COVID-19 pandemic, it’s only gotten more difficult. But even a simple cold or stomach bug can leave an athlete sidelined without a clear idea of when it’s safe or advisable to return to sport.

Here, Dr. Michele LaBotz, TrueSport Expert and sports medicine physician, will dig into the signs, symptoms, and feelings that can help athletes, parents, and coaches determine when it’s time to get back in the game.

Before we dive into specific ailments and illnesses, it’s important to note that even when an athlete is no longer infectious or isn’t running a fever, they may still not be ready to return to play. “Even something like an ear infection can be really difficult when it comes to returning to play,” says LaBotz. “An athlete may technically be cleared to return to practice, but I think it’s critical to understand that an athlete’s comfort and capacity to be fully engaged with the sport are just as important as a fever being gone. If a player is distracted because their ear hurts too much or because their tooth hurts too much, they're potentially risking injury. An athlete has to be feeling well enough that they can perform effectively.”

Assuming your athlete is ready to get back on the field, here’s what you need to know:

Asymptomatic COVID-19

We’ve written about returning to sport after COVID in the past, but as LaBotz points out, the recommendations are changing constantly. Unfortunately, it’s not as simple as getting a negative test -- there also needs to be a complete resolution of even mild symptoms, and an all-clear from a physician before an athlete comes back. “Once symptoms have resolved, it is recommended that they touch base with their primary care provider,” says LaBotz. “Many primary care providers are doing a phone call follow up to make sure that there are no other factors that need to be considered.”

Approach an athlete’s comeback the same way you would progress an athlete with a concussion, LaBotz says: “Take a stepwise approach, starting with low intensity activity, and then gradually building back up to sport-specific and higher intensity training over the course of five to seven days.”

Symptomatic COVID-19

“For moderate symptoms, the current recommendation is that athletes get seen by their primary care provider before returning to play,” says LaBotz. “In the United States, the recommendations are that an EKG be done, and the doctor may decide to order additional tests looking at the health of the heart muscle.”

With severe symptoms, it is presumed that an athlete has myocarditis, which is an inflammation of the heart muscles. “For them, it's a three-to-six-month time period before they can get back to sport,” says LaBotz. “The recommendation is that all of those children with severe symptoms get cleared by a cardiologist before going back.” (If you want to learn more about how COVID-19 can impact heart health, check out this article.)

Cold / Flu / Bronchitis

You may have heard of the ‘neck rule’ in the past, and LaBotz is a firm believer in it when it comes to dealing with colds and flues. “If you have symptoms that are isolated to above the neck, like an earache, a runny nose or a sore throat, then generally speaking, you can return to sport safely if you feel OK,” she says.

However, anything below the neck -- a fever, vomiting, diarrhea, lung symptoms, a significant cough, wheezing or shortness of breath -- then those need to be addressed before an athlete can go back to sport. “For fevers, you need to be fever free for 24 hours before being able to return to sport,” she adds. To check your athlete’s temperature, LaBotz recommends a digital thermometer that goes in the mouth. Forehead thermometers -- popularized during COVID-19 -- are much less accurate.

“If an athlete is on an antibiotic for an ear infection or for a strep throat or a similar illness, once the fever is gone and they're feeling OK, they can go back,” says LaBotz. “They don't have to wait until they're done with antibiotics to go back to training.” (Just be aware that athletes may experience some gut issues like diarrhea because of antibiotics, and in that case, may want to wait until those gut issues resolve.)

LaBotz adds that it’s a great idea to ensure your athlete gets a flu shot this year. “If you're part of a team, you put not only yourself at risk, but you also put your teammates at risk if you're not vaccinated. So, making sure that athletes get their influenza vaccine is important,” she adds.

Mononucleosis

Mononucleosis is one of the scary high school illnesses that can set an athlete back for a full season in some cases. LaBotz notes that first and foremost, before even considering fever or spleen status, an athlete should be feeling better and their energy level should be coming back before return to play should be considered. Once an athlete is feeling energetic and their fever is gone, it’s still important to check with a doctor to get the all-clear to return, though.

