Testing Options for Athletes: The Proven, Unproven, and TBD

Questions contact: results@athletebloodtest.com

The wide world of sports is being inundated with physiology tests promising data to determine your unique physiological needs. From blood tests to genetic tests, saliva tests, and even hair analysis, the options seem to be expanding.

For this reason, we decided to grade each testing method based on research available. The Four Factors used in scoring include:

  1. Validity – is the data factually sound?
  2. Reliability – is the data consistently accurate?
  3. Is there research specific to athletes?
  4. Is there an option that is proven more valid and reliable?

Blood Testing

Grade: A

Blood testing is the undisputed gold standard within the athlete performance testing. Blood testing has loads of research behind it, and this research has been built upon by innovative companies such as AthleteBloodTest.com (ABT). For example, ABT research has established ideal ranges of many blood tests for athletes based on age, gender, and frequency/duration/intensity of training.

Highlights:

  • Undisputed Gold Standard
  • Extensive and innovative research

Lowlights:

  • Data is only truly useful when interpreted by an expert with extensive training on biomarker monitoring in athletes (aka to get useful information you must use a service like AthleteBloodTest.com)
  • For biomarkers that fluctuate, such as cortisol, blood testing provides only a snapshot. Thus, athletes with borderline “functional” disorders may be missed on a single test unless more extensive panels providing cross references are performed. Example: ABT Gold Panel vs. Bronze Panel.
  • A visit to a blood draw lab is still required. Accurate results and comprehensive testing are only available through venous blood, which requires a blood draw. Services offering testing through finger pricks offer a very limited test selection and the tests available through this method have limited use in athletes. Yes, a visit to a lab is a hassle, but the information is worth it.

Genetic Testing

Grade: B

Genetic testing as it relates to performance is still in its infancy. The possibilities within genetic testing seem limitless, however how to interpret and utilize the data has yet to be mastered. As an example, see the article “Genetic Tests Promised to Help Me Achieve Peak Fitness. What I got was a Fiasco”. In this article, the author gets 5 tests from 5 different entities offering genetic testing for peak performance. The results and interpretation of the results vary greatly, and even contradict each other between different testing entities. However, our high grade of a B for genetic testing is given because the information can be very useful when isolated to just proven biomarkers and compared to blood values. AthleteBloodTest.com offers a genetic component within our Platinum Panel in addition to blood. We use the genetic component to help provide deeper understanding of the relationship between blood levels and physiology (absorption, utilization), and determine the best course of action based on these factors.

Highlights:

  • When combined with blood tests, genetic tests can provide deeper understanding of why micronutrient levels are what they are and how to best manage intake or supplementation.
  • Many genetic markers are well studied and accurate
  • Easy test. Most kits contain a simple mouth swab and take just seconds to perform at home. Put the swab in the pre-labeled shipping bag and send it off.

Lowlights:

  • Of questionable value alone. Best use is when compared to blood test findings
  • Still much to learn for many genetic markers

Saliva Testing

Grade: B-

Saliva testing is easy, safe, and accurate…for SOME tests. Saliva testing is useful for testing certain hormones. However, beyond hormones saliva testing is of questionable value. The real highlight of saliva testing is its ease of acquiring a sample. Simply spit into a tube. For a hormone like cortisol, which fluctuates throughout the day, watching the fluctuations is possible. Thus, we can get a more complete understanding of how cortisol is reacting throughout the day.

Highlights:

  • Reliable and valid for certain hormones (especially cortisol, which can be tested over time)
  • Can easily acquire several samples in a day

Lowlights:

  • Value is limited being it is limited in its use. In the right scenario, saliva testing can be extremely useful, such as borderline over-reaching syndrome.

Intracellular Micronutrient Testing

Grade: Cannot award a grade due to limited science

Intracellular micronutrient testing is complex. In our early research we used intracellular testing as a comparison to blood testing. We had difficulty finding consistent associations. Is this because blood tests are inaccurate or intracellular testing is inaccurate. In the end, we chose to stick with blood testing research because of the validity, reliability, and volume of research that can be used to cross-reference our research results. A highlight of intracellular testing is the extensive panels and potentially the innovative thinking behind testing a more stable environment. A lowlight is the lack of comparison studies by which to compare validity and reliability, claims that are questionable, and results that are not tailored toward athletes. Thus, we can’t responsibly give intracellular micronutrient testing a grade. There is too much of the “unknown” and invalidated.

Metabolite Micronutrient Testing

Grade: Cannot award a grade due to limited science

Like Intracellular Micronutrient Testing, Metabolite Micronutrient Testing is also proprietary and severely lacking comparison studies by which to test validity and reliability. Also similar to Intracellular Micronutrient Testing, in our comparison research with blood studies we had difficulty finding consistent associations. Therefore, we are not able to provide a grade for Metabolite Micronutrient Testing.

Hair Analysis

Grade: D

Hair Analysis is a newer offering in the sports field. This is largely being used by solo practitioners and has not hit mainstream. In our research

Hair analysis is an accurate method for determining illicit drug use. A study in the May 2013 issue of the Journal of Clinical Endocrinology & Metabolism also concluded that hair analysis can accurately determine average cortisol levels over a three month period. Although it does not appear to be able to land on an exact number, determining whether cortisol levels run high, average, or low can be determined. This could be useful if chronic adrenal fatigue is suspected, although historically being “high, average, or low” has extremely limited clinical relevance. What matters is what the condition looks like now.

Most importantly in discussing hair analysis is noting what hair analysis cannot accurately determine. Hair analysis is plagued by inaccuracies and poor research results for the use of determining micronutrient levels in the body. Blood testing is the gold standard, is more accurate, and more affordable.

