MCHB 2006 Federal/State Partnership Meeting

Getting Adolescents Started in a Physical Activity and Nutrition Programs: New Roles for Public Health

October 15-18, 2006

JOSEPH CHORLEY: Instruction to the people who are teaching them to make sure we're doing them properly. And injure prevention and treatment are important for long-term participation in physical activity. So with that, I will turn the mike over to Bonnie.

BONNIE SPEARS: Thanks. And then thanks for setting me up with some questions. That was great. My job is to kind of go through and make the practical applications and what we, as people and state health agencies or health departments can do. Often we're not the frontline person to do. We refer those out.

But I want to do is now just get a little bit over more into the fluid and hydration. And as just said, you have to understand that heat illness or heat is the second leading cause of death in high school players' non-cardiac cause of deaths. And there's some question over where the cardiac is fitting in? Is it dehydration that's causing irregular heartbeats? He talked about the dry bulb effect. And

I come from Alabama, in case you didn't notice of my accent. And football is not a sport in Alabama. It's a religion. So what we look at and what we've try to do because we're had in Houston and in Birmingham, we've had over--six deaths in the last year of high school players from heat. So we are very cognizant of that but if you look at this. This is done by Fox and Matthews and you plot the humidity on the horizontal axis and the temperature on the vertical axis, And then you compare it where a safety exercise outside, a dangered exercise and a counsel.

In August in the south, we have 90-degree temperature with about 80 percent humidity, which puts in the counsel zone. Beyond counseling fall football, which is not going to happen. Is how do you come up with that?

Our health officer worked with the Athletic Association and what they did is they put mandatory water breaks in each quarter of a football game. And if there's a timeout called by one team with five minutes left to go in the quarter, they have to stop and have a water break. It's official timeout. So there's things that you can do on a state level to make it mandatory because coaches aren't going to stop. And we know that so we've got to come up with that type of thing. We also know that younger teens or at--they loaded the wrong program.

So I'm going to keep talking but I'm going to load another program. Yeah, but I have more pictures and more with that--let me.

JOSEPH CHORLEY: While she's doing that, I can talk to that female athlete overuse.

One of the things that we deal with when you talk about young female and adolescent athletes is that the female athlete triad, and the triad is that's a disorder meaning not necessarily an eating disorder but they're not getting into the calories for the demands of their sport.

Number two, they have algomenorrhea or amenorrhea, so they start having menstrual dysfunction. And then the third thing is bone-densed issues that either get osteopenic or osteoperodic. It is a lot more common in sports that or thought to be if you're thinner, you have an advantage such as running, swimming, those kind of things. It's also a lot more prevalent in activities that are scored, and physical appearance is thought to be in advance like gymnastics, diving, those kind of things.

And so those are kind of your high-risk sports. And part of the pre-season exam is talk to them. Number one, you pick up about menstrual function whether that they're all algomenorrheic, whether they still have regular periods and those kind of things. We also have a height and weight is one of those things that we look at their body mass index that gives us and then next is the suspicion.

And one of the questions in the recommendations on the pre-screening and exam is if you want to gain weight or lose weight. And if you have someone who is relatively underweight already and is trying to lose weight again, those are some of the Red Flags that kind of go on in my mind. And so those people don't need a physical activity program. They need Bonnie and an interdisciplinary approach to taking care of those problems because there are very deep-seated other issues that go along with that.

BONNIE SPEARS: I'm back. What we're talking about is younger children are at higher risk for the heat illness because they don't have this high sweating rate. They have a higher body surface area so they're ready at heat, heats their body up much quicker. And they also produce more heat with exercise. So these kids are a bit at higher risk.

And often, unfortunately, these are-I saw the kids that are in community programs, not in organized sports within the school system. At last check, only three states had any kind of formal training for volunteer coaches. And this is an area that--as a health prevention that we need to look at is training volunteer coaches as well.

And just as an example of the sweating rate, and this is sweating rate for grounds per meter squared. And you can see at puberty with the androgen and testosterones that the increase in sweating rate goes up significantly. And the kids are then able to dissipate heat better. With dehydration, even a one percent weight loss from fluids can increase the body temperature. As small as a three percent can impair performance and when you get to seven or 10 percent. And this is not unusual for big football players to lose this in one practice. It can cause hallucinations or circulatory collapse, and this if they're not being paid a close attention to.