“The biggest concern, especially with contact sports, is the risk for splenic rupture. Splenic rupture will most commonly happen within the first three weeks of illness, so that's when the risk is highest,” LaBotz says. “For most young athletes, there will be the recommendation that even if they're feeling a lot better, they stay out for that period of time. Return to sport is largely based on how the patient feels, as well as if there's any tenderness to palpation over the spleen area.”

LaBotz notes that “kids can end up in a vicious cycle with mono. Symptoms may take a while to resolve, but after they do, kids are still feeling a lack of energy because they’ve been doing nothing for weeks.

Generally, LaBotz recommends starting a low impact activity like walking or yoga once symptoms subside and it’s been a few weeks, even if energy levels are low. “It's also a good time to focus on rehabilitation, flexibility, and other lower intensity stuff,” she says. “When you're coming back from a serious illness like that, a slow progression is helpful.” It can also help them mentally get back in the game. (The same applies for athletes coming back from long bouts of the flu.)

Gut issues

For stomach bugs, food poisoning and any tummy trouble that includes vomiting, diarrhea or stomach pain, it’s important to stay away from practice until it resolves -- both for the sake of the athlete and the team. Especially in high contact sports or sports with shared equipment, stomach bugs can easily pass between players.

“These days, we’re all talking about respiratory transmission and wearing masks, but when it comes to gastrointestinal illnesses, it’s all about hand washing,” LaBotz says. “And those bugs are not just spread by hands, they spread by contact with the basketball and the gymnastics equipment and the wrestling mat. So, it’s important to be cautious.”

“If there's still active diarrheal episodes or vomiting, stay out of practice,” she adds. “Not only because of transmission, but because with both vomiting and diarrhea, athletes are at higher risk for dehydration. And with some of these illnesses, the virus can affect muscle as well -- in particular the heart muscle -- so myocarditis is another concern.”

Takeaway

Knowing when it’s safe to return to sport after illness can be tricky and depends not only on how the athlete feels, but also the potential for spreading the illness to others. Particularly when athletes have been away from sport for more than several days, return to sport is not “all or nothing” but should include a few days where activity is gradually increased based upon the athlete’s energy and performance. Following the above guidance from Dr. LaBotz can help your athlete and their teammates stay healthy and return to sport safely if they do get sick.

Resource: https://truesport.org/preparation-recovery/young-athletes-return-to-sport/

Iron and vitamin D are two common athlete nutrient deficiencies that can have a big impact on athletic performance and overall health. But treating them with food or supplements isn’t the only answer -- finding out the reason for the deficiency is just as important.

Laura Lewis, PhD, Director of Science at the U.S. Anti-Doping Agency, explains that before an athlete considers supplementing with a pill or liquid form of iron or vitamin D, it’s important to consult a doctor and get bloodwork to confirm a deficiency exists. “It's really important not to just self-manage and assume you’re nutrient deficient,” says Lewis. “You always want to get your levels assessed, and it's really important to find out the reason for the deficiency. You want to fix the cause of that deficiency as well as resolve the immediate need for the nutrient.”

Here, Lewis explains signs and symptoms of these common nutrient deficiencies, as well as how they can be treated.

IRON

Signs and impacts of deficiency

“When you’re low on iron, you may get quite pale and look washed out,” says Lewis. “You may also be very tired, irritable, unable to concentrate on schoolwork or even struggling to get out of bed.”

“In terms of trying to do any sporting activity, an athlete may really struggle,” says Lewis. “Sometimes, your legs feel like jelly, particularly after a hard effort. You just don't feel you have the ability to recover between those efforts. You’ll be constantly out of breath. You might also have a massive decline in a task that was easy at one point, so that now it's become super hard.”

Why the deficiency exists

Iron is an essential component of red blood cells. If we don’t have enough iron, our bodies can’t continue to maintain those red cell levels at an appropriate level and the numbers start to decline. Left untreated, a mild iron deficiency can ultimately spiral into severe anemia.

“With iron deficiency, there can be some quite drastic causes, like a major blood loss, which you'd probably know about. But alternatively, there could be internal bleeding or ulcers,” says Lewis. “Or if you have celiac disease or inflammation in the gut, you may not be absorbing the iron that you're taking in.”

