158 | The Nutrition Mistake Every Injured Athlete Makes

You're no longer fueling for your high-intensity sport. You're now fueling for recovery. But the key word is still fueling. Welcome back to the Exam Room Nutrition Podcast. I'm your host, Colleen Sloan. I'm a PA and dietitian, and today we're talking about something that I think gets missed all the time. How to adjust our nutrition advice when an athlete is recovering from an injury. Because when an athlete goes from training every day to suddenly sitting on the couch with an ACL tear, crutches, a brace, or post-op nausea, the instinct is often, well, I'm not moving, so I probably need to eat less. But my guest today is going to explain why that's usually not the case. Emily Barnhart is a sports dietitian who helps injured athletes tackle both the logistical and mental side of nutrition during recovery through her program Feed the Quad. She's worked with the Texas Rangers, USA Volleyball, and she's currently with Memorial Herman Sports Medicine in Houston. So in this episode, we talk about what to prioritize during injury rehab, why athletes need to think about protein timing, not just total grams per day, and what clinicians should ask instead of, so how's your nutrition going? Emily also gives advice on what supplements might be helpful and which ones to stay away from. So even if you're not a sports dietitian, these patients may still be showing up in your office for a sore throat, a checkup, a pre-op visit, or a simple referral. And that might be the perfect opportunity to help them fuel their recovery and get them back in the game. So get comfy or drive safe and enjoy my conversation with Emily. Emily, I'm really excited to unpack this topic with you. Thank you so much for the gift of your time. Welcome to the podcast. Yeah, thanks for having me, Colleen. So I've talked about sports nutrition kind of a lot on my podcast. And so let's start kind of broad. Help me and my listeners understand what exactly exactly is changing nutritionally when an athlete goes from training daily to suddenly being injured. Yeah, I think not as much changes nutritionally as you would expect. I mean, a way I like to phrase it sometimes is you're no longer fueling for your high-intensity sport, you're now fueling for recovery. But the key word is still fueling. Now, I'm curious if a lot of patients worry about weight gain during injury, right? They go from training hours each day to maybe none at all for weeks, sometimes months. So that might be a worry. And how would you help them kind of reframe that concern without totally dismissing that? Yeah, and I see, I mean, this is why I have a business. This is why everyone wants to talk, because everybody is worried about the unknown. They're worried about how their body is going to change. And I see it on both ends. I see athletes really scared of gaining weight in the way that you're talking about. But I also see athletes that have worked really hard to build a bunch of muscle and to maintain their weight or even gain weight. And they're really nervous about losing all of their weight and all of that hard work that they've put in. So it really goes both ways, but a helpful kind of tool to understand here is your body needs calories and needs food just to exist, right? When I'm working with anybody and I'm calculating how much energy or how many calories they need, I'm always doing a couple different pieces of that calculation. The first one's called your resting metabolic rate. And that is the energy it takes your body to function. That is obviously your brain uses quite a bit of energy all day long, your heart, your immune system, your digestive system, um, your hormones, all of that stuff. And I think people forget that that is a really big piece of the puzzle. That's like 50 to 70% of the calories that you need in a day. So there's a really big piece of the puzzle there called your RMR. And then on top of that, we calculate activity and those two things together is how much energy you need. Well, especially after a surgery, but anytime after an injury, that RMR factor increases. So the amount of calories your body needs at rest increases after you're hurt. Sometimes up to 20%. There's even some theories out there up to like 50% for a major surgery. That feels a bit extreme to me. I kind of lean more in that 20% category. So even though it feels like you're hanging out watching TV all day long, your body has an extra factor that it's trying to fuel and it's working really hard to heal. And then everybody thinks that the activity piece completely goes away, but it doesn't. You still might be kind of fidgeting around, you're still hobbling around. Walking on crutches uses three times more energy than just regular walking because you're like a little baby giraffe trying to figure things out, right? So your body uses quite a bit of energy, even if you feel like you're laying around doing nothing. And what I see time and time again is the amount of calories people need before injury and after injury is actually almost the same. Wow, that's really a very helpful explanation. As you're talking, I'm thinking, do you explain this and walk patients through this energy