TrueSport: June 2021 - Body Image

Did you know supplements aren’t regulated like medications? Did you know that a ‘natural’ supplement doesn’t mean a safer supplement? Did you know that you can’t trust supplement labels? Due to post-market regulation, all supplements come with some amount of risk, which you can learn more about below.

This five-part series on supplements will give you an overview of the dietary supplement industry so that you can decide if the potential benefits of dietary supplements outweigh those risks. And, if you find you do need to use supplements, how you can better choose a low-risk product.

Post-market regulation

For both athletes and other consumers, there is often a misconception that dietary supplements are safe since they must go through the same rigorous vetting process that medicines and medical devices go through. Unfortunately, that isn’t the case. Supplements are regulated in a post-market manner, meaning that neither the Food and Drug Administration (FDA) nor any other regulatory body evaluates the contents or safety of supplements before they are sold online and at major retailers, including grocery stores and GNCs.

Contamination

Due to post-market regulation, the use of unhealthy, low-quality, or unlisted ingredients is a big problem in the supplement industry. Even though there are many high-quality and safe dietary supplements on the market, there is always the possibility that the supplement an athlete chooses could contain dangerous or illegal ingredients.

There are often no warning signs that a product is unsafe, and many athletes have suffered health problems or had positive drug tests from using products that are incorrectly labeled or contaminated with dangerous ingredients, such as anabolic steroids, pharmaceuticals or research drugs. Sometimes, risky or dangerous ingredients are even listed right on the label or identified by a confusing name. Supplements can also contain low-quality ingredients, or old or unstable ingredients that degrade very quickly.

Other supplements might not even contain the ingredients on the label. The FDA and other organizations list many examples of tested products containing zero amounts of a listed ingredient. In some situations, this could lead to malnutrition if the athlete stops eating foods with the ingredient because they relied solely on the supplement.

False advertising

Because the benefits of dietary supplements are often exaggerated, the decision to use a product should be based on nutritional needs and not any competitive advantage a product claims to offer. Despite the claims a dietary supplement might make in its advertising, there are no regulatory or enforcement agencies that check to make sure the advertisements are accurate.

Sometimes dietary supplements with the same ingredients even claim to improve wildly different aspects of performance. For example, whey protein is advertised to be the key ingredient in both weight-gain and weight-loss products, implying that the same ingredient somehow has opposite effects. The benefits listed on supplement packaging and advertising sound nice, but it’s important to remember that what a product can do for an athlete doesn’t always match up with the label. Because of this, athletes and consumers should ignore advertising and focus instead on the research about the individual dietary ingredients, such as basic vitamins and minerals.

CASE STUDY: EVERY SAFE SUPPLEMENT CAN POSE A RISK

In 2013, a Long Island doctor noticed that his patients were showing symptoms normally associated with anabolic steroid use, such as liver damage, blood clots, muscle pain, masculine features appearing in women, and even testicular shrinkage, infertility and gynecomastia (breast tissue development) in men. These patients had all gone to the same chiropractor, who prescribed Healthy Life Chemistry vitamins by Purity First to each of them.

Although the label of these products appeared normal and didn’t list unusual ingredients for a vitamin, regulators discovered anabolic steroids in the products after investigating health complaints. The ensuing warning letter from the FDA was initially ignored by Purity First, and the contaminated products remained on sale until they were finally recalled and destroyed after further federal pressure.

Although Purity First supplements are no longer on the market, stories like this are all too common, and the FDA’s list of recalled supplements grows every month. It’s important for consumers to remember that the label does not always paint an accurate picture of what is, or isn’t, in a supplement.

Even simple, safe-looking products from seemingly reputable companies can be contaminated with dangerous ingredients that can cause serious health problems and violate anti-doping rules.

Takeaway

All supplements, even vitamins and all-natural products, come with some amount of risk. The next three articles in the Supplement Series will explore the possible need for supplements, as well as which supplements you should always avoid, and which may be safer.

