Case Study Take-Away Messages

Included are points we feel are important for each case study. Some of your unique ideas and recommendations may be very appropriate as well!

Case Study #1: School Vending Machines

You are a Registered Dietitian hired by the public school board to make recommendations about types of beverages to be sold in vending machines in high schools. Types of beverages that have been available in vending machines in the past include caffeinated and non-caffeinated regular sodas, Gatorade sports drink, and Starbucks Frappucino.

The decision-making process has become somewhat difficult for the school board because the beverage companies have provided a significant amount of funding for the schools. In fact, last year, the companies donated football uniforms and equipment for every player at every high school in the district (70 players at $650 each at all 15 schools). They also donated computer equipment to the libraries of each school. Athletic directors, coaches, and some teachers are extremely concerned about losing this funding. Others feel that optimal nutrition and hydration should be the priority.

Each vending machine can hold 6 beverages. What beverages do you feel should be included for the high school students?

Water: most teenagers could improve hydration habits.
Milk: skim or 1% plain milk or even chocolate milk may be recommended. Research has shown that U.S. high school-aged students consume only about 40% of their calcium needs each day, which can result in poor bone health at a time when maximizing bone density is extremely important.
Sports Drinks: especially critical for student-athletes. Sports drinks hydrate better than plain water partially because they contain electrolytes. They can also help enhance athletic performance because they contain a small amount of carbohydrates. Sports drinks are also a better choice than regular soda for all students due to containing less calories and sugar than soda.
100% Fruit Juices: these may be an important source of Vitamin C and other micronutrients for students, especially those with diets low in fruits and veggies. Juices can serve as a good source of carbohydrates for student-athletes. Calcium-fortified juices may be an appropriate suggestion.
Diet, Caffeine-free sodas: some RD’s feel these are an appropriate option for high school students. They certainly are better in terms of calories than regular sodas and caffeinated sodas. The American Academy of Pediatrics recommends that students under 18 years of age avoid caffeine.
Fitness Waters: these may be a recommendation for students as a calorie-free alternative to water. The flavor of many of these drinks helps students who don’t favor the taste of plain water.

Would you put any restrictions on times or places in which drinks can be sold?

Some RD’s feel it’s best to allow vending machine sales just before and after school and during lunch.
Before school may be important for students who haven’t consumed any fluids or nutrients before coming to school.
After school may be important for all students who haven’t had any fluids during the afternoon (many schools don’t allow students to have water bottles in class).
Sales after school are especially important for student-athletes. Remember, participation in high school sports is high. The National Federation of State High School Associations reports that over 53% of high school students participate in athletics. Research has shown that up to 70% of high school athletes arrive for practice already dehydrated (Stover, E. Consistently high urine specific gravity in adolescent American football players and the impact of an acute drinking strategy. Int J Sports Med 2006; 27: 330-335).
Purchasing beverages from vending machines can help these student-athletes stay better hydrated.
It may be a good idea to put a vending machine containing water and sports drinks in the locker room area specifically for student-athletes.

Do you think your changes will result in decreased profit from vending machine sales?

Probably not. Research studies have shown that when healthier options are available, sales do not decrease. Sometimes they even increase.
Limiting the time frame for which vending machines are turned on may or may not decrease total sales.

What suggestions do you have regarding the potential loss of funding from the beverage companies?

Schools may be able to negotiate with beverage companies to appease both “sides”. Sometimes, it’s just a matter of changing the beverages offered. In other words, trading out regular sodas for diet/caffeine-free sodas, sports drinks, 100% juices, and bottled water from the same company may be an effective strategy.

Case Study #2: “Bulking Up”

You are consulting with a 15 year-old sophomore high school football player named Kyle who is 6’3” and weighs 211 pounds. Kyle’s father brought him to see you because Kyle had not been gaining weight at the rate they expected despite starting a rigorous weight training program and following a nutrition regimen recommended by their neighbor who is a former NFL player. Kyle’s father explains that in order to be considered for a college scholarship, he feels his son needs to weigh at least 275 pounds by his senior year.

Currently, Kyle’s daily diet includes 6 eggs and a protein shake for breakfast, two protein bars throughout the day (he misses his lunch period due to extra weight lifting), 16 ounces of meat at dinner, and then a fast food value meal (usually Big Mac, Fries, Orange Soda) at 11pm since eating a lot right before bed is supposed to help with weight gain. Additionally, Kyle is taking creatine at a level of 25 grams/day to help “put on the weight as fast as possible”.

Regarding workouts, Kyle states that he feels “sore all the time”. His strength has not decreased during the last 2 months despite training in the weight room 5-6 sessions/week. Kyle drinks 2-3 Rock Star energy drinks before conditioning; without these he says he doesn’t have nearly enough energy to make it through the whole session.