The other main reason for a deficiency is that you don't have a good source of iron in your diet, or the source is insufficient. Vegetarians, vegans and athletes going off to college and only eating plain pasta are all athletes who may be at risk of low iron.

“There's also a lot of pressure on young women to have lower energy diets, so often you're seeing young women doing a lot of high training load but then trying to keep their energy intake quite low to maintain a low body mass. They’re at high risk,” says Lewis. “There is a fair amount of pressure on boys to lower body composition as well, which can affect their overall iron intake.”

How to address deficiency with food and when to supplement

First, figure out the reason for the deficiency. “If there's something more sinister going on, like an ulcer or an energy deficiency issue, it's really important to get to the bottom of that,” says Lewis. “Otherwise, if you do try and treat the problem, it might work for a little bit, but then you're going to go back to square one.”

If you're just not eating enough iron rich foods, that's fairly easy to identify and fix through dietary practices: Adding iron-rich foods like red meat or legumes to your diet is a simple starting point. “Working with a registered dietitian is a good place to start if you're really struggling and if you want someone to work out exactly how much iron you're taking in with your diet,” says Lewis. “But there are a lot of cereals and breads that are fortified with iron, various legumes and other vegetables have iron, and even dark chocolate is actually quite a good source of iron!”

Before we talk about supplements, it’s important to note that too much iron is a bad thing. That’s why it’s important to get bloodwork to make sure that low iron is actually a problem before starting any kind of supplemental routine.

Vegan or vegetarian athletes doing a high amount of training will likely need to use an iron supplement because it will be quite hard for them to get enough iron, says Lewis. “You have heme iron sources or non-heme iron sources, and the non-heme iron sources like vegetables and grains don’t absorb as well,” she explains. “Steak is going to trump spinach in terms of what the body can absorb. So often, the vegans and vegetarians will end up having to go to an iron supplement.”

Ferrous sulfate is one of the most common types of iron that's easily absorbed into the body. If a doctor has approved supplementation, Lewis recommends finding a source that contains a minimum of 50 milligrams of elemental iron. “Ask a doctor or a dietitian to help navigate the different sources,” she adds. “Liquid iron is often recommended for people who have trouble absorbing it, or if they get gastrointestinal problems from taking iron in pill form.”

If you're taking an iron supplement, take it with food and a source of vitamin C to promote optimal absorption. Lewis suggests having it at breakfast with a few sips of orange juice. “But on the flip side, caffeine, calcium, and tannins in tea actually block iron absorption. So, an iron supplement with your milky coffee in the morning would not be so good,” she adds.

You don’t necessarily need to supplement forever: How long you supplement for depends on the reason why you were deficient in the first place. Usually, a dietitian or the doctor would want to do a follow up between six weeks and three months after, depending on what the cause was. They might recommend another blood test. Then, you may check in every six months or yearly after that, just to make sure that you didn't go back down into a low state.

VITAMIN D

Signs and impacts of deficiency

Low vitamin D can result in low bone density, so the first warning sign of a deficiency might be a stress fracture. But you may also have similar symptoms to low iron: fatigue, muscle weakness, poor sleep, pain, a weakened immune system and even depression. Ultimately, a blood test is necessary to determine if an athlete has low vitamin D.

Why the deficiency exists

“People who are going to be at risk of low vitamin D are those who don't go outside very much and see the sun. So particularly in parts of Canada or in Europe, where there are really long nights and short days, it can be an issue,” says Lewis. “But in the U.S., we're so worried about going out in the sun because of the potential for skin damage, so even if you’re outside often, you won't absorb much vitamin D if you’re covered up.”

How to address deficiency with food and when to supplement

Food isn’t the issue here, sunshine is. “While we don’t want people to be getting skin cancer, getting at least an hour of sun in that middle part of the day goes a really long way to ensuring that you're getting your vitamin D dose naturally,” she says. “If you're going for a run midday, I recommend covering the top parts of your arms and legs and wearing a hat, but then letting your lower arms and your lower legs stay exposed. That's enough: You don't have to be in a bikini to get that healthy dose of sun exposure!”

