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Authors: Katz, David L.; Friedman, Rachel S.C.

Title: Nutrition in Clinical Practice: A Comprehensive, Evidence-Based Manual for the Practitioner,
2nd Edition
Copyright 2008 Lippincott Williams & Wilkins
> Table of Contents > Section III - Special Topics in Clinical Nutrition > Chapter 32 - Ergogenic
Effects of Foods and Nutrients: Diet and Athletic Performance
Chapter 32

Ergogenic Effects of Foods and Nutrients: Diet and Athletic Performance
The role of diet in optimizing athletic performance has long been a topic of considerable interest, a
natural extrapolation of efforts to optimize dietary health. Diet provides the fuel that is burned to
sustain physical activity, and it seems reasonable that alterations in the fuel will influence the
efficiency of that combustion. Although the recommended dietary allowance of protein is not
adjusted on the basis of physical activity, sports enthusiasts and competitive athletes generally
perceive a need for increased protein intake. Recent evidence supports this position but is
preliminary (1).
A variety of micronutrients play defined roles in energy metabolism and have received attention as
potential enhancers of athletic performance, among them carnitine, creatine, boron, coenzyme Q
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,
and other nutriceutical agents, such as dehydroepiandrosterone (DHEA). Evidence of enhanced
athletic performance in response to supplementation exists for some of these substances but is
generally both inconsistent and of marginal quality to date. That the overall adequacy of diet can
influence physical performance in an athlete, as well as in general, is beyond dispute.
Ideally, the well-established link between diet and physical prowess in athletes would foster a
general appreciation for the importance of diet to vitality. Instead, all too often, it promote
marketing schemes, misleading messages, and misguided practices, such as the consumption of
sports drinks and energy bars by masses of consumers far more subject to obesity and nutritional
excesses than to dehydration and depletion. The clinician has a role to play both in guiding the
athlete toward optimal nutrition and guiding the more typical and sedentary patient away from
eating like an athlete without acting like one.

Overview
Diet
In general, the US population engages in too little physical activity and consumes too many calories.
Therefore, although sufficient calorie intake is a fundamental requirement to maintain physical
activity, it is not a concern for the majority of patients. Individuals engaging in extremely intense
physical activity for extended periods, particularly competitive endurance athletes, may actually
need to make an effort to meet energy requirements. There is also the potential for dangerous and
even life-threatening dehydration and nutrient depletion when prolonged and hard force is
combined with stressful environmental conditions. Under such conditions, specialized dehydration
formulas (e.g., Gatorade), sports drinks, and energy bar offer potentially important advantages (2
4). excessive reliance on such products by patients at modest levels of exertion is appropriate to
contribute to a disadvantageous excess of calories and sugar.
For the most part, little evidence exists that the dietary pattern for physically active individuals
should be altered from that generally recommended for health promotion (see Chapter 45).
However, fat is the most calorically dense macronutrient, and fat restriction may be untenable in
athletes with high energy expenditure. The average calorie requirements of a sedentary, 70 kg male
adult are estimated at approximately 2,400 kcal. Studies in elite human athletes have demonstrated
24-hour expenditures of more than 10,000 calories, and a maximal sustainable expenditure of up to
12,000 kcal is estimated on the basis of animal research (5). The energy demands of various
representative physical activities are shown in Table 32-1.
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Carbohydrate is generally the predominant energy source in the human diet and is readily oxidized
to support physical activity. Studies generally suggest that monosaccharides and polysaccharides are
comparable energy sources, although glucose is metabolized somewhat more efficiently than are
other sugars. Preliminary studies suggest that carbohydrate sources with a low glycemic index/load,
such as lentils, may support endurance better than foods with a high glycemic index, such as
potatoes, when consumed prior to exercise (6) (see Chapter 6). The low glycemic index may favor
availability of carbohydrate stores during exercise and reconstitution of muscle glycogen following
exercise.