needs? Because I feel like it's very eye-opening. Does it help them when you kind of talk through it? Yeah, I'll literally draw out a picture of, you know, the two columns of RMR and activity stacked on top of each other and say, this is how I calculate pre. And then I'll show that RMR column increasing and that activity decreasing, but they're still the same height, and this is what we're doing post. And I think that visual really helps a lot of. Yeah. And I'm I'm glad that you mentioned to my previous question that patients aren't just worried about like gaining weight, but they're worried about losing muscle that they have put on. Can you explain what is happening with like muscle loss during those periods of immobilization or maybe just reduced activity? And then do we have to worry about that? And is it preventable with nutrition? I think there's two different ways we can look at the literature when we ask does nutrition make an impact during immobilization to help kind of try our best to prevent that muscle atrophy or losing all that muscle? And uh the difference, the big difference, is whether someone got surgery or not. So there are studies where we take healthy individuals and we put them in a cast or we kind of keep them in a bed for I've seen up to like six weeks, um, and take a look at can specific nutrition goals impact the amount of muscle loss. And yes, 100%. If we are getting adequate calories, if we're getting adequate protein, there's some great studies around omega-3s helping prevent muscle atrophy and um creatine. When surgery is not involved, they work really well. When surgery is involved, we basically lose the connection of your brain talking to your muscle. And all of those strategies don't work as well. I have a theory, the study that I would love to see is through physical therapy practices to help kind of get muscles back on board after surgery. If we can get those faster and get those back on board quicker, do our nutrition kind of interventions work better post op, but that study doesn't exist yet. Um, so I can't say for certain. But I, you know, obviously the sooner you can get into physical therapy after surgery, the better. So I would love to hear what are like your top, I don't know, I'm sure there's a lot, but make give us two to three things that you focus on for your nutrition priorities during injury rehab. Yeah. Step number one, you guys probably can already guess it right now. Step number one is eating enough. And that's a lot harder than you would think. Again, especially when a surgery is involved, maybe we're dealing with some nausea, we're dealing with some constipation, we're dealing with the societal pressure of like, I don't want to gain weight, or I feel like I'm not earning my food right now. I have been seeing athletes after injury for over four years now, and I've never had to tell a single one that they're eating too much. But I've had to tell a lot that they need to eat more. And then the other big thing is gonna be your protein timing and source. So all of us are probably very well aware that protein is gonna be a priority during this stage. And yes, the amount of protein is important, but I think sometimes we're starting to maybe over-emphasize it a little bit. And I'm more worried about spreading that protein evenly throughout the day because at the end of the day, we want to stimulate muscle protein synthesis. And if I'm eating, let's go with a crazy number, if I'm eating 200 grams of protein in one meal and getting that all my protein goal throughout the day, but only one time, I'm still only stimulating muscle protein synthesis one time. And I'm not stimulating it longer or any bigger. Versus if I spread that 200 grams out over five times throughout the day, then I get five, five hits of protein um stimulus. So research tells us that if we can get at least 20 grams of protein every like four hours, that's what's gonna be best at stimulating muscle protein synthesis. And then specifically, we want to look for protein sources that have a high leucine content. That's the amino acid that actually turns on that signal. So that's gonna come from something like a whey protein, any animal or dairy is gonna be high in leucine. And then for our vegans out there, tofu is a really great option for you. Or if you do want to go with more plant-based sources, like, you know, nuts and beans and things like that, those are wonderful. Maybe we want to add a BCAA supplement sometimes to make sure we're hitting that leucine goal. The other one that I think has some research behind it can potentially help us limit muscle atrophy, even potentially when surgery is involved, is an omega-3 supplement. And this is something that I feel so comfortable recommending to everyone because omega-3s are so beneficial in so many ways, and so many of us are not getting enough through food. I want to talk about protein, but like you said, as a society, there's like an over-proteinification of everything right now, thanks to the weight loss movement. So most people are comfortable with recommending protein, but I'm just curious on numbers. I've got a smart audience. What is your target um goals, grams per kilogram for an athlete in