Vitamin D can be a bit tricky because it's not a quick fix. Your vitamin D levels take a long time to change in either direction. So, it can be the middle of summer when you actually present with low vitamin D from the winter before! And it's going to also take quite a long time to build it back up again.

Unfortunately, you can't really supplement vitamin D with just food (although consuming vitamin-D rich foods such as fatty fish and fortified dairy products are a good start) -- but that doesn’t mean you should start supplementing if you haven’t confirmed low vitamin D. Get tested first. “If a doctor does decide that you need to supplement, there are various options, and there are some slow-release tablets where you only have to take one and it lasts for three months,” Lewis says. “But the doctor has to decide the best dose for you.”

Takeaway

Both iron and vitamin D deficiencies can result in negative health effects and a decrease in athletic performance. Both should be diagnosed by a doctor who looks at an athlete’s bloodwork and helps the athlete determine the root cause of the deficiency before prescribing a supplement or a food-focused fix. Talk to a doctor or dietitian if you suspect your athlete has a deficiency in either nutrient, and in the meantime, ensure that your athlete is eating plenty of iron-rich food sources and maintaining some sun exposure when possible.

Resource: https://truesport.org/clean-sport/iron-vitamin-d-deficiencies-athletes/

If your high school team is from Florida where you train at sea level year-round, you might be feeling intimidated when you hear that the national championships will be held high in a mountain town in Colorado. On the other hand, players from Northern California may start to feel nervous when competing in championships in the hot, humid Midwest after training for months in mild, dry weather.

Whether the extreme environment your athletes are headed to is hot, cold, or at high altitude, you may be tempted to look for a supplement or treatment that can help them quickly adapt and adjust. But Laura Lewis, PhD, Director of Science at the U.S. Ant-Doping Agency, says there’s no pill out there that can help an athlete adapt. However, she does have some advice for performing in adverse situations like heat waves, blizzards and high altitude.

1. Your body is built to adapt

“Our bodies are amazing, and they can respond to each of these different environments that we expose them to,” she says. “It just takes time. There's no magic pill. Respect the environment that you're in and adjust your training or your level of exertion accordingly, and then make sure that you're allowing your body to recover while you're in these different environments.”

2. Early is better

The gold standard for athletes is to go as early as possible to the location that has different conditions in order to get acclimatized. “Your body does adapt quite quickly: for example, just an extra week in a hot environment can make a big difference to how you're going to feel and perform,” Lewis adds.

It will feel harder when you first arrive. “If you are able to go to a location a few days before and do some acclimatization, the first time you go and do a run, you're going to notice that your heart rate is really, really high,” Lewis says. “But then the body starts to adapt to that. By the fifth day, it's going to feel a lot easier doing that same exercise, because the heat has stimulated a number of adaptations within your body that allow you to cope better overall.”

3. Prep at home for heat

“Obviously, early travel to event locations is not going to be accessible for everybody,” Lewis admits. But you can still prepare at home for the heat. “If you're a track athlete, do some more runs on a treadmill in a warm environment, or even just without a fan in the gym,” Lewis suggests. “The more you can raise your core temperature and stimulate your body to adapt that way, the better.”

But be careful, she adds. “It's obviously really important to be safe, because high schoolers are not going to have the same level of monitoring and support as an Olympic athlete would have doing these various trial sessions.”

4. Stay cool

“If you're not doing much acclimatization work, particularly when going into a hot environment, then you just need to think about your strategies when you're there to try to keep yourself as cool as possible,” Lewis explains. “Stay in the hotel or in the air conditioning until quite close to the game, making sure that you're adequately hydrated and that you do have access to drinks during and after.”

Essentially, Lewis recommends pre-cooling your body. If your body starts at a lower core temperature before your event, then it's going to take longer for your body temperature to reach that critical temperature where it can't perform, or where you're going to struggle. “Drink a slushy or have some shaved ice,” she adds. “Have something like that where the drink is in ice form, and then has to change from ice to a liquid inside of you. That change of state actually takes away body heat from your core and cools you down.” Other tactics include wearing an ice vest or using cold towels that are dipped in ice on the back of the neck. “Do what you can to lower your core temperature in advance of the event to buy yourself a bit more time when you're actually playing the game.”