Carbohydrate loading apparently is of no benefit for exercise of short or moderate duration. When
high-intensity exercise lasts for more than 90 minutes, muscle glycogen depletion tends to occur. A
modest benefit of carbohydrate loading under such circumstances is probable (7,8), although it may
be due to neuroprotective effects on perception of fatigue rather than changes in glycogen or
protein metabolism (9,10). Sustained elevations in muscle glycogen following several days of
carbohydrate loading have been reported (11,12). There is some evidence that the effects of
carbohydrate loading differ by gender, with less evidence of benefit in women, but these limited
findings may be explained in part by lower carbohydrate intakes by women or menstrual cycle
fluctuations in glycogen storage (1315).
Endurance training enhances fatty acid utilization in muscle; if fat intake is sustained at a high level,
the efficiency of fat oxidation improves with time (5). There is some suggestion that a short period of
high fat intake may enhance fat oxidation, spare carbohydrate, and delay fatigue (16,17). However,
there is little evidence that these effects actually enhance performance (18). Concern has been
raised about fat loading, both on the basis of limited and contrary evidence and because the practice
is potentially at odds with dietary practices for health promotion, although that depends in part on
the variety of fat ingested (15,19).
High fat intake is the most efficient means for meeting very high energy requirements associated
with extreme exertion, such as endurance training or mountain-climbing expeditions. The health
hazards to the general public of excessive dietary fat intake should be bear in mind, and
recommendations for individual athletes to increase dietary fat intake should be made judiciously,
with a clear emphasis on the distinctions among fatty acid classes. Evidence in other areas suggests
the virtue of prioritizing intake of monounsaturated fatty acids and a mixture of n-3 and n-6
polyunsaturates in a ratio of 1:1 to 1:4. Saturated and trans fatty acid intake should be kept
proportionately low (see Chapters 2, 7, and 45). Studies characterizing the ideal profile of fatty acids
in a high-fat diet designed for athletic performance are lacking to date, and the evidence for a role of
high-fat diets in influencing athletic performance other than by meeting high energy requirements is
equivocal (20). When energy requirements are high and increased fat intake is desirable, nuts, seeds,
nut butters, avocado, fatty fish such as salmon, and olives all represent salutary means to the
desired ends.
Thus, controversy persists regarding optimal alterations of diet for the enhancement of sustained,
high-intensity exercise. The preponderance of evidence generally supports the prevailing practice of
carbohydrate loading for endurance sports such as marathon running.
Dietary protein is of particular interest to bodybuilders and other athletes involved in strength
training and is the most commonly used ergogenic aid (21). An intake of 3 g protein for every 4 g of
carbohydrate is touted to promote health and enhance athletic performance in the book Enter the
Zone by Sears and Lawren (22). Despite its popularity, the Zone diet is not supported by evidence
accessible in the peer-reviewed literature. An evaluation by Cheuvront (23) suggested that the Zone
diet is more likely to compromise than enhance athletic performance.
The role of increasing dietary protein in augmenting muscle mass and strength remains
controversial. Some studies have demonstrated benefit with protein intake three or more times


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the recommended dietary allowance of 0.8 g/kg/day. Consensus is emerging that moderate
increases in protein intake may be indicated for some athletes (24). Intake in the range 1.2 to 1.4
g/kg/day is recommended for endurance athletes, 1.7 to 1.8 g/kg/day for athletes engaged in
strength training, and 1.3 to 1.8 g/kg/day for vegetarian athletes (25,26). These levels of intake may
be optimal in terms of the athletic effort, but the long-term effects of such a diet on specific health
outcomes and chronic disease risk have not been adequately studied. Therefore, an athlete should
prepare to modify dietary intake to meet prevailing recommendations whenever he or she tapers
the level of physical activity. The use of amino acid beverages and supplementation with specific
classes of amino acids are popular practices, but the evidence of beneficial effects is equivocal
(21,2729).