When a competitive athlete leaves sport, permanently or briefly to recover from an injury or pursue another activity, it's normal to feel a mixture of emotions. Even if the athlete is choosing to take a break from sport, issues surrounding body image, nutrition and exercise outside of regimented practice can still come up.

Here, TrueSport Expert and licensed clinical psychologist Dr. Melissa Streno explains how parents can help guide athletes through this transition period while maintaining a positive body image.

Start before they finish

Parents should be helping athletes create an identity outside of sport and within other support systems even before an athlete is considering a break. Our interests contribute to how we define ourselves, so parents can help make their child's identity diverse by letting them choose many activities to try, and by role modeling and encouraging them with realistic, healthy expectations.

"This way, when sport does inevitably come to an end, they can feel there are other realms in their life where they're connected, comfortable and accepted. Then it doesn't feel like their whole world is caving in after sport," says Streno. "And as a side note, diverse interests actually help us be more successful in sport anyway!"

Help them create new routines

"Many young athletes have followed a certain path that's centered around attaining or maintaining an appearance, often in a really detrimental way," Streno says. "They have very specific routines and behaviors, and they've been on autopilot. It's hard to change when that's all they've known. When redefining a relationship with food and exercise after sport, help them get the appropriate professional help to learn what their body really needs."

Finding a new way to move is important

Even if your child is leaving sport because he or she isn't enjoying it, movement is still important and healthy for any young person. Find exercise or movement that feels fun and not like training. This could be hiking, biking, strength training, yoga or -- depending on the situation -- joining a recreational sport league. "Try to make sure that the urge to exercise is coming from a healthy place, not just being done to control what their body looks like," says Streno.

Understand what your child could be dealing with

"Any sort of shift in sport is significant because of the role this plays in our identity: not just the physical part, but also who we are," says Streno. "Struggling with the question of 'who we are' can lead somebody down a path of using food and exercise to maintain some sense of control when they feel everything else is shifting."

Encourage your child to dig into their identity

On a practical level, Streno recommends some journaling prompts for students struggling with identity beyond sport. Encourage your child to sit down and spend some time answering questions like:

• Who am I?
• Who am I without sport?
• What is important to me outside of sport?
• What have I gained from sport?
• Who I am because of sport?
• How do I use that in this next realm, this next endeavor, and this next challenge?

Prepare your athlete for changes

"After sport, there is going to be a transition period where your athlete likely experiences some body transformation," says Streno. "It's important to talk about the reality of what's going to happen. We're going to encounter physical changes throughout our entire life, so normalize that identity is not just how you look or how strong you are as an athlete."

"We also see a huge uptick in disordered eating and eating disorders post athletic career because it's the one thing that athletes feel they can control.” Learn more about disordered eating here.

Let your child grieve

Leaving sport for any reason can lead a child to feel a huge range of emotions. "I would encourage your child to wade through the really uncomfortable emotions. If they're not, that's actually riskier when it comes to eating disorders since coping with those feelings in private can become an avenue for disordered behavior," Streno says.

Takeaway

An athlete’s body image can be dramatically impacted when it’s time to move away from sport. Use this expert guidance to help your athlete navigate the transition and come out on the other side with a positive body image.

Disordered eating covers a large amount of dieting and exercising behaviors -- and while it may not be as severe as a full-blown eating disorder, it can seriously affect a young athlete's health in the short and long term. Here, TrueSport Expert and licensed clinical psychologist Dr. Melissa Streno explains what disordered eating really is, and how coaches can help their athletes avoid and address disordered eating.

1) Disordered eating isn't an eating disorder

"Disordered eating is a step before a serious eating disorder, which is where we see a lot more clinical, psychological and physical consequences happening," says Streno. "An eating disorder, as it's defined by the Diagnostic and Statistical Manual, really affects one’s routine, functioning ability, relationships, etc. Disordered behaviors can cumulatively lead to this."