5. Cold weather is all about clothing choice

Adapting to cold isn’t too difficult for most athletes, but the clothing can be tricky. “Clothing choices are obviously going to be your big friend here,” Lewis says. “There's not too much body adaptation: Dress appropriately to try to keep yourself warm. It's important to test the clothes you're going to wear though, because running in gloves and tights versus shorts and a singlet has a different feeling. And if you’re wearing gloves, having any drinks or fuel during a race will impact your dexterity.”

6. Altitude is worth the early arrival

“The longer you can be at altitude before an event, the better. If it was a really important event for an elite athlete, you'd be getting there at least three weeks before, but obviously, that's not going to be practical for most of us,” says Lewis. “Even a couple of days can help, though. And for most high school and college level athletes, it's better to spend money to go to the place a few days early rather than investing in expensive altitude training equipment,” she adds.

There are different stages of adaptation to altitude. “In the first day or two, your body's just trying to go into survival mode,” says Lewis. “Your breathing rate increases, you'll end up urinating a lot in order to concentrate your blood. You haven't made any more blood, but you've just really concentrated it so that it can carry oxygen around the body a bit more efficiently. Sleep is often quite disrupted. It's not uncommon to wake up in the middle of the night gasping for breath, but that’s just your body adapting and trying to work on a short-term solution.”

Then, it gets easier: “The longer you spend at altitude, the more those acute responses calm down and the adaptive responses take over. Your body actually starts to make more red blood cells, you have more blood to carry oxygen around your body, and everything gradually starts to feel a little bit easier.”

7. Pay attention to nutrition in extreme conditions

“After really hot games, you might not feel like eating,” Lewis warns. “But if you're at a tournament, it will be really important to restore your energy sources. You might just need to think about different ways to get the nutrition in, maybe using liquid-based energy. Even if you really can't stomach anything solid to start with, don't neglect the recovery and the restoration of nutrients just because you don't feel like eating.”

In cold environments, athletes may find that the body is using more energy to keep itself warm. “When it’s cold, you may find that you need to fuel yourself a bit more than normal,” says Lewis. “Prioritize having a little more food around your training session or your event.”

Hydration is also key at altitude. “Because of the increased breathing rate, you actually get a bit more dehydrated because you're losing water every time you breathe,” Lewis says. “So, you need to think about hydration. You might also need a bit more fuel because you're burning carbohydrate, not fat, which means you can run out of energy a bit quicker.”

8. Manage expectations

“It's really important for athletes going to altitude or any extreme environment to realize that it is going to feel hard, so their pacing and performance is going to be lower to start with,” says Lewis. “Athletes also need to respect that they're going to need longer recovery in between efforts.”

Takeaway

Extreme environments present major challenges for athletes who can’t go early to acclimate, but with some early interventions like hotter training indoors, choosing the right clothing or understanding how the body responds to altitude, it’s possible to have a safe and healthy performance.

Resource: https://truesport.org/clean-sport/help-athletes-extreme-environments/

As your athlete gets older and more competitive in sport, you may be wondering if adding protein powder into their daily routine is a good idea. But before you go out and buy the biggest tub of protein that you can find in the grocery store, there are a few things you should know about supplementing with protein powders, especially for young athletes.

The problem with protein powders

Unfortunately, protein powders, like all supplements, are regulated post-market by the Food and Drug Administration (FDA). That means despite the list of ingredients on the back of the tub or bag, you can’t guarantee that you know what's in them. In fact, over the years, many professional athletes have tested positive for banned substances like anabolic steroids that were eventually traced back to an off-the-shelf supplement that was tainted with the steroids. Even choosing a supplement that has been third-party tested and is certified safe for sport, can’t fully guarantee that it doesn’t contain a substance that might have negative health effects. So first and foremost, understand the risk that comes with taking any supplement.