In order of most effective to least based on our Four Factors at the beginning of this article:

Test Grade
Blood Testing A
Genetic Testing B
Saliva Testing B-
Intracellular Testing No Grade Given
Metabolite Testing No Grade Given
Hair Analysis D

Questions contact: results@athletebloodtest.com

Is There a One-Size Fits All Diet for Athletes?

For those of you “get to the point” people, the answer to the title is no. But, that is not the real point of this blog. Read on, it will be worth your time, I promise.

Dietary advice for athletes is everywhere. Bananas make you fat, avocados make you fast, asparagus is high in performance enhancing vitamins, Scottish Highland cattle have the perfect fat to protein ratio, and on and on. (Disclaimer: the preceding sentence is nonsense, do not take any of those claims seriously.) Then there are supplements. One could easily spend their monthly income on supplements if they took the many “performance enhancing” supplements advertised in the sports world.

So, what works and what doesn’t? This is one of the most common questions we get from athletes.

After 9 years of research we’ve found an answer to this million-dollar question. The answer is “all of it, none of it, and some of it”. There you go, thousands of hours went into finding this answer and we just shared it for free.

Let me explain.

We at Phuel Sports Science, the research entity offering AthleteBloodTest.com, have been researching physiological responses to training and micronutrient needs in athletes since 2008. A clear conclusion we’ve come to is that every athlete has unique dietary and supplemental needs for optimizing performance.

We’ve examined our research in an attempt to identify trends based on gender and weight, level of performance, training plans, and everything in-between. Although we have identified some trends, ultimately the conclusion has not changed. Every athlete has unique dietary and supplemental needs for optimizing performance.

Identifying these needs is critical to optimizing performance. Whether optimal performance is getting faster or stronger, or simply enjoying the experience of training and competing more, knowing your unique needs is essential to achieving your goals.

In the research world, physiological needs and responses are often over-generalizing. For example, there have been many studies looking at whether a multivitamin can help performance. The research involves giving the experimental group a multivitamin and the control group a placebo (fake multivitamin in this case). The participants then run on treadmills or maybe stationary bikes regularly over a period of time. Conclusions of the studies cover the entire spectrum, concluding that multivitamins are detrimental to performance, improve performance, and everything between. Then an article is written in a magazine titled “Multivitamins Are Hurting Your Performance”.

Our research clearly indicates that we cannot generalize the physiological needs or response in athletes. This explains why studies such as multivitamin studies have conflicting conclusions, and why most unbiased supplement studies in athletes have conflicting results.

Our research has created an explanation for the many studies on supplements unable to come to a clear conclusion. For example, just some of the factors that influence dietary and supplement needs include:

  • gender;
  • age;
  • genetics;
  • environment (geographical location, work environment, home environment);
  • gastrointestinal health;
  • frequency, duration, and intensity of training/competition;
  • dietary habits;

Yes, it’s complex. So, how do you find the ideal diet for you?  There are two important steps to finding the right diet.

  1. Get a blood test through AthleteBloodTest.com. Testing is the only way to identify micronutrient needs unique to you.
  2. Hire help or do your research. Hiring the help of a dietitian will save you a lot of time and trial and error. A dietitian that specializes in working with athletes will be able to take the information provided through an Athlete Blood Test and tailor a dietary plan specific to your needs. It is well worth the money and the information remains pertinent for years.

There is only one way to truly identify how to optimize your diet, training, recovery, race preparation. That is through a blood test that tailors its recommendations to you as a unique individual. Visit AthleteBloodTest.com and order your test today.

Supplements for Triathletes: What Works?

The world of endurance sports is being inundated with supplements manufactured with the endurance athlete in mind. It’s easy to get wrapped up in supplementing. Before you know it you’re taking a handful of pills in the morning, a special powder for your water bottles, and another handful of pills in the afternoon. The goal of this series of posts is to help you understand which supplements appear to be effective through solid research, and which may not be worth the money.  Of course, individuals may have different needs, but for the purpose of this article, I am discussing the general endurance athlete population. But first, one important concept…

Although it is sometimes difficult to get all of the nutrients needed through diet, it is almost always better to try to meet your nutrient needs through foods than supplements. Foods, especially fruits and vegetables, have enzymes that optimize bioavailability (how much you absorb) of nutrients within the food. When nutrients are isolated to be made into supplements some of those enzymes are lost. Bioavailability of supplements varies depending on many factors, including the supplement quality, how the supplement is manufactured, what the supplement is, time of day you take it, what you take it with, and on and on. Some popular supplements have been shown to have absorption rates of less than 5%!  It is because of the variables above that you should strive to get the majority of your nutrients through an ultra-healthy diet. Put the same emphasis on diet as you do training.

Of course, there are supplements that appear to benefit endurance athletes in well designed, double blind studies. Below is a summary of well-researched supplements. There are more supplements that may be effective. This list is simply a list of those that consistently show to be effective.

The “A” List

The following supplements have consistently shown through quality, peer reviewed research to be effective for endurance athletes.