Kyle and his dad express confusion that despite following the high protein diet and working hard in the weight room, Kyle isn’t gaining weight (in fact, last week he lost 2 pounds). He is cramping up more than usually during conditioning runs. They hope that you can make further diet recommendations and also suggest a different or better brand of creatine and any additional supplements necessary for Kyle to reach his goals.

What is your assessment of Kyle’s current nutrition and training regimen?

Kyle’s diet is low in calories (about 2800 now; over 4000 could be recommended for Kyle), especially low in carbohydrates, fiber, and vitamins and minerals (no fruits and vegetables!). Kyle’s diet is high in protein. If we recommend that Kyle consume 1.7g/kg of protein/day, that would be about 160 grams. His current intake is about 250 grams.
It’s difficult to determine if Kyle’s training is excessive because by consuming a diet so low in carbohydrates, there’s little chance he’d have adequate glycogen stores to support his training. Some exercise physiology experts suggest that weight training sessions be limited to 4 times per week for teenage athletes. It’s clear that missing lunch for workouts is a problem in terms of achieving calorie goals.
It’s unfortunate that Kyle has been relying on caffeinated energy drinks before workouts. Two Rock Star energy sodas contain about 300 mg of caffeine. This is the maximum recommended amount per day for most people. Increasing carbohydrates should dramatically improve energy levels.

Do you feel his weight gain goal is reasonable?

Kyle’s goal is to gain 60+ pounds in two years. Depending on Kyle’s frame size, growth rate, and genetic potential, this may or may not be realistic. Being in a consistent positive energy balance (by consuming at least 4000-4500 calories/day) and continuing to strength train should help Kyle gain weight at an appropriate rate (which would be no more than 2 pounds/week).
Kyle’s father seems very involved in his son’s nutrition and training plans. He is the one who told you about the 275-pound body weight goal and plans for a college scholarship. It may be important to assess whether Kyle himself truly has these goals or if he feels “pushed” by his father. With teenage clients, it’s often appropriate and extremely helpful to have some counseling time without parents being present.

What specific nutritional strategies and modifications would you recommend?

4500 calories, 675 grams carbs, 160 grams protein
Currently eating 5 times/day. Increase to 6 times/day by having a snack immediately after weight lifting at lunch. This snack should be at least 500 calories and contain both protein and carbohydrates. Since he will likely have limited time, easy-to-eat foods/drinks should be recommended. Suggestions could include: the protein bar he already eats plus fig newtons and a 32-ounce bottle of Gatorade; 2 PBJ sandwiches plus fruit juice and water; trail mix (nuts, dried fruit, etc) plus a cereal bar and thermos of chocolate milk. It would be ideal to lift weights at a time other than lunch.
Change the second protein bar to either a mixed carbohydrate-protein bar or actual food (yogurt/cereal or cheese & crackers or bagel with peanut butter & honey). Also increase calories in that snack by having caloric beverage such as fruit juice, or meal replacement shake (ex: Carnation Instant Breakfast, Boost, Gatorade Nutrition Shake, etc).
Change breakfast to include more carbohydrates and less protein. Replace the protein shake with a fruit/yogurt smoothie or milkshake. Have cereal, pancakes, French toast, waffles, bagels, etc. If Kyle wishes to keep eggs as his breakfast protein source, recommend using some whole eggs and some egg whites to limit saturated fat and cholesterol. Suggest adding chopped veggies to scrambled eggs. Add 100% fruit juice for calories, carbohydrates, and Vitamin C.
Reduce meat portion at dinner to 6 to 8 ounces so he has “room” for carbohydrates. In addition to some type of starch (potatoes, rice, noodles), eat some veggies! Work with Kyle to see which he likes and will actually eat.
Having a snack late in the evening is appropriate, but it should be lower in fat than the current fast food meal. Provide recommendations for a night-time small meal from home (ex: bean burritos and fruit juice, cheese pizza and milk, large sub and sports drink) or lower fat fast food options.
The muscle cramping that Kyle is experiencing is probably due to inadequate fluids consumed throughout the day. The problem is likely compounded by the high protein/low carbohydrate diet. Many of your other recommendations include increasing fluids. Specifically suggest that Kyle consume Gatorade before/during/after weights and conditioning in addition to drinking plenty of water and sports drink during class. He can monitor his hydration status by checking his urine color throughout the day. Suggest weighing himself before and after workouts to be sure he is drinking enough during workouts. He should lose less than 2 pounds during each workout session. Replace fluids lost in workouts by drinking 3 cups of fluids for every pound lost.

What supplements would you recommend to Kyle?