It creates a supplement-first mentality

The more a young athlete relies on supplements now, the more they think it's okay to do so later. It might not seem like much, but it's a slippery slope. It might start with opting for a protein powder over a filet of salmon and some steamed veggies for dinner, but can quickly progress to a point where an athlete is eating bars, gels, and powders for most meals, and adding pills and capsules throughout the day, instead of simply eating a well-balanced, nutrient-dense diet. Supplements generally should only be used on the recommendation of a doctor or registered dietitian in response to a diagnosed deficiency…a coach or friend shouldn’t be the one to recommend any supplementation.

Young athletes need more than protein alone

The other problem with a post-game protein powder mixture is that it often skips other vital nutrients your athlete needs to replenish, including carbohydrates. And even if the powder is more 'recovery based' and includes carbs, it misses other important micronutrients and fiber that your athlete should be getting from a meal. A chicken wrap or whole-grain peanut butter and jelly sandwich is just as portable and protein-packed as a shake, but with much denser nutritional content. It's also a lot more satisfying.

Athletes don't need as much protein as you think

Protein might seem hard to find, but a well-rounded diet with plenty of whole foods, including meat, seafood, beans, dairy, nuts and/or soy products, can easily provide the protein your athlete needs in a day. The National Institute for Health acknowledges that athletes have elevated demands for protein and says that as a general recommendation for maintaining health, athletes should aim for between 0.8 and 1.2 grams of protein per kilogram of body mass daily. It’s important to do the math before leaning into supplements that may pack as much as 40 grams of protein into a serving. For a 100-pound (45.3 kg) 12-year-old athlete, for example, that would mean needing roughly 45.3 grams of protein per day. That could be as simple as eating two eggs (14 grams), one serving of steak (25 grams) and two tablespoons of peanut butter (8 grams) for plenty of protein over the course of a day.

What do you do for convenient protein instead?

One of the main reasons athletes turn to protein powder is because it’s easy and convenient. If your athlete loves a post-exercise protein shake, you can still whip one up easily without the powder -- and it'll be tastier and more nutrient-dense. Swap the scoop of protein powder for a serving of low-fat Greek or Icelandic yogurt, which has between 20 and 30 grams of protein per serving.

Here's one of our favorites, but feel free to experiment depending on your athlete's preferences. Simply blend all the ingredients together, adding milk as needed to achieve a texture your athlete will enjoy.

• 1 serving of plain Greek yogurt (2 percent or zero fat)
• Chopped frozen banana
• Handful of frozen blueberries
• Teaspoon of cocoa powder
• Tablespoon of peanut butter or almond butter
• Handful of spinach
• Splash of milk
• Maple syrup to taste

Don't have time for that? Check the label on the chocolate milk options at the convenience store: Often, there will be a lower fat, higher protein option that just contains milk, cocoa and sugar, but packs nearly 20 grams of protein. Find out more about other protein sources here. We also have a few easy post-practice recipes here.

If your athlete is lactose-intolerant or vegan, swap a smoothie for something like lactose-free milk paired with an apple, or use soy yogurt in the smoothie instead.

Still interested in protein powder?

Dr. Amy Eichner, PhD, the Special Advisor on Drug Reference and Supplements at the U.S. Anti-Doping Agency, believes in a food-first mentality, but she does understand that some athletes are still going to turn to protein powders for convenience. She explains:

You can definitely get enough protein from your diet, and that's always going to be better and have less risk of contamination, but protein powders can have their place in an athlete’s diet. Some athletes, especially older ones with busy schedules, are under a lot of pressure between school, work, training, and extracurriculars. Honestly, it can just be hard to get a square meal. But if you are going to use a protein powder, choose a complete protein that contains all eight essential amino acids that your body can't make (like a whey protein), one that doesn’t have a lot of added sugar, and one that’s third-party certified.

Takeaway

Protein powders should not replace eating nutrient-dense, protein-rich meals for athletes. Athletes have elevated protein needs, but they can usually be met with whole foods that are rich in protein.

Resource: https://truesport.org/nutrition/athletes-protein-powders/