  • Multivitamin – although multivitamin supplements do not appear to improve performance in endurance athletes, they are generally an accepted general health strategy. Endurance athletes burn through a lot of nutrients during and after workouts, which can lead to depleted micronutrients. Even if these depletions are marginal, they can affect performance, recovery, and immune function. There is debate around the whether multivitamins are actually beneficial for athletes. A couple years ago a small study saw very slight performance declines in the athletes taking a multivitamin. After reviewing this study, there are many flaws to it and in my opinion it is not a valid conclusion. Therefore, I base my opinions on the many other studies that are well organized. These studies generally conclude that a multivitamin will not enhance performance, or may very slightly. However, I have yet to come across a study that tests micronutrients as part of the study. To truly understand the correlation between micronutrients and performance, a study of this sort should be performed. I can say, however, that through my experience with professional and elite amateur athletes that when we find deficiencies in an intracellular micronutrient test, then correct for those deficiencies, I typically get very positive feedback from the athlete about improved performance and quicker recovery. *Processing and brand make a difference with multivitamins, as a poorly processed multivitamin is not well absorbed. Take as indicated. My top choice for a multivitamin is from the Douglas Labs Klean Athlete line. Find it here: http://www.douglaslabs.com/product.cfm?litm=KA201344-60Must be ordered with a physician code, use the following: 2142213   
  • Fish Oils/Omega 3’s – fish oils should be an essential supplement for every endurance athlete. These super powered anti-inflammatory and antioxidant supplements are one of the most well-researched and supported supplements. They fight free radicals and oxidative stress, and reduce post-exercise inflammation. *Processing makes a difference. Omega 3’s in the triglyceride form have shown to be superior. The huge majority of omega 3/fish oil supplements out there are in the ethyl ester form because this form is easier and cheaper to produce. One over-the-counter brand that is in triglyceride form and can easily be found is Nordic Naturals. The ideal EPA to DHA ratio for athletes is 4:1. Most supplements are 2:1. This ratio is fine, but if you can find a 4:1 supplement (such as Nordic Naturals ProEPA) that is ideal. I recommend 1200-1800 mg per day with food. My top pick is Nordic Naturals ProEPA, which can be found online or in many health food stores and pharmacies.
  • Vitamin C – strenuous exercise increases production of free radicals, which can damage muscle tissue, increase muscle soreness, and create inflammation. Vitamin C is an effective antioxidant, and can be taken in high quantities safely, easily, and cheaply. Antioxidants fight the production of free radicals. Vitamin C is also an immune booster and high intensity training decreases immune function. Most professional triathletes and ultramarathoners I see have deficient immune systems throughout the peak of their training. There are well run studies that show vitamin C does reduce post-exercise muscle pain and speed recovery, then there are well run studies that conclude it likely does not. My opinion…vitamin C is easy to take, is cheap, boosts the immune system, and probably helps with recovery. I recommend taking it throughout the peak training season. My top pick for a vitamin C supplement is the Emergen-C packets, as they are bioavailable and easy to take. One packet per day (1,000mg) is adequate.
  • Iron (when indicated!) – iron should be taken under the guidance of a physician. I will repeat, iron should be taken under the guidance of a physician. The need for iron supplementation should be shown through blood testing (see my blog post on blood work monitoring). There are hundreds of thousands of endurance athletes blindly taking iron. When iron is indicated, this supplement can be essential to your well-being and ability to train and race. It can boost performance WHEN NEEDED. When taken in excess, it can be hard on the liver, cause gastrointestinal problems, inhibit zinc absorption (an important nutrient for athletes), and cause fatigue. There are several different forms of iron. My top choice is iron carbonyl, as it appears to be the most bioavailable form. Take as directed by a physician and be sure to supplement zinc when you are supplementing iron. Iron will typically cause increased intestinal gas. If you require iron supplementation, be sure to read my blog post about iron supplementation, as there are important steps to optimizing absorption of the supplement. My top pick for an iron supplement is Douglas Labs Time Released Iron (product number 7962). 90 capsules cost $10.20. Find it here: http://www.douglaslabs.com/product.cfm?litm=7962-90X  good zinc supplement also comes from Douglas labs, the Zinc Lozenges. Both must be ordered with a physician code, use the following: 2142213   
  • B12 (when indicated!) – when used correctly and at the appropriate time, B12 can help ward off anemia and pre-anemia. If you are monitoring your blood work during your training, a sudden change in the MPV (which indicates the shape of the red blood cells) and slight drop in hemoglobin and hematocrit suggest that it may be time to supplement B12 or increase your folate intake. Folate intake is best increased by using a vitamix type blender (see my blog post on Juicing). I have found that in high performing endurance athletes, B12 is often high in the blood, however deficient in intracellular (within the cell) micronutrient tests. More to come on this in a future blog post. B12 is best taken either sublingually (under the tongue), which can be found at almost any pharmacy or health food store, or via intramuscular injection, which costs more and typically requires a visit to a clinic.
  • Magnesium – research shows magnesium can increase lactic acid clearance, decrease muscle aches and cramping, and possibly improve power output and performance. Magnesium is plentiful in foods, however some studies show that in endurance athletes magnesium levels are very slow to rebuild once depleted by prolonged muscle use or training in hot, humid weather. In addition, alcohol, coffee, refined sugar, and high salt intake can deplete magnesium. Being we endurance athletes love our beer, coffee, and frequently partake in salty food binges, supplementation should be considered during peak training, especially if in hot, humid weather. Magnesium is also closely linked to potassium and calcium. When magnesium levels drop, potassium and calcium will soon follow. Drops in potassium result in severe muscle cramps. Drops beyond certain levels can be dangerous and will surely end your race and possibly send you on a ride to the hospital. 500-1000 mg/day during training (can be part of a multivitamin). For two days prior to a race, up to 1500 mg/day can be taken, however if it leads to an uneasy stomach, back off to your regular levels (too much can cause diarrhea). My pick for a magnesium supplement is Douglas Labs Magnesium Aspartate, a readily bioavailable form (product number 7405). 250mg per pill, 250 pills per bottle, $20.90. Find it here: http://www.douglaslabs.com/product.cfm?litm=7405-250X  Must be ordered with a physician code, use the following: 2142213   

Red Blood Cell Turnover In Endurance Athletes: How to Apply This Information

Red blood cells are one of the most important physiological components for athletes, especially endurance athletes. These cells are responsible for carrying oxygen to the body’s tissues (including muscles). Without adequate oxygen delivery, muscles cannot perform well. When red blood cells become too low, a person becomes anemic, which is characterized by extreme fatigue. Anemia and “pre-anemia” are somewhat common in long-distance triathletes, runners, and cyclists. This is because of a higher turnover rate of red blood cells.