What the physiological responses are, is that GI distress, nausea, vomiting, diarrhea, the heart rate increases significantly. And the temperature at which your body sweats begins to sweat increases. So usually, if you're able to sweat early on, this stops. People that are dehydrated become cold and clammy. And that is about a five percent dehydration if you're not sweating and you're cold and clammy. You have a decrease in plasma blood volume. You have a decrease in cardiac output. You're sweating rate goes down and your performance decreases significantly.

Just already talked about this but one other thing I wanted to put out there, the increase is fluid loss, and we'll talk about this a little bit later is caffeine ingestion, as well.

This is what appeared in our Birmingham news. This young man had a heat instance and this is the paper of him, "Star on the rise again as he begins his training to regain football." As you can see he's still walking with a cane, and this is seven months after his heat illness event. This is what was in the paper, "I felt tired the entire practice." One of his teammates had already passed out and been taken to the hospital. Although he did not feel well, he refused to quit the drill and that implies to great heat. On his last grip of sprints he fell down but quickly pulled himself up. A few steps later, he fell again but not wanting to appear weak, he did not stop and pulled himself up and began to run. That was the last thing he remembered for four weeks. He was hospitalized for eight weeks, in a wheelchair for another three months. Where was the coach? You've already sent one kid to the hospital while this practice still going on, while we're watching the other. And the rest of the story, it says that they were not allowed water breaks for--but every 45 minutes. So this is the things we're dealing with. So what are the dehydration guidelines? These are the recommendations from the American Sports and Medicine Institute is one to two hours before an event is 10 to 14 ounces and making sure the water is cooler than the ambient temperature. And this allows a hydration's test but also allows urination before an event. And in 10 to 15 minutes before the event, another 10 to 12 ounces of fluid is recommended. In this case you kind of pee, kind of tops it off ready for the event. During the exercises, 46 ounces of cool fluids every 15 or 20 minutes. This doesn't happen. Can you imagine me telling a football coach, "Okay, every 15 minutes during practice, you're going to stop and make everybody drink." That's not going to happen. So how do you do that? We have a very large soccer program, new soccer program and what we do is--the Steering Committee has decided to mandate a water mom or water dad and that it's their sole responsibility to make sure these kids drink. The coaches don't have to pay attention to it but they'll keep a clipboard and they have to turn these in of how much they--they're ensuring that every kid is drinking during the game.

So there's some things that we can do at the policy level that increases that. Then after exercise is that the recommendations are 16 to 24 ounces of cool fluids for every pound that lost. What we do recommend is that the players or athletes be weighed before and after a practice, especially in the two-days. With football is that if you don't recover from the first practice that you're such at high risk for the second practice. And you know, my high school is the one. If you've watched MTV recently, the two-days--yes, we are so proud of the coach.  But, we also know that research shows that kids drink more flavored fluids, which we're talking about sports drinks predominantly here than they do water. So that they really don't need the sports drinks under an hour of practice, but if they're going to drink more of it, then that's what needs to be offered.

So looking at the carbohydrates. Most people there are wanting to weigh, to lose weight or improve performance. Tend to not tend to avoid this. With the Atkins revolution, we've had--our carbohydrates have gotten a real bad rep. So let's look a little bit about what we're talking about--talk at diet for adolescents. As you can see, this goes with the new recommendations from the National Academy of Science. Carbohydrates are preferred choice for fuel for short duration, so anything that starts and stops very quickly. It's a very rapid breakdown of muscle glycogen so the more muscle glycogen you have, the better you're going to perform, and as more rapidly during the early stages of exercise. If you're a runner and you start off the first five or 10 minutes is you struggle a little bit, but then you hear runners say, "I get in my rhythm." What happens is you get into your fat burning stage. It takes fat burning a little bit longer to kick in and then so you have a higher ITP with that but you're burning more fat than carbohydrate. The beginning of running is usually (inaudible) carbohydrate.

So as Joe was talking about, things such as soccer, football, basketball, swimming, which are not long-term, which are usually short, especially the sprints and the down alignment for football, who have just have 10 to 68 seconds of activity. You start over on your carbohydrate gluzation at every time with that.