recovery? Yeah, I think in a perfect world, we're looking for body weight and protein. That um one gram per pound or 2.2 grams per kilo. Thing to remember with that is that's a very intimidating, intimidating number for a lot of people. And if they hear that and then they kind of try to figure out the math on their own, they're like 170, 200 grams, whatever that number is for them, they're gonna be like, whatever, I'm not even gonna try. And it feels defeating from the get. If I can get someone to at least um a strength building range, so at least like a 1.3 grams per kilo, I feel pretty good about that. 1.8 would be even better. That's the high end of that range. Um, so if we're within there, I feel I feel good. It doesn't always have to be body weight. And then the other thing to remember with um protein recommendations going too high, if we're getting to a point, you know, especially again, talking about diet culture or talking about people's um desire to restrict calories at this time. If our protein is getting to 40-ish or higher percent of total calories, uh your athletes or your patients, they're they're gonna smell bad and they're gonna be constipated. That's probably the easiest way to put it, right? We start to run into other problems. Um, and we're potentially missing out on some other nutrients that they really need. So, yes, protein is important, but you're spot on. We are sometimes overemphasizing it. Yeah. Well, when you said one gram per pound, right? I bet I know I my audience is probably like, oh, that's so much, because a lot of us are not in the injury rehab world. So I want to make sure it's clear that you work with athletes and so their calories are also extremely high. So this isn't, you know, for someone who is just starting their weight loss journey and wanting to put on a little bit of extra muscle, right? So that's this is for someone who is in injury rehab who really needs these nutrients to heal. Now, I'm curious if that number changes depending on if their recovery is just rest or if they did have surgery. Does that number change of protein needs? Not really. No, I think typically I look at recovery as like an immobilization phase, kind of that rebuild phase where they're in the peak of physical therapy working on tissue strength, and then a return to play phase. Um, and whether there's surgery or not, that immobilization phase goal is always gonna be kind of 1.8 to 2.2 grams per kilo, or that gram per pound, like you're referencing. Uh, you also had mentioned supplements, so I want to go there. I love that you talked about omega-3s, fantastic. BCAA, so branch chain amino acids is like a case-by-case, or is that something you routinely recommend? Yeah, I think it's a tool in our toolbox for meals that aren't going to have enough leucine. So really I'm looking for like vegetarians and vegans that might not be getting that animal-based protein source at a meal because at the end of the day, yes, we need the leucine, but we need all of our amino acids. So if you're looking to just take a protein supplement to help kind of supplement your intake and reach your goal, I'm always going to recommend a whey protein powder because we want the extra amino acids in addition to the branch chains. Okay. And I love that you talked about creatine. I did a fantastic creatine episode with one of the leading researchers on creatine. So you guys can go check out that episode too if you're interested in that. We won't spend too much time on it. But I'm curious if there are any supplements that a patient should avoid. And if so, why? You know, you so you sent this question to me before, right? And I probably spent 20 minutes looking at it, thinking, what direction do I want to take this? Because there are 10 different routes we can go. I think the biggest overarching is we want it to be evidence-based and we want it to be third-party tested. So third-party tested, we talk about in the sports world all the time because it has to do with anti-doping. Um, but if you're not familiar, the supplement industry is the wild, wild west. And uh it's very, very common for what is in the supplement to not correctly relate to what's on the label. So in the US, the last time this was checked, which I believe was 2019, about 20% of ergogenic supplements. So think of like your whey protein powders, your creatine, things like that, about 20% had additional steroids or anabolic um steroids in them that were not listed on the label. And then on the other hand, especially a lot of times with herbal supplements, they are listed on the label, but they're not actually in the supplement itself. Um, so my favorite example of this one is there was a pretty popular turmeric supplement that when they went into third-party test it, there was zero turmeric in there. It was just 100% garlic powder. And this had been on the shelves for for years. So we want to look for third-party testing resources like um NSF or sport or informed choice are kind of our baseline things that we're looking for. I also want it to be evidence-based. And right now in the sport and rehab world, peptides are all the rage. Um, and I'm almost scared to bring it up because people feel very strongly