The red blood cell turnover rate (rate of cell death and reproduction) is higher in endurance athletes. Triathletes are especially prone to a high red blood cell turnover rate due to the demands of participating in three sports and one of those sports being running, which is a high impact sport. During endurance events, athletes require a rapid uptake and then delivery of oxygen, which requires adequate numbers and function of red blood cells. With the high demands placed on the red blood cells, and the increased breakdown of red blood cells (RBC’s) due to stress on the cells, this predisposes endurance athletes to dropping RBC numbers, which will ultimately decrease performance.

However, in a well adapted endurance athlete, the production of new RBC’s also increases in order to compensate for the increased death rate. This creates an environment where the majority of RBC’s will be younger cells, which have shown to be more efficient oxygen carriers. But not all athletes adapt well, which is why myself, and many others recommend blood test monitoring during training. By monitoring RBC numbers and seeing the size, shape, and volume of the cells, we are able to easily view these adaptations and ensure they are occurring appropriately. There are interventions that can be implemented (that are legal!) if the adaptations are not occurring.

 

When looking at RBC indices on blood test results, much of the focus should be on the MCH, MPV, and MCV numbers. These are indicators of the health of the RBC’s. A high MCV can indicate folic acid or B12 deficiencies, among other things, while a low MCV can be an indication of an iron deficiency.

In summary, the RBC turnover rate is higher in endurance athletes, especially those training at higher intensities and longer distances. For these athletes, it is beneficial to monitor the red blood cells to ensure proper adaptation is occurring.

Want to learn more? Try one of our Panels and we’ll unlock the secrets to your unique physiology: http://www.athletebloodtest.com/our-test-panels/

PLEASE NOTE: There is much more to reading blood work for endurance athletes and this should only be performed by a practitioner trained in working with endurance athletes, as the blood findings often have false positives and “within normal limits” may not apply to the athlete, depending on the intensity and number of hours training per week.

 

Juicer: The Athletes Friend

Endurance athletes demand a lot from their bodies. Hours of training depletes micronutrients (vitamins and minerals) and stresses cells. Although some supplements can help replete important micronutrients, research suggests repletion through whole foods is far superior. Whole, unadulterated foods contain thousands of enzymes. At the current time, the complete role of these enzymes in our bodies is not fully understood, however it appears that one role the enzymes play is to make micronutrients more bioavailable to the cells. As science moves forward, it is my guess that we will learn these enzymes are critical to our health.

An easy way of ensuring you are getting all of your micronutrients and the associated enzymes is through juicing. I MUCH prefer the blender type of juicers, where you get 100% of what you put into the blender out. I use a Vitamix blender.

In creating your juice, it is optimal to include both fruits and vegetables. As a general rule of thumb, the deeper the color, the better it is for you. Here are some of my favorite ingredients to use in juices:

  • Kale
  • Chard 
  • Beets
  • Blood Oranges
  • Apples
  • Carrots
  • Spinach
  • Yams 
  • Pears
A favorite recipe of mine that is power-packed with nutrients is the following:
Kale 
Red Chard
1 Small Beet
1 Blood Orange
1 Pear
3 Large Carrots
1/2 Small Yam
1 Cup Orange-Pineapple Juice
3 Cups Water
Breakfast Smoothies:

Another great utilization for the blender is breakfast smoothies. During training, it is important that you are starting your day with a meal that provides sustained energy. I prefer to start my day with a protein smoothie. Protein is essential in your diet during training. It is crucial to muscle recovery. 
Here are a couple of my favorite breakfast smoothie recipes:
Shake #1:
1 Large Banana
1 Tbsp Peanut Butter
1 Scoop Vanilla Protein Powder
1 Tbsp Honey (optional) – adds calories, so if you aren’t burning them be careful
1 Cup Frozen Mixed Berries or Frozen Strawberries 
1 1/2 – 2 Cups Vanilla Almond or Coconut Milk
Shake #2:
1 Large Banana
1 Tbsp Almond Butter
1 Scoop Vanilla Protein Powder
1 Large Mango
1 Kiwi
3 Strawberries
1 1/2 – 2 Cups Vanilla Almond or Coconut Milk

Cramps: What We Know About Prevention

Cramps are a very common occurance in endurance athletes. Despite plenty of research, the science of cramping is still a bit inconclusive. Despite our desire to pin cramping down to a single nutrient deficiency or event, it does not appear we will find this. So, what do we know? Here is the short version of a couple key concepts in preventing cramps?

The Science of Cramping

There are different types of cramping. Some are serious (and if you get them you will know they are serious), and some are benign. This blog is going to focus only on the benign cramps, the ones most of us have experienced.

The two primary culprits for cramps appear to be fitness and hydration status.

Fatigue Induced Cramps

Fatigue cramps are the most prevelant types of cramps. They are essentially the consequence of a muscle hitting a point of exhaustion and going into a hyper-excitability state due to aberrant brain-muscle communication.

Have you ever noticed that your muscles seem to cramp only at the worst times, such as during a race? This is most likely to be fatigue cramps, and an indicator that you are missing out on an important aspect of training. That aspect is typically race intensity training.

For those that follow my blog, you know I am a fan of base building using your heart rate for monitoring. This type of training helps prevent injury and results in improvements in “aerobic speed” (see post on heart rate monitoring), which is important to becoming faster over longer distances. I put myself through an experiment prior to last season where I didn’t do anything but heart rate training for several months leading up to the race season. The results? I was a much faster triathlete all season despite not ever doing speed work, but I did have cramping issues during races.