Suggest discontinuing creatine supplement for two reasons: muscle cramping and the fact that dietary changes may have a tremendous effect. Educate about the inherent risk involved with taking all supplements in the U.S. If Kyle does insist on taking creatine, educate that 25 grams/day is much too high; many research studies have shown that the “loading phase” is not necessary. He should take 3 grams/day. Help him understand that meat contains creatine, so he is already getting some creatine through his diet.
Other useful supplements for Kyle may be: a general multivitamin, sports bars (look for mixed carbohydrate-protein bars and not just high protein bars), sports drinks, recovery drinks, or meal replacement shakes.

Case Study #3: Weight Gained During Injury

Allie is an All-American female collegiate gymnast is returning from ACL (knee) surgery that occurred 6 months ago. She has been medically cleared to do basic gymnastics skills and cardiovascular work in the pool and on the stationary bike. Allie is 5’2” and has always competed at 112 pounds. She has never had to “try” very hard to maintain this weight. Currently Allie weighs 131 pounds. She does not feel comfortable at this weight and she and her coach agree that she needs to lose 15 pounds by the start of the season, which is 6 weeks away.

Allie’s coach prescribes a diet that limits carbs to 50grams/day. She is instructed to eat “absolutely no sugar”. He also requires her to do 60 minutes of extra cardio work each morning. He will not allow Allie to try any of her gymnastics skills until she has lost 5 pounds. He said that is a way to “reward and motivate her”. The gymnast adheres to the diet during the day, eating primarily chicken breast, salad, and diet soda, but feels lethargic and very hungry. She stopped eating apples and berries (her favorite foods) since they are “so high in sugar”. She craves sweet foods all the time, so she eats lots of sugar-free candy. Late at night she wakes up “starving” and says she “stuffs myself with ice cream, cereal, and everything else in sight”. Allie wants this to remain a secret from her coach who doesn’t understand why she hasn’t lost any weight yet.

What nutritional recommendations would you provide for this athlete?
First reassure Allie that the reason she is hungry, lethargic, and overeating/binging in the evenings is that the carbohydrate recommendation she was trying to follow during the day is completely inappropriate. The easiest way to create an atmosphere for binging, especially on sweet foods, is to dramatically restrict carbohydrates. She may need a lot of reassurance that the evening behaviors are not her “fault”. Many athletes feel a sense of shame for overeating and not being able to follow diets prescribed by coaches. Commend Allie for being honest and up front with you and help build her confidence in your recommendations and her ability to achieve her weight, healing, and gymnastics goals.
An athlete participating in the amount of exercise that Allie is requires at least 150 grams of carbohydrates. This is based on the recommendations for a 1200 calorie diet (often the absolute lowest that female anaerobic athletes can consume without severely compromising energy level). At 1200 calories, 50% carbohydrates would be 150 grams, three times what was prescribed by the coach. Recommend that Allie reintroduce fruits, veggies, and at least a serving or two of whole grains. She certainly should not have to restrict her favorite fruits! Ideally these carbohydrates would be spread throughout the day, with some before training and some in the evening. About 50 grams immediately after the cardiovascular workouts would be ideal to support glycogen restoration.
Designing a couple of sample meal plans that include the 1200 calories, 150 grams of carbohydrates, along with 100 grams of protein (1.7 g/kg body weight) and high fiber foods (to promote fullness) and important healing vitamins and minerals (ex: Vitamin C, zinc, etc.) may be very helpful for Allie. Eating three small meals a day with one snack (after workout if no meal is scheduled right after workouts) may be a good place to start.
The increased level of carbohydrates throughout the day may dramatically reduce the temptation to overeat in the evening. However, work on hunger/satiety and alternative methods for handling emotions and stress could be appropriate.
Also, the goal of a 15-pound weight loss in 6 weeks is unreasonable and inappropriate. One pound per week would be appropriate progress. Help Allie realize that she shouldn’t feel like she “failed” if she can’t lose weight at her original goal.

Do you feel that Allie’s current diet may be impairing her body’s ability to heal?

Certainly a diet so low in calories and protein in addition to inadequate in vitamins and minerals may slow down Allie’s healing.

What is the minimum level of carbohydrate you feel an athlete of this size, doing this type of workouts, needs?

See above.

How would you justify your changes to the coach?

Explain that you are on board with helping Allie ultimately achieve her weight loss, healing, and gymnastics performance goals. Describe your strategy and how science and top sports nutrition recommendations support your guidelines of increased carbohydrates. The calorie level that you have recommended is quite low, so Allie will definitely be expending more calories than she burns, promoting weight loss. Remind the coach that you don’t want to jeopardize Allie’s healing since she’s already missed so much training due to her injury and surgery rehab. Finally, you may want to state that in your previous experience, athletes cannot maintain extremely low carbohydrate diets and ultimately wind up very fatigued, tempted to binge, or re-gaining the weight they lose.

Would you keep Allie’s information confidential as she requested?