about them. But when I say I want something evidence-based, I need to see not just one, but multiple human trials that are randomized and controlled that show it's effective. And right now, when we're talking about some of these peptides like BPC157 and things that are getting more and more popular in the rehab world, there are no human trials. So I have zero evidence that taking something like this is safe or that it's working more effectively than just really great rehab. So I want it to be evidence-based, I want it to be third-party tested. That's my soapbox for this. If we want to go specific supplements that I don't recommend, collagen gummies are a never. The dose is not there. Collagen, maybe we can debate that, but collagen gummies are not doing anything for you. I'm so sorry. Um, and then um there is such a thing as too much of a good thing. So too much zinc is not what we're looking for. I usually don't recommend a zinc supplement. And too much magnesium, specifically magnesium citrate, um, leads to diarrhea for a lot of people. So there is such a thing as too much of a good thing, and we don't want to just take something for the sake of taking it. Well, I love that answer. That was extremely helpful. And I'm actually really glad you went to the peptide route because it is so popular right now in honestly, in every space. I mean, they are marketing it to anyone and everyone, and it is like the miracle that's going to solve all problems and heal everything and make you stronger and make you thinner. And I agree with you. We don't have any human studies right now, and I'm not sure if people know that. And that's yeah, what we need in order for something to be evidence-based. So I actually agree with you in that, Camp, that I don't recommend them either yet. You know, who knows down the line. Yeah, I mean, I hope they are a miracle. I hope that this makes, you know, ACL rehab or or anything going on easier and better and safer. Uh I hope that, but I can't recommend them now because I don't know that yet. Yeah. And that's like the blessing and the curse of being an evidence-based clinician. Most dietitians are, most PAs, we do follow the science. I would love to be an influencer and make thousands of dollars off selling a peptide if I'm being honest, but I can't consciously do that. Yeah. Ethically, if I was okay with fear-mongering, I would make so much money, but I'm not into scaring you. Yeah. Yeah. Yep. All right. I would love to hear some realistic tips. So let's talk about maybe a high school athlete, a college athlete who tears their ACL. They did go through surgical repair and they're not training now. So, what would a realistic day of eating look like? Maybe give us early rehab and later rehab. What are some things that this person would be eating? So, early rehab, again, especially talking surgical, the food is not the number one priority. It's usually a pain in the butt. So, early eating, a lot of times I'm like, can we get a smoothie, a protein shake, maybe some like protein waffles and berries, or a bar? I mean, can we get anything easy in? A lot of times people want to do things like soup, and maybe we're just adding some extra shredded chicken to the soup to help them hit their protein goals. And then realistically, as kind of the stomach gets back on board and life starts to look normal again. A lot of dietitians follow something called performance plates. So anytime I'm I'm working with someone, granted, I'm gonna meet them where they're at, and you know, this is all individualized. But in general, we're looking for at least three meals a day that have these three categories. We want a protein on there, we want a carbohydrate, and we want a color. And color to me is a fruit or a vegetable. So I know that there's carbohydrates in color, but that's okay. There's other great things in there too. And by using that system, we can get the athletes everything that they need from a nutrition standpoint, but they also get to include all their favorite foods. And if we can get our athletes or anybody to do that, they're doing better than 90% of the rest of the world. Yeah, I agree. And I love the add-in approach. That's the best way to help patients. Yeah, and also think of like the psychosocial piece going on. If I have someone who is injured, they're away from their team or they're away from their normal like gym schedule or whatever that social component is, and they want to go get ice cream. I want to support that. Or if I have someone going through an injury and like life kind of sucks. Life, life kind of sucks after an injury. It's it's completely turned upside down. I'm not gonna shame them or take away their favorite food. We're gonna keep that in there as a comfort component and have that as a tool in our toolbox. Yeah, thank you for bringing that up because I think that's a piece that when you're a clinician, maybe in clinic or wherever you are, we forget that life exists outside of the thing we're helping them fix right now, right? They still have social life and they may be and likely are, like you said, struggling with some anxiety, depression, loneliness, because their whole world just got rocked. So I love that we can keep