As race season approaches, it is important that you mix in race-effort intensity into your training. If you don’t, you are asking for a bonk, muscle fatigue, and fatigue cramps. A race is generally not the time to introduce your muscles to a new level of intensity. That doesn’t mean you should go out and cook yourself each workout. But, it does mean your body should at least be adapted to the intensity level. Typically, 1-2 days per week of intervaled race intensity work is enough. Anymore, and you risk over-training (see my blog on cumulative stress and over-training syndrome).

Try mixing in these workouts into your routine (for a 70.3 or Half-Ironman distance triathlon):

Key Interval Run Off Bike:

Spin easy on trainer or flat outdoor route for 60 minutes, then do a 1:15 – 1:30 run off the bike with the following sets (4 x 10 minutes at 10 seconds below goal race pace with 5 minute recovery run between sets. Follow this with 5 x 3 minutes at 20 seconds below goal race pace with 2 minute recovery run between).

Key Interval Bike With Short Run Off Bike

On your long ride day, mix in 5-8 sets of 10 minutes at your race pace with 2-3 minutes rest between sets. End the bike with a 20 minute time trial. Do a short, easy effort 20 minute run off the bike.

Drink a protein shake or recovery shake immediately after these workouts. Here is my favorite recovery shake:

1 Banana
1 TBSP Honey
2 Level Scoops Hammer Nutrition Recoverite (chocolate!)
2 Cups Vanilla Almond Milk (Coconut Milk or Regular Milk can be subsituted)
4 Ice Cubes

Make sure you follow this workout with a low intensity day the following day, such as a long easy/moderate swim. Putting your muscles and joints through that intensity requires recovery.

Hydration and Cramps

Both dehydration and over-hydration can cause cramps. Both result in a loss of electrolytes. There are several different opinions on proper hydration leading up to a race. Because of variable sweat and water loss rates among individuals, it is very difficult to give specific recommendations on how much fluid to take in leading up to a race.

I generally simply recommend monitoring your urine color. Prior to the start of the race, your urine should be relatively clear and colorless. During the race, I subscribe to the 1 bottle per hour during the bike with electrolytes every other bottle as a starting point. During the run, grab something every aid station for an Ironman and at least every other aid station during a 70.3 as a starting point. If conditions are hot and humid, or you are at higher altitudes, or you have a higher than normal sweat rate, you may want to increase your fluid intake during the race. But, don’t overdo it. If water is sloshing around your gut, slow the fluid intake down.

Proper hydration can be made more complex than the above if you so desire. I generally choose to keep it simple, as there isn’t a lot of research showing the more complex methods result in better outcomes. This is where experimenting during training can make all the difference. Train in all types of conditions and experiment with different intakes.

Happy Training!

Supplementing Iron In Athletes: The How and Why

In past blog posts, I have briefly touched on iron supplementation. This practice is common among endurance athletes, especially triathletes, cyclists, and long distance runners. It is done because of the high risk of anemia and pre-anemia due to increased red blood cell turnover secondary to training. However, iron supplementation should be done with caution and under the watch of a professional.

My general rule of thumb is to avoid iron supplementation until you see an indication for supplementing. Indications include a reduction in hemoglobin, hematocrit, and red blood cell numbers, along with an increase in size of red blood cells compared to your base numbers and beyond what is normal secondary to training. I am a strong advocate for regular blood work monitoring in athletes training more than 10-12 hours per week, especially if there is intensity added to some of those workouts. There is research that shows high iron levels of iron can cause gastrointestinal problems, fatigue, appears to increase the risk of cancer, and it does interfere with zinc absorption, a very important micronutrient to endurance athletes. Therefore, iron should not be blindly supplemented. When iron is indicated, it is crucial to performance, when it is not it can be very detrimental to your health, and decrease performance. Blood work monitoring should be performed by a doctor familiar with working with endurance athletes.

Before simply treating iron deficiency by taking a pill, it is important to take some time to consider why this deficiency may have occurred in the first place. For starters, a few questions that should be asked include:

  • Is there blood loss occurring in the body (gastrointestinal bleeding, heavy menses, infection, etc)?
  • Other disease processes?
  • Are there absorption problems?
  • Are co-nutrients deficient?
  • Is the athlete over-training?
  • Is this definitely iron deficiency and not folic acid/folate or a B12 deficiency?
If iron supplementation is the answer, it is time to start iron. However, iron supplementation is not as easy as simply taking a pill for some. Some people have trouble absorbing iron when it is supplemented by itself. In fact, in the last month I have been contacted by three professional endurance athletes that cannot seem to shake their anemia/pre-anemia, which is hugely affecting their performance. After reviewing tests and further testing in all of them, it became apparent that they had trouble absorbing iron in the pill form.
How to Supplement Iron
An iron supplement should be paired with a significant source of organic vitamin C (non-synthetic). Organic vitamin C greatly enhances iron absorption. The key is that it must be “organic”. Synthetic vitamin C, such as that found in supplements does not have nearly the iron absorption enhancement effect as organic. Iron should not be taken with dairy products, or within 1 1/2 to 2 hours of drinking coffee or soda (this includes diet soda). 
The ideal method for supplementing iron is to take it with a fruit smoothie. Vitamin C and protein containing lactoferrin increase absorption of the iron. Interestingly, dairy products, specifically cow’s milk have been shown to decrease iron absorption, while whey protein supplements containing lactoferrin increase absorption. The following recipe tastes delicious:
1 banana
1 scoop vanilla whey protein
1 cup frozen mixed berries
1 cup frozen strawberries
Coconut milk
(optional: 1 tbsp peanut butter or 1/3 cup rolled oats)
While supplementing iron, you should also supplement zinc, as iron supplementation decreases zinc absorption rates.