Table 32-1 Energy Expenditure of Some Representative Physical Activities
a

Activity METs
b
(Multiples of RMR) Kcal/Min
Resting (sitting or lying down) 1.0 1.2 to 1.7
Sweeping 1.5 1.8 to 2.6
Driving a car 2.0 2.4 to 3.4
Walking slowly (2 mph) 2.0 to 3.5 2.8 to 4.0
Cycling slowly (6 mph) 2.0 to 3.5 2.8 to 4.0
Horseback riding (at a walk) 2.5 3.0 to 4.2
Volleyball 3.0 3.5
Mopping 3.5 4.2 to 6.0
Golf 4.0 to 5.0 4.2 to 5.8
Swimming slowly 4.0 to 5.0 4.2 to 5.8
Walking moderately fast (3 mph) 4.0 to 5.0 4.2 to 5.8
Baseball 4.5 5.4 to 7.6
Cycling moderately fast (12 mph) 4.5 to 9.0 6.0 to 8.3
Dancing 4.5 to 9.0 6.0 to 8.3
Skiing 4.5 to 9.0 6.0 to 8.3
Skating 4.5 to 9.0 6.0 to 8.3
Walking fast (4.5 mph) 4.5 to 9.0 6.0 to 8.3
Swimming moderately fast 4.5 to 9.0 6.0 to 8.3
Tennis (singles) 6.0 7.7
Chopping wood 6.5 7.8 to 11.0
Shoveling 7.0 8.4 to 12.0
Digging 7.5 9.0 to 12.8
Cross-country skiing 7.5 to 12.0 8.5 to 12.5
Jogging 7.5 to 12.0 8.5 to 12.5
Football 9.0 9.1
Basketball 9.0 9.8
Running 15.0 12.7 to 16.7
Running at 4-min. mile pace 30.0 36.0 to 51.0
Swimming (crawl) fast 30.0 36.0 to 51.0
a
All values are estimates and based on a prototypical 70 kg male. Energy expenditure generally is
lower in women and higher in larger individuals. MET and kilocalorie values derived from different
sources may not correspond exactly.
b
A MET is the rate of energy expenditure at rest, attributable to the resting (or basal) metabolic rate
(RMR). Whereas resting energy expenditure varies with body size and habitus, a MET generally is
accepted to equal approximately 3.5 mL/kg/min of oxygen consumption. The energy expenditure at
1 MET generally varies over the range of 1.2 to 1.7 kcal/min. The intensity of exercise can be
measured relative to the RMR in METs.
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Source: Derived from Ensminger AH, Ensminger M, Konlande J, et al. The concise encyclopedia of
foods and nutrition. Boca Raton, FL: CRC Press, 1995; Wilmore JH, Costill DL. Physiology of sport and
exercise. Human kinetics. Champaign, IL: 1994; American College of Sports Medicine. Resource
manual for guidelines for exercise testing and prescription, 2nd ed. Philadelphia: Williams & Wilkins,
1993; Burke L, Deakin V, eds. Clinical sports nutrition. Sydney, Australia: McGraw-Hill Book Company,
1994; and McArdle WD, Katch FI, Katch VL. Sports exercise nutrition. Baltimore: Lippincott Williams &
Wilkins, 1999.
Replenishment of water and electrolytes before and during exercise is vital for maintaining
homeostasis and health (30). Dehydration can degrade aerobic performance, increase risk of heat
exhaustion, and may also lead to cognitive impairment. Exact sweat losses vary by individual, type of
activity, and other environmental variables, ranging from 0.5 to 2.0 L per hour of activity (31).
Drinking only water or other hypotonic solutions during prolonged or strenuous exercise may lead to
hyponatremia, especially among women (32); consumption of isotonic fluids containing electrolytes,
as well as avoiding overhydration at a rate exceeding sweat losses, can help prevent symptomatic
hyponatremia (33). It has been recommended that fluid replacement beverages contain
approximately 20 to 30 mEq per L sodium chloride to replace electrolyte losses, stimulate thirst, and
promote fluid retention; 2 to 5 mEq per L potassium to replace electrolyte losses; and 5% to 10%
carbohydrate for energy (34).