Absolutely. Confidentiality is critical in creating confidence and rapport with athletes. However, communication with the rest of the sports medicine team and coaching staff can be an effective way to make everyone feel “on the same page” and collaborate effectively. Sometimes athletes may want you to communicate some, but not all, information with their coach.

Case Study #4: Master’s Marathoner who is Tired and Cramping

Ed is a 52 year-old man training for his 15th marathon. His general health is excellent and his goal is to run 2 marathons every year until he is 60. He runs 6 days/week with a group of friends and has successfully improved his running time each year. Lately, however, Ed has been experiencing two problems, which is why he seeks the advice of a Registered Dietitian (you). First, he has not been able to complete his long training runs due to just being more worn out than normal. At his recent medical check-up, Ed’s doctor determined that he had slightly reduced hemolglobin and a ferritin of 18ng/mL. The doctor gave Ed an iron supplement which he took for a week but discontinued because it caused constipation.

Secondly, Ed has a history of developing muscle cramps (especially in his hamstrings and calves) on runs that last longer than 16 miles. Recently, his running partner even took him to the hospital where he was treated with IV fluids. Ed always runs with a camelback (water pouch that sits in a small backpack) filled with water. He drinks about 20 ounces of water per hour that he runs (more if it is extremely hot), so he feels there’s no way he could be dehydrated. He also started taking potassium supplements because he has heard they will prevent leg cramping.

Ed and his family emphasize healthy eating in their home. They are vegetarians (no meat or eggs but they do eat animal dairy products) and strictly avoid processed foods and adding sugar and salt to foods they make at home.

What recommendations would you make to Ed regarding his iron levels? What diet changes should he make? Should he try taking the iron supplement again?

Low ferritin and relative iron deficiency anemia are concerns for Ed considering his training level and goal of running another marathon. Many endurance athletes’ training capacity is impacted, sometimes significantly, by iron deficiency (even reduced ferritin without low hemoglobin my have negative performance consequences). Being a vegetarian makes it more difficult for Ed to meet his iron needs. Suggest some of the following dietary recommendations:

Increase nuts, dried fruits as snacks
Eat eggs regularly
Eat beans, bean/lentil soups, and vegetarian burgers in meals
Add iron-fortified cereals at breakfast and as a snack throughout the day
Consume a source of Vitamin C (citrus juice, berries, watermelon,
broccoli, spinach, etc) along with cereals and other plant sources of
iron to increase absorption

Iron supplements do cause constipation, nausea, and other gastrointestinal side effects in some people. Suggest that Ed ease into the supplement process by alternating days (take supplement one day, but not the next, and so on). He should also take the supplement with food (preferably high Vitamin C foods) right before bed. That way he may sleep through any undesirable side effects. If these changes are ineffective, suggest an alternate type of iron supplement – there are several designed to be easier on the GI tract. His physician may be able to provide some suggestions. It will be extremely difficult for Ed to increase his iron stores to the normal range without supplementation.

Are there any other nutritional factors you would assess considering that Ed is a vegetarian?

Assess protein, zinc, and Vitamin B-12 in Ed’s diet as well since they are likely low in a no-meat diet. With Ed’s serious focus on healthy eating, he may be undereating in terms of total calories as well.

What do you suspect is causing Ed’s muscle cramping? What changes would you recommend in Ed’s daily diet? How about in his fluid regimen during runs?

With the limited information that we have, it is most likely that Ed’s muscle cramping is related to inadequate sodium. Although his fluid intake could be greater (I may recommend increasing up to 30 ounces per hour), he is already off to a great start by using a camelback and drinking during runs. What is likely missing is salt to replace that lost through sweating. Use a sports drink instead of plain water in the camelback during runs. On hot days or extremely long runs, consider adding salt to the sports drink or using a specialized endurance formula. Also add salt to meals and increase intake of high sodium foods. In effort to eat as “healthy” as possible, many athletes neglect their sodium needs (since the general population is so often advised to limit this).

To be sure Ed’s fluid intake is appropriate, have him calculate his fluid loss. To do this, he should weigh himself before a run, closely monitor the volume of fluids he consumes, and then weigh himself after the run. Add the amount he drinks to the total fluid lost (with 1kg of weight = 1L of water). For example, if Ed loses 2 kg (4.4 pounds) and drinks 1 L of Gatorade during a 2 hour run, his total fluid loss is about 3 kg, or equal to about 3L of fluids. Helping him replace this amount as closely as possible during runs is advised. Weight loss should be limited to <1% of body weight which would be less than about 2 pounds or so. After runs, Ed should drink 24 ounces of fluids for any remaining weight lost to re-hydrate for upcoming training runs.

As long as potassium in the diet is adequate, potassium supplements are likely ineffective as a means of preventing muscle cramping. If Ed was prescribed the potassium supplement by a physician for a reason other than exercise-induced muscle cramping, he should speak to his physician before discontinuing.