Which Iron Form to Take

There are several different forms of iron out there. My top pick among the different forms is iron carbonyl, as it appears to be the best absorbed form of iron because of slower absorption rates, which have also shown to decrease the side effect of gastrointestinal discomfort and decrease potential toxicity. A company I am particularly fond of is Douglas Laboratories (no I am not a paid spokesman). They make a great iron supplement in the form of time released iron carbonyl. The benefits of having it time released are typically less gastrointestinal side effects, which are very common when supplementing iron (gas, loose stools, or constipation).

You can find this supplement here: http://www.douglaslabs.com/product.cfm?litm=7962-90X. To order you must use a physician referral code. You can use the following: 2142213. Just remember, test first!

If you are interested in testing and don’t have a relationship with a doctor, I am available for blood work monitoring to athletes both locally and distantly. Simply contact me at garretrock1@gmail.com to inquire. This is performed through the 51 Speedshop Performance Advising (www.fiftyonespeedshop.com). 

Folate For Athletes: Don’t Ignore This Micronutrient!

Over the last few years, iron has become a supplement found on the shelves of most endurance athletes. Rightfully so, depleting iron levels leads to pre-anemia and anemia. For more information on iron, see my blog post on the topic (http://scienceoftriathlon.blogspot.com/2012/05/supplementing-iron-how-and-why.html).

However, somehow the micronutrient folate has not received adquate attention. Endurance athletes have come to believe that if they are abnormally fatigued and feeling anemic, it is because of an iron deficiency. Yes, iron is the most common deficiency leading to anemia, but folate deficiencies also lead to anemia. In my clinical experience, folate deficiencies are not overly uncommon among 140.6 and 70.3 distance athletes. Whereas, iron is more difficult to prevent strictly through diet in high level endurance athletes, folate deficiencies are typically easily prevented simply by eating the right foods.

Folate is a B vitamin. It plays an important role in red blood cell production and tissue repair. It is also an important component of cell division, especially in cells with higher turnover rates. In endurance athletes, the red blood cells have a significantly higher turnover rate due to the stresses of training. It is not stored in the body, therefore adequate amounts must be ingested every day. A healthy diet is essential to ingesting adequate amounts. 





Folate and folic acid are often used interchangeably. However, I treat them differently. Folic Acid is a synthetic, lab produced form of folate. Folic acid is often fortified in foods. In my experience, folic acid supplementation and/or ingestion is not equivalent to eating folate in its unadulterated form (as is the case for most micronutrients). In my clinical experience, folate repletion occurs rapidly and the benefits on the red blood cells can often be seen within days when done through increasing dietary folate. Folic acid supplementation has often been disappointing in athletes I work with that rely on this method due to travel or other life situations that inhibit their ability to eat high amounts of folate.


Endurance athletes should try to ingest at least one meal per day high in folate. Folate is prominent in spinach, romaine lettuce, chard, broccoli, lentils, red beets, and alike vegetables and legumes. The easy way to get a high concentration of folate is by juicing (see my blog post on juicing here: http://scienceoftriathlon.blogspot.com/2012/03/juicer-triathletes-friend.html). If juicing doesn’t appeal to you, salads easily supply what you need.

Does Running Make You Fat? – Debunked

Warning…the first seven paragraphs are a preamble. If you just want the tips, feel free to skip to the “Meat and Potatoes” section.

Several months ago my wife told me I need to read a blog post one of her friends shared on Facebook. Her friend shared the post with an attached comment of “This really makes sense”. The post was an amateur post by a personal trainer who makes the claim that running makes you fat. An impressively long list of over 80 references followed the post, making this claim look legitimate on the surface.

I read the post. The author did a great job selling their theory. They did such a great job that I began to doubt my knowledge on this topic…and yes, I am very well trained, read, and researched on this stuff. According to the post, steady effort exercising, such as running and cycling elicit “self preservation”, a state where the body slows metabolism, thyroid function, and fat utilization in order to “save itself” from dwindling down to nothing. Now, I am trained in this stuff, and I knew this to be largely untrue except in specific circumstances, however this list of references was really impressive. In addition, the titles of most of the references supported this conclusion. Could I really have been led so far astray?

So, I pulled out the credit card and dropped a bunch of money on the full reports for many of the referenced studies. For the next week I spent my lunch breaks reading the complete studies. The good news following my review was that I no longer doubted my expertise. The bad news was that this post was irresponsibly written, poorly researched, inaccurate, and self-serving. The majority of the studies from the list of references, when read in their entirety, had much different findings than the titles would lead one to believe.

The post was spreading like wildfire, influencing hundreds of thousands of people into believing that running, triathlon, and cycling are not good for them. What reading the full studies led to is a conclusion I was already familiar with, which is that under certain circumstances the body will go into a “self preservation” mode. The author took this particular consequence due to certain circumstances, and generalized it to everyone. I’m giving the author the benefit of the doubt and chalking it up to inexperience.

Initially I blew it off. However, in the last several months I have been seeing more and more articles making the claim that running will “make you fat”. The posts seem to be getting more dogmatic as well…this is the way it is and we are right! I even read one rather strong article by an exercise physiologist turned testosterone supplemented beach body trainer ranting about Ironman athletes and marathoners idiotically setting themselves up for getting fat with their training. For those that have competed in, or at least watched, an Ironman, it has the appearance of a giant meeting of the fittest looking people on earth. As some of my friends say (male and female), watching an Ironman is eye candy. In a funny twist, this particular gentleman has a picture of himself on his website without a shirt on…and interestingly, he would be the “fat guy” toeing the line of an Ironman.

Well, after reading too many of these articles I can’t stand it anymore, I need to debunk the claim.