Streno explains that disordered eating refers to behaviors that deviate from authentically choosing food that sounds good, finding a good variety, eating a moderate amount and listening to hunger and fullness cues. "Deviating from those behaviors and using a fad diet, any sort of rigid rules, or even using exercise in a disordered way -- over exercising with the intention of changing your body weight, shape and size for example -- can be disordered eating," she says. "Disordered eating also comes down to intention: If a young athlete is doing the keto diet or cutting out carbs because they want to lose weight, that is disordered eating. If they're under fueling and over exercising to fit into a particular clothing size or to meet a particular body image ideal, that would be disordered."

Both can be about control, though. "Food and exercise are examples of things that people try to control when everything else feels unpredictable or uncertain," Streno says.

2) COVID-19 has made disordered eating more common for athletes

“The stress and change surrounding COVID-19 has contributed to a noticeable uptick in eating disorders and disordered eating behaviors, especially due to the unpredictable and sudden change that occurred in athletes' familiar routines and structure," says Streno. "Isolation is a big risk factor, as eating disorders thrive on secrecy and isolation. There's less accountability from others to hold on to healthy behaviors and choices. There's less community and less interaction with people, especially within sport."

Additionally, COVID-19 has made getting help harder. "I think also, with everything being virtual, I've seen a lot of resistance to going to treatment or joining support groups or seeing a recommended practitioner because they just don't want to do another Zoom meeting," Streno adds.

3) Watch your language with the team

"It's so important for coaches to hold everyone to the same standard. Be careful how you speak about weight, food, exercise and body image to everyone on the team," says Streno. "Be aware of what you're modeling by comments you make to other people. Don't talk about numbers or weight and steer away from focusing on appearance. Because if you say, 'Wow, you look really fit,' to one person on the team, another athlete who's struggling may hear that as, 'My coach is looking at my appearance, they're critiquing, they're judging.' Be aware of your language."

4) Know the warning signs

According to Streno, coaches should be on the lookout for any combination of these warning signs of disordered eating:

• Anxiety, OCD, depression, or mood change
• Loss of energy from those whose normally have good energy
• An increased focus on social media or influencers who conform to a particular body image or ideal image for that sport
• Difficulty focusing or concentrating during practice
• Avoiding any sort of team activity like team meals
• Starting to train outside of the prescribed routine (doing their own runs in the morning or adding extra strength training)
• Obvious physical changes, like big fluctuations in weight or strength
• Noticeable injuries, including stress fractures and overuse injuries

5) Open lines of communication

If you suspect an athlete is struggling, have a conversation with them early…don't wait for it to become a more serious problem. "Try to frame it as concern, rather than blame," says Streno. "Let the athlete know that you care, and your concern is coming from caring about the athlete, and their health and safety. Explain what you've noticed and ask the athlete to help you understand what you think is going on." Rather than calling them out, you can say that you're worried and that you hope you're wrong. Let the athlete know that you can help them, or that you can help them find professional support.

"If there is real concern -- if an athlete is passing out at practice, or if weight has dropped dramatically -- you can escalate the situation more, but if you catch it early enough, you can usually begin with a simple conversation," Streno adds. "But remember, the athlete has to be ready to get help on their own. So instead of shaming them, let them choose the direction they want to go with support. Sometimes they might not know the answer in that moment, but they'll know that you are there to help."

6) Set a team standard and protocols early

Especially in sports where weight plays a role, establish protocols and open lines of communication early. "As a coach, you need to be looking out for the whole person and not be afraid to take an athlete out of play so that they can get help," Streno says. "There should also be a consistent protocol and standards that must be met before athletes are cleared to play again, similar to concussion protocols." If needed, bring in experts to assess what's going on and if an athlete should continue.

7) Make sure athletes are ready to come back

There is no exact timeline for making a comeback from disordered eating. Mountjoy and colleagues' statement around Relative Energy Deficiency in Sport (RED-S) demonstrates long-term consequences if left untreated, or if an athlete returns to sport too early.

"An athlete should be medically cleared to come back after dealing with disordered eating. There are milestones that should be met, like being able to maintain their meal plan and stay at an appropriate weight," Streno says. “Then there should be a very gradual reintroduction of activity that parallels appropriate nutrition. And that's not something a coach should be assessing themselves. There should be a medical and psychological evaluation to see if this person is ready to return to play."