that comfort piece in there. And that's what I think a lot of social media advice and you know, influencers and honestly, like politicians right now who are trying to jump on the nutrition bandwagon, forget, right? They forget the humanness, the connection, and the comfort that food provides. And I really love that dietitians do a great job of that. All right, let's talk red flags because I I'm sure you see this all the time. You had said you never really need to tell someone to eat less. You need to tell them to eat more. And so, what are some things that you're looking for of a red flag that maybe that athlete is underfueling your during rehab? Yeah. Well, and again, especially in the beginning stages, this can be quite confusing because all the signs we look for for underfueling are already going to be happening. We typically look for um trouble sleeping. Well, when my leg is locked in a brace, I'm not going to be sleeping well. Um, we typically look for low energy, obviously, that's already happening. Sometimes there's GI disturbances or bloating or constipation, things like that. That's already going to be happening post-op, anyways. Um, and a big red flag is a missing menstrual cycle. But it's very, very common for people to lose their cycle for a few months after surgery. And again, another study I'd love to see is is that surgery related or is that underfueling related? Um so in the immediate post-op phase, it's tough. I think probably the biggest red flag would be if we're fighting little illnesses all the time or kind of those sutures aren't healing in the timeline that we'd expect. That's that's a big red flag that we're underfueling. As their recovery goes on, we can look for the things like poor sleep, low energy, low focus, uh, maybe some GI struggles. Um, but also we're gonna look at their recovery timeline. I think one that I see all the time is a stress, a stress fracture and that bone, bone healing timeline. We're looking to see improvement around six weeks. And then someone comes to me and they're three months out, and their physical therapist is like, I don't know what's going on there, this fracture won't heal. And I'm like, oh, it's probably bad nutrition all along. And then as soon as we can get some of those habits on board, the the healing process gets back on. Yeah. So if you're a clinician, you might not, you know, work in a sports injury, rehab, you might not work side by side with PT, but you're seeing these patients in clinic for checkups, for sore throats. You might be the one making the referral to ortho or to PT. So ask those questions about nutrition, ask about fueling, how they're doing. So, Emily, I would love to hear what are some questions that you think would be fantastic for a clinician. It could be a PA or maybe another dietitian that might be working with the family for another reason. What can they ask to really unpack if that person is underfueling? Yeah. So I think a big mistake that a lot of clinicians make is they just ask a very straightforward direct question of like, how's nutrition going? And people either are really poor at self-assessing or they don't want to have that conversation. So they're just gonna hit you with like, it's great, right? And then maybe you'll follow up and say, Are you eating or are you getting your protein in or are you whatever? And they're gonna say, Yep, no problem. And a lot of people fall through the cracks. So if we can try to suss out some feelings without being so direct about it, that can be really helpful. This is very indirect, but sometimes I'll use um like would you rather or just like question of the day, type random questions. Now, granted, clinicians might not have enough time to do this, but I often will be like, you know, question of the day, what's your favorite Gatorade flavor? And I'll have like a poll on a whiteboard and people will mark it down. And I will get at least a handful of patients who say, Gatorade, there's way too much sugar in that. Right. So that automatically tells me that they have a belief, um, without them like realizing that they just kind of showed their cards. Obviously, if you don't have enough time for that, ask a little bit more indirectly of like, what are some things that you're trying to help heal? Right. So they might tell you supplements that they're taking, or they might tell you medications that they're taking or what they're doing in physical therapy. And then you can follow up with, have you thought about making sure you are including fruits and veg or including protein at every meal? Or, you know, make sure you're getting enough calories for this healing process. Um, and sometimes with a question like, what are you doing to make sure you heal? And this goes how you want, they'll say, like, oh, I'm I'm cutting out carbs or I'm cutting out blah, blah, blah. And then you can directly talk to them about why that's not what we want them to do. Um, so yeah, it's it's so easy to be direct and just say, How's your nutrition? and check that box. But usually that's not gonna give us the answer that we want. No, so true. But you feel so good. You're like, well, I talked about nutrition. It's like, yeah. Um, not really. You didn't