Meat and Potatoes…because that’s what us endurance athlete fatties love most, right? :)

Does running make you fat? No. Can it? Given the right set of circumstances, it can lead to slowed metabolism, hypothyroidism, and fat preservation. Are these circumstances avoidable? Absolutely. Should you continue reading this so that you know how to avoid these circumstances? Yes. Can running lead to fat loss? MOST DEFINITELY! Are endurance sports a good way to “get skinny”? Yep.

The truth is that our body tolerates steady state exercise extremely well. In fact, many experts on exercise physiology believe that our physiology is made for steady state exercises. My opinion is that we are an incredibly adaptable species that can thrive doing both burst activities and steady state activities. Just look at the incredible adaptability in football players, who are able to explode out of a crouch and push with enormous forces, compared to Ironman athletes who are running sub-6 minute miles after swimming hard for nearly an hour and biking hard for almost 5 hours. Both are very different, yet we are achieving mind-blowing feats in both. I don’t think it is fair to say we are meant for one type of activity.

When the body is given the fuel it needs and limits are not exceeded too quickly, running is great for your health. It is also convenient. You don’t need a gym or fancy equipment. You just lace up a pair of shoes and go. Mentally, running has incredible benefits. Research links running to reduced rates of depression, mental illness, suicide, and greater happiness.

Physiologically, we also tolerate running very well. Adaptations in hormones, red blood cell turnover, metabolism, and fat burning are clear indicators that our bodies are meant to do endurance activities. If we weren’t, some of the adaptations, such as the transition between carbs and fats as fuels, just wouldn’t occur.

As I mentioned, circumstances do exist that may lead to a state of “self preservation”, which is characterized by slowed metabolism, fat preservation, decreased thyroid function, and more. The circumstances are largely related to dieting or nutrient deprivation, such as low fat diets while training. Here are some tips to ensure you avoid sending your body into “self preservation”:

1. Do not restrict calories when initiating your training. The start of endurance training is NOT the time to start a new diet. If weight loss is a goal, ramp up training for at least 4-6 weeks and then start cutting calories in small quantities, if you are not dropping weight already, until your calorie output slightly exceeds your calorie input. During training, do not restrict calories more than 200 less per day than what you are burning, and do not sustain this deficiency for more than a week or so at a time without 2-3 even calorie days (in equals out).

2. Eat fat! The 90’s brought about a fear of dietary fat. I remember a good friend of mine in high school once saying at the end of the day, “Yes! I only ate 2 grams of fat today!”. Fats are absolutely essential for hormone production, and the absorption of many essential nutrients, such as Vitamin D. If you are not eating fats during training, your body will do all it can preserve body and dietary fats. In addition, your training and racing will suffer because your body will not go into a fat burning state as quickly…if at all.

3. Make your calories count. Before you eat or drink anything, ask yourself “What is this doing for me?” If the answer is nothing, don’t eat it. Of course, there are definitely times for exceptions to this rule…I’m not a complete stick in the mud. But, in your daily diet, every bit of food and drink you eat should provide your body with something it needs. Eat your veges. Eat your fruits. Eat adequate amounts of fats and proteins.

4. Do NOT crash diet…ever.

Medications and Endurance Training: What You Should Know

Recently, a drug rep was in our clinic telling me how their pain medications would be good for the pains commonly experienced by athletes. I immediately thought about the importance of this topic and figured I better share some words on the blog about it. Not all primary care docs, nurse practitioners, and PA’s are familiar with the unique physiology of endurance athletes. It is important to take this into consideration when considering taking certain medications.

For this post, I am only going to cover common pain medications (both OTC and prescription) and antibiotics.

Over-the-Counter Pain Relievers

In a study conducted in 2007, runners took either aspirin (650mg), ibuprofen (400mg), or a placebo 24 hours prior to running 60 minutes on a treadmill at 70% VO2max. Researchers found that both ibuprofen and aspirin increase gastric permeability. Aspirin also increases small intestine permeability. In laymen’s terms, this means you are not absorbing nutrients as well, or you have a mild “leaky gut”. Some of the carbohydrates you take in during your race/training will not be absorbed.

Increased gastric and intestinal permeability can lead to gastrointestinal (GI) discomfort. There is also evidence that NSAID use during intense exercise can increase GI bleeding, which is somewhat common in triathletes who incorporate a significant amount of intensity to their training. Increasing blood loss through the GI system often leads to a decrease in hemoglobin and red blood cells, and is a common cause of anemia in triathletes.

For general health, it is best to avoid these prior to prolonged exercise. However, I must avoid bias here and share the entire story. There is research suggesting that acetaminophen can aid performance. As pain perception increases our speed decreases. Research exists that shows that in short events, such as a short cycling time trial, reducing the pain by taking an OTC pain reliever may result in cyclists riding faster due to the lack of pain. However, in long events, NSAIDs, aspirin, and acetaminophen have generally been shown to be unsafe and have little to no positive effect on performance.

A study performed on Ironman distance triathletes several years ago found an increased risk of exertional hyponatremia due to altered kidney function when taking NSAIDs. NSAIDs increase the effect of anti-diuretic hormone, causing the kidneys to retain water and thus diluting sodium levels. Similar findings have been found in newer studies. This complication is especially concerning if it is hot and humid on race day.

OTC Pain Reliever Summary
Although acetaminophen use may be very slightly beneficial to performance in very short events, OTC pain relievers are generally not a good idea. Acetaminophen in high doses can cause liver damage. It is unlikely that an athlete would take the sort of dose to cause acute liver damage (approximate dose in adult is 8,000 mg in 24 hour period in “normal adult”). However, in long distance training and racing, the liver is typically burdened. In fact, in nearly every professional endurance athlete I perform blood tests on I am seeing high liver function numbers, meaning the liver is “stressed”. Although this topic has not been studied much, we do know that a risk factor for liver damaging side effects from acetaminophen is a history of liver conditions. The stress your liver endures in a long distance event may be enough to be considered a predisposition for acetaminophen toxicity. I can’t say this with conviction, as I have not seen any research on it, but it sure makes sense and is not something I would personally risk.