Takeaway

While disordered eating is a serious issue that may require professional support, there are things that coaches can do to prevent and address problematic behaviors, from being mindful of their language to setting healthy protocols.

Your young athlete works hard on the field, at practice, in training and at school -- which means their bodies need proper nutrients and fuel to keep up. But with so much going on, it can be hard to prioritize a healthy nutrition plan and that can sometimes lead to certain nutrient deficiencies. Here, we're looking at a few of the most common nutrient deficiencies in teens.

Before we dive in, though, it's important to note that generally, these deficiencies can be fixed with real, whole foods versus supplements. If you believe your athlete needs a supplement, it's a good idea to check with your family doctor, get screened for deficiencies and determine the best course of action before adding supplements. Remember: Food first whenever possible!

Iron

Teens, especially those who are opting to eat less meat -- or who truly hate their dark leafy greens -- while still training at a high level, may find that they're deficient in iron. This is a problem worldwide, researchers have found. In 2016, researchers noted that for preteens and teens aged 10 to 14, iron deficiency is the leading cause of "ill health." And overall, females face more health issues due to iron deficiency, which is often tied to iron loss during menstruation.

According to the American Society of Hematology, iron deficiency (also referred to as anemia) can lead to fatigue, headaches, unexplained weakness, rapid heartbeat and brittle nails or hair loss.

Iron levels can be raised by adding iron-rich foods into an athlete's diet. The Mayo Clinic lists the obvious red meat, pork, poultry and seafood as the easiest ways to get iron, but your teen could also add beans, dark leafy greens, and even dried fruit and iron-fortified cereals into their diet.

Vitamin D

Since most young athletes get their vitamin D largely from sunlight, it's common to see deficiencies in teens -- one study found nearly a quarter of teens surveyed were severely deficient. Wintertime for outdoor athletes, and anytime for indoor-sport athletes who spend most of their sunny hours inside for school and practice, means less vitamin D from the sun. However, food can also help supplement vitamin D for adolescents, who need around 600 IUs per day.

Vitamin D deficiency can be hard for an athlete, since symptoms include fatigue and weakness in addition to bone pain and even depression, according to the Cleveland Clinic.

To boost vitamin D through food, think dairy products, eggs and seafood. The easiest way to hit your daily dose? A single tablespoon of cod liver oil contains 1360 IUs of vitamin D.

Protein

While most research is based on specific micronutrient deficiencies, many teens -- especially those who are extremely active athletes -- may be missing enough of the macronutrient protein. Since protein is vital for not only muscle building, but also for repair and recovery, it's critical that young athletes are eating enough of it throughout the day. Often, children will have a carbohydrate-heavy breakfast like cereal, followed by a carbohydrate-heavy lunch like a peanut butter and jelly sandwich or a bagel, then another serving of carbohydrate around practice, so it's not until dinner that they're eating a solid serving of protein in the form of meat or fish. But young athletes should be prioritizing protein throughout the day for optimal benefits. Add eggs or Greek yogurt to breakfast, consider adding a low-fat milk to the side of a sandwich at lunch and keep that healthy protein at dinner.

Other micronutrients teens tend to miss out on

Zinc and calcium are less common deficiencies but still are important for immunity and bone health, respectively. Research has shown that these are common micronutrients that get missed -- but they aren't too hard to add back in. Zinc can be easily found in whole grains, dairy, red meat, poultry and oysters (if you have a teen with an adventurous palate). Calcium can also be found in dairy. For vegetarian and vegan athletes, vitamin B12 deficiency can also be a problem, as can calcium for vegans. For a vegan athlete needing B12, consider adding nutritional yeast on top of meals (it has a tasty, cheesy flavor) or simply opt for plant-based milks that are fortified with B12 as well as calcium.

Takeaway

While nutrient deficiencies seem like a daunting challenge to parents of a picky eater, consider this: a bowl of cereal that's fortified with iron and zinc, plus a handful of raisins, with milk that's rich in calcium, vitamins D and B12 and protein covers most of these deficiencies. And for most teen athletes, cereal isn't exactly a tough sell.