The sports drink market has become a multi-billion-dollar industry, with numerous products
available that claim to optimize athletic performance and improve health. Most sports drinks contain
a combination of simple carbohydrates, including glucose, sucrose, fructose, and maltodextrins;
there is little evidence to suggest the superiority of any one sports drink over another (35). Although
sports drinks may be helpful in avoiding dehydration and replenishing nutrient loss during strenuous
exercise, they are nonetheless high-calorie sugared drinks; as such, they become virtually
indistinguishable from other obesigenic sugared beverages such as soda when consumed in quantity
by non-exercising individuals (36). While such beverages offer convincing benefit to athletes under
duress, the marketing of them to the population at large is a dubious practice at best.
Although notable as a modern phenomenon, the proclivity to seek performance enhancement by
altering diet is ancient. In antiquity, such practices were rooted in what is easily seen today as
superstition, such as the belief that eating the heart of an enemy would impart courage (21).
Although modern practices are more likely to derive from science than superstition, interest in
performance-enhancing dietary regimens consistently runs ahead of available evidence. So-called
ergogenic aids are often promoted on the basis of animal or in vitro data, before human
interventions can be conducted (37). Although the quality of evidence to support certain ergogenic
supplements has improved, the financial imperative and loose regulation driving the promotion of
such products warrant cautious skepticism (38,39).
Nutrients, Nutriceuticals, and Functional Foods
Creatine
Creatine phosphate in muscle donates phosphate to adenosine diphosphate to reconstitute
adenosine triphosphate. The intent of creatine supplementation is to increase energy storage in
muscle as a means to enhance performance. There is some evidence of benefit in high-intensity,
short-term exercise, but currently there is little evidence of benefit in endurance activities (37,40). A
double-blind, randomized trial in college football players demonstrated significant benefits of
creatine supplementation in muscle mass and sprint performance. Adverse effects with common
doses appear to be minimal, limited largely to gastrointestinal cramping and weight gain (41).
Several studies of weight lifters have demonstrated significant increases in repetitions following
short-term creatine supplementation (42). The preponderance of evidence suggests some benefit in
high-intensity, repetitive activities and in muscle building (43,44). Creatine appears to be safe in
doses commonly used (see Section VIE).
Carnitine
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Carnitine participates in the transport of long-chain fatty acids into mitochondria and is thought to
spare muscle glycogen by facilitating fat oxidation (37). Carnitine supplementation may also increase
levels of coenzyme A, enhancing the efficiency of the Krebs cycle (45). Preliminary studies suggest
that carnitine may suppress accumulation of lactic acid during high-intensity exercise, leading to
enhanced performance and quicker recovery (46). However, despite many trials documenting
benefits, the overall evidence to date suggesting that carnitine may enhance athletic performance is
inconsistent (37,45) (see Section VIE).
Bicarbonate
Sodium bicarbonate loading is used as an ergogenic aid in the belief that it will buffer lactic acid
accumulated in muscle and prevent or delay muscle fatigue and dysfunction. The evidence suggests
that bicarbonate does enhance performance, provided that the activity is brief (i.e., several minutes)
and intense, but not too brief (e.g., 30 seconds), and that the dose of bicarbonate is adequate (300
mg per kg sodium bicarbonate) (37,4750). In particular, bicarbonate loading may enhance recovery
time between repeated bouts of short, high-intensity activity, such as sprinting, by neutralizing
muscle lactate (37,51). Sodium citrate may have similar effects, though the evidence is preliminary.
A double-blind crossover trial on well-trained college runners found that the ingestion of 0.5 g per kg
body mass of sodium citrate significantly improved 5k run times and reduced post-run lactate
concentration compared to placebo (52).There is some suggestion that the benefit attributed to
bicarbonate may instead be due to the effects of a sodium load on intravascular volume (37).
Beta-Hydroxy-Beta-Methylbutyrate (HMB)
Beta-hydroxy-beta-methylbutyrate (HMB), a metabolite of the amino acid leucine, is a relatively new
ergogenic aid. One placebo-controlled study found short-term HMB use to be associated with
significant increases in strength during resistance training (53). Early trials have shown potential
benefit for resistance and endurance training, but the evidence is insufficient to establish safety and
efficacy at this time.