For long distance triathletes, NSAIDs can be detrimental to performance, and even be dangerous. You are better off avoiding them. Although, if there is simply no other option and/or you are one of those people whose opinion is “I’ve been doing this for years and I haven’t had a problem yet, so no matter what you say I’m still taking my OTC meds”, acetaminophen is likely the safest. The fear of hyponatremia (abnormally low sodium concentration in blood) is a very real risk, and a big enough risk for many experts, myself included, to consider NSAID use for ultra-distance events (ex. Ironman) an absolute “no-no”. Hyponatremia can result in brain swelling, brain herniation, cardiopulmonary arrest, seizures, coma, and even death in severe cases. Think this can’t happen to you? You better think again. Researchers found that 13% of 2002 Boston Marathon finishers were clinically hyponatremic. Yep, that is after a marathon…and not one that came after swimming 2.4 miles and biking 112.

Prescription Pain Relievers

Muscle Relaxants – Muscle relaxants should be discontinued a couple days before competition and should never be taken just prior to competition or training. Ideally, an endurance athlete would not take them at all. However, these are very commonly prescribed and some endurance athletes find them helpful for injuries not sustained from running, biking, or swimming. The biggest danger with muscle relaxants is the side effects. They are CNS depressants and common side effects include drowsiness and dizziness. Regarding performance, it would be awfully tough to have a good race when you feel drowsy. Regarding safety, drowsiness and dizziness can be an issue when you are competing in a race where common side effects of the race itself are dizziness and lightheadedness. Falls are a concern.

Vicodin – Vicodin is a combination of acetaminophen and hydrocodone. Vicodin is indicated for moderate to severe pain. Put simply, Vicodin is not for the training athlete, except in VERY special circumstances and under VERY careful guidance. If you think you may be one of those VERY special circumstances, be sure to speak with a doctor familiar with the physiological demands of training for whatever event you are training for.

Percocet – Percocet is a combination of acetaminophen and oxycodone. Similar to Vicodin and my opinions are the same. See Vicodin for more information.

Celebrex – Celebrex is a strong NSAID. Bottom line, don’t use it if you are an endurance athlete. There are better alternatives if absolutely needed.

Solutions for Pain


If the pain is localized, be sure to consider a topical cream based pain reliever. Topical pain relievers provide adequate pain relief for many of the conditions experienced by endurance athletes, such as tendinopathy’s and minor sprains/strains. Topicals can also be compounded to include both pain relievers and anti-inflammatory medications. By using topical creams you are bypassing the GI system, and less medication is absorbed into the bloodstream to be filtered through the liver. Topical cream based pain relievers are my choice for localized pain relief when needed.

Antibiotics

There are times when antibiotics are needed. As an athlete, nothing is more frustrating than being ill. Not only do you feel terrible, but you are also missing out on valuable training time. However, before your impatience leads to a hasty decision to take antibiotics, make sure the illness is truly bacterial. Why? Because antibiotics come with a price on functional health.

There are many studies that show the negative effects of antibiotics on the vital microflora (probiotics) in our guts. A recent study shows that following a single short course of ciprofloxacin certain strains of probiotics are still not recovered 6 months following the treatment! Yikes. The microflora in your gut appears to have a connection with micronutrient absorption. Certain micronutrients are essential to red blood cell production, cellular functions, and certain critical components of recovery following workouts.

There appears to be evidence in favor of taking probiotics following the completion of antibiotics. However, probiotics are much more complicated than simply going to your local grocery store and buying a bottle that reads “Probiotic”. There are many strains of probiotics, and research has yet to determine how to best supplement them. How probiotics are prepared, bottled, their source, etc, etc all make a difference in their viability. Choosing a quality company is important. If you are looking for a quality probiotic, send me an e-mail at garretrock1 at gmail dot com (yes, I don’t want spam so I spelled my e-mail address out on purpose…beware of those internet robots).

Happy training!



Resources


Lambert GP, Boylan M, Laventure JP, Bull A, Lanspa S. Effect of aspirin and ibuprofen on GI permeability during exercise. Int J Sports Med 2007 Sep; 28(9); 722-6. 


Piatkowski TS, Day WW, Weiner M. Increased renal drug metabolism in treadmill-exercised Fischer-344 male rats. 1993 May-Jun; 21(3): 474-9.


Mauger AR, Jones AM, Williams CAInfluence of acetaminophen on performance during time trial cycling. J Appl Physiol. 2010 Jan;108(1):98-104. 


Rudzki SJ, Hazard H, Collinson DGastrointestinal blood loss in triathletes: it’s etiology and relationship to sports anaemia. Aust J Sci Med Sport. 1995 Mar;27(1):3-8.


Wharam PC, Speedy DB, Noakes TD, Thompson JM, Reid SA, Holtzhausen LM. NSAID use increases the risk of developing hyponatremia during an Ironman triathlon. Medicine and Science Sports and Exercise. 2006 Apr; 38(4): 618-22.


R. E. O. Williams, M. J. Hill, and B. S. Drasar. The influence of intestinal bacteria on the absorption and metabolism of foreign compounds. J Clin Pathol Suppl (R Coll Pathol). 1971; 5: 125–129. 
Dethlefsen L, Huse S, Sogin ML, Relman DAThe pervasive effects of an antibiotic on the human gut microbiota, as revealed by deep 16S rRNA sequencing.  2008 Nov 18;6(11).