So what are we talking about carbohydrates and this is grams per--kilogram per day but only put it into kind of a perspective is the moderate or heavy training, which is what most athletes or--it's around, for males, about 300 to 350 grams of carbohydrate a day. That's difficult to eat if you're watching the calories with that. For the pre-event it's a little bit higher, and we'll talk about the post-event in just a minute.

Another newer component--this is the glycemic indexes been looked at in weight loss as well as in athletic performance. And a glycemic index of food is based on the blood sugar response to 50 grams of a product. So it shows how different foods raise your blood sugar at different levels and what they are showing is that athletes, that are especially distance athletes may want to eat a low to moderate glycemic index food because it tends to control the blood sugar a little bit more stable. But after exercise, a high index, glycemic index food would be beneficial because it replaces the muscle glycogen very rapidly. Now, I'm just giving you some examples of what are high, moderate and low. As you can see in the high are the sports drinks, potatoes, honey, carrots, chips. In the moderate are bagels, white and wheat bread, it doesn't seem to make a difference, potato chips, and in the low were all your fruits, your vegetables and nuts.

For the post-event and a lot of people don't realized especially high school athletes is the body--the muscles are very receptive for about two hours after extreme exercise to replace the carbohydrates and so you have a--just kind of a two-window--two-hour window of opportunity to just do that. And so it's really important that coaches or teams or players eat or drink carbohydrates immediately after an event. It's often much easier to drink than eat. I'm a heavy into no supplements in high school. This was one that one of the coaches gave me that they were trying to market and it's 55 grams of carbohydrates per serving. And if you look at the ingredients, it's granulated medium length complex carbohydrates extracted from grains. What does that sound like? Flour. And it tastes like flour mixed with water and it's 55 grams of carbs, it's two dollars--about approximately two dollars per serving. If you put it into bread, that's about two--three and a half slices of bread. And just briefly pre-exercising this--the steak and the protein pre-exercises is a no-no. High carbohydrate is low fat and lots and lots and lots and lots of fluids, is what's recommend for pre-exercise.

I've given you a little bit of an idea of what we're talking about and some examples of that, but even a heavy meal that's eaten before you get on the bus, they may and they have to travel a couple of several hours to an event that they may wanted a light snack when they get there just to keep the carbohydrate's level up and keep them from getting hungry. The whole purpose of a pre-game, pre-event meal is to prevent hunger during the event. And you're running, and you're exercising, and you're playing, and what you've eaten in the last two or three days.

Protein. I wish I could market it as a--because this is what all athletes think they have to have and actually, the intake, the recommendations are very low. Most U.S. teens consume almost twice the recommendations. Athletes do need a little bit more protein than what the recommend--RDA is just for building muscle, but you can see most adolescents get that anyway. So the danger comes with greater than two grams of protein per kilogram per day. And we have one coach that was mandating the players and take protein supplements in addition to what they were already eating and when the--several of the players were our primary care patients and they came to us and they had renal baleens really at the roof and when we approached the coach, he threatened to sue us. So it's just that he thinks he thought it was and he mandated and a lot of the parents were buying the products and just don't throw them away because you had to buy them from him. So that leads us into sports supplements and I think this is one of the biggest dangers in high school athletics. It's dangerous everywhere but the high school players don't have the knowledge or skills to do this and the coach is the all-powerful.

In 2003, Blue Cross and Blue Shield did a survey of over a million teenagers and what they found is that 76 percent of these students could not even identify side effects that may result from steroid use, the (inaudible) or other centimeter substances. Other students surveyed that knew someone taking that 38 percent were using Creatine and 34 percent were using steroids. Most of the teens took it to look better and which has a significant increase for 2001. Football players were taught to use it followed closely by baseball players. When Mark McGuire admitted to the interesting down effect of the increase of that substance went up 60 percent in high school baseball players. Parents in this survey said that their number one concern for athletic competition was supplements. It was even higher than sports injuries. But yet, 81 percent of these of these kids said their parents have never talked to them about it.

So what are we talking about supplements? If supplements were marketed before 1994, there's no FDA review required on their safety. Let me repeat that, no review required for their safety. It is at the discretion of the drug-the manufacturer as what they disclosed. There's no standardization required in the United States .