Dehydroepiandrosterone (DHEA)
DHEA is a steroid hormone with potential for both estrogenic and androgenic effects (54). There is
interest in the role of DHEA in enhancing athletic performance, but to date no reliable data on which
to base a conclusion are available (55). There is a general consensus that data from human
intervention trials with DHEA are inadequate to support its use as a supplement for an ergogenic
effect (56,57). Levels of DHEA decline significantly over the course of adulthood, suggesting
theoretical benefit for supplementation in the elderly. One randomized controlled trial found
beneficial effect of DHEA replacement in increasing muscle mass and strength during weight training
by elderly individuals (58).
Caffeine
Caffeine, taken alone, is considered a drug rather than a nutrient and is banned by the International
Olympic Committee. Caffeine functions as a stimulant via adenosine receptor blockade and possibly
by increasing adrenergic tone (59). It may enhance fat oxidation and sparing of muscle glycogen.
Evidence suggesting that endurance is increased by short-term caffeine supplementation is
convincing (37,60); however, long-term caffeine supplementation may have little to no ergogenic
effect (61,62). Most studies to date have enrolled only men, so effects on athletic performance in
women are speculative.
Chromium Picolinate
Chromium functions as a cofactor in the metabolism of glucose and protein, principally by enhancing
insulin action. Chromium picolinate is reputed to enhance energy metabolism in muscle and thereby
improve strength and stamina. There is some evidence to suggest that exercise may increase urinary
losses of chromium, and strenuous activity is associated with the excretion of minerals in sweat. No
convincing evidence exists to date, however, of enhanced athletic performance attributable to
chromium supplementation (63). There is evidence from randomized and crossover trials of the
failure of chromium supplementation to enhance the effects
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of resistance training on muscle size and strength (6467). Thus, the popular notion that chromium
picolinate is an ergogenic aid must be considered unsubstantiated. Other more likely benefits are
discussed in Chapter 7.
Coenzyme Q
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Coenzyme Q
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functions in mitochondrial electron transfer and therefore is fundamental to energy
metabolism in all cells. There is interest in the potential role of coenzyme Q
10
supplementation in the
enhancement of athletic performance. Although the evidence is relatively strong for a therapeutic
role of coenzyme Q
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in certain pathologic states (see Chapter 7 and Section VIE), evidence at
present is lacking for an ergogenic effect (68).

Clinical Highlights
Although interest in the potential for dietary manipulations to enhance athletic performance is
widespread and long-standing, evidence of such effects is relatively sparse. A dietary pattern
associated with health promotion (see Chapter 45) is, for the most part, associated with optimal
functional status as well.
Small deviations from a health-promoting diet, however, may be conducive to enhancements in
strength or endurance. Although the recommended protein intake for healthy adults is
approximately 0.8 g/kg/day, a level twice that much may support muscle development with
resistance training and clearly is safe over the short term. A protein intake above 2 g/kg/day may
support strength as opposed to endurance training, and there is limited evidence that an intake as
high as 2.5 g/kg/day may facilitate bodybuilding. The long-term health effects of protein intake at
this level are uncertain; a return to more moderate intake once the period of intense training is over
is indicated.
Although the protein consumed should be of high biologic value (see Chapter 3), there is no
evidence to support the use of protein formulas or modified commercial protein products. Studies of
putatively ergogenic nutrients have largely been negative, although there is some evidence of
improved endurance with creatine supplementation. The evidence that bicarbonate loading
enhances tolerance of short bouts of high-intensity exercise is fairly convincing. Caffeine enhances
endurance; of note, the International Olympic Committee considers it a drug rather than a nutrient.
High carbohydrate ingestion for several days before an endurance event seems likely to delay
fatigue by sustaining muscle glycogen stores, with the evidence of benefit more convincing in men
than in women. Fluid replenishment with isotonic fluids is recommended, particularly during high-
intensity endurance exercise. Patients engaged in only modest physical activity should generally be
dissuaded from use of sports drinks and energy bars, which can readily contribute more calories to
the diet than are being utilized in such exertions; the scientific support for such products pertains to
the serious athlete.