at all. And it's very true, especially like with teens, young adults, they're just gonna yes you, you know, like, are you eating okay? Yep. And like they're absolutely not. So I love asking, you know, open-ended questions. Let the patient give you some feedback, some answer, because that will help you direct kind of the next question to know where to take the conversation. So that was really helpful. Yeah. Listen to the self-judgment as well. Anytime food comes up, or even sometimes, even if I like if I'm rounding with some of our physicians here and I just step into the room and they're and I'm introduced as the dietitian, they're like, oh, all I eat is junk, or I eat like crap, I know, blah, blah, blah, blah, blah. And they'll just like self-identify as a terrible eater. And that doesn't necessarily mean we need to give them a lecture about what they need. That might open up the door for a conversation of like a lot of people feel a lot of pressure to eat a certain way during this time and can be really hard on themselves during this. Or a lot of people start to feel really uncomfortable with their food choices or uncomfortable in their bodies. And to me, for my business and why I love working with injured athletes so much is yeah, the food is one piece, but I think it's a great time to have conversations about relationship with food and relationship with body. Um, because it really shines a spotlight on people's kind of negative self-talk. And food can be a big piece of that. Yeah, I want to close with that. When you do hear someone, you know, judge themselves in a negative way, which uh we all hear. And if you're a dietitian, you're always labeled the food police or oh, don't look at what I'm eating because it's bad, right? It's so far from the truth. We actually are not doing that at all. But Emily, if we hear that, how would you how would you respond to someone? Like, what's the next step of the education or the conversation that you have with someone who says that? Yeah. Oh, I love this question. So there's actually, again, talking about making sure we're evidence-based, there's some research when people make self-deprecating comments like that, either about their body or about their food choices. There's research of what types of responses are helpful and what types are hurtful. So typically the ones that are hurtful, like let's use if someone was saying, like, oh gosh, my hips look so bad, or someone makes a comment about their body, right? What is typically unhelpful is immediately dismissing that with like, no, you look great. Right. Um, or kind of a lecture of how they can fix that problem, or or what you a suggestion is typically not helpful. What is helpful is um kind of sitting in the mud with them and saying, like, that must feel really frustrating to feel that way. I'm really sorry. Don't turn it on yourself and say I feel that way too, but saying, like, if it must feel that feel frustrating. Or if we can even on a bigger scale make it societal of like, isn't it so frustrating that there's so much pressure on women to look a certain way? I'm sorry. Right? That can be really helpful. And then the next step to like sitting in the mud with them is letting them opt in to a suggestion. So instead of again, just lecturing them or referring them to a dietitian, say, is that something you want to talk about today? And if they say no, you have to respect that and not talk about it. Um, or hey, I know a really great dietitian, can I refer you to her? She talks with people about these feelings all the time. Are you okay if I share his or her information? And letting them say yes gives them agency again, instead of just feeling like you are judging them. I think with those conversations comes a lot of shame and self-judgment. So giving some collaboration and agency to your patients is really helpful. Oh my gosh, I am so passionate about this topic. And I think it's such a beautiful way to make your patient feel seen and heard because we are all just dismissed all the time. You know, and sometimes we don't even realize that we're our feelings are dismissed. We can dismiss it or invalidate it ourselves. So having someone with authority, right? A PA, a dietitian, we all have some form of authority. Come and just sit with you and sympathize with you and say, like, man, this stuff is hard, you know? Really just sympathize and see them. Man, that can be so impactful. Oh, Emily, this was such a really good conversation. I'm so glad I had you on the podcast. If people want to learn more about you or the work that you're doing, doing, where can they connect with you online? Yeah, so my website is injuryrd.com. I'm on Substack both for uh practitioners and for anyone going through injury. Or um, if you want to send your patients somewhere, I drop a free menu and kind of meal idea every Friday on Feed the Quad. Uh, I'm also on Instagram and all the other socials. That's awesome. What a great resource. I will link down to all of that down below so you can definitely get connected with Emily. But Emily, thank you so much for the gift of your time today. Thanks, Colleen. And thank you for carving out some time for nutrition today. I will see you next week.