##VIDEO ID:N60BU4iGEjE## Thank you all for being here
tonight. Thanks, Julie. I'm really happy to be here. So as Julie mentioned, I'm
Amanda McCarthy. I am a sports dietician, and I'm
also the program manager for Sports Nutrition at Children's
Hospital Colorado Sports Medicine Center. My role is really taking care of
young, young athletes, teaching them how to fuel themselves well
for normal growth and development as well as I like to
tell my athletes I have some competitive spirit in myself as
well, which is why I became a sports dietitian. So not only am I trying to
direct them for fueling, for normal growth and development. Health long term. But I also
like to throw in some pieces that are going to help them
competitively as well. So we're specifically going to
talk about sports, nutrition and the teen athlete. Tonight I'm going to cover a lot
of ground, but I'm hoping this can be quite informational for
you guys. And then as Julie mentioned, we'll have the the
Q&A at the end. I'm happy to answer any
questions. So where I like to start with my presentations is
just my general philosophy on sports nutrition for the young
athlete. Often times I see that athletes,
families, coaches want to kind of jump to the top of this
pyramid and say what's going to make me faster? What supplement
can I take that's going to make me a better athlete, make me
healthier when in reality what we need to. Be addressing is that bottom
part of the pyramid 1st and then building up from there. So we're going to talk a lot
about the bottom part of this pyramid tonight and then at the
end, I'm going to touch a little bit on that top piece of the
pyramid. But basically, to build a solid
foundation in nutrition for young athletes, we need to be
focused on are they meeting their energy needs. And their macronutrient needs. Macronutrients are protein.
Carbs and fat. Are we timing their nutrition appropriately
and are we meeting micronutrient needs like their vitamins and
minerals, and then at the top of that pyramid I have ergogenic
AIDS, which is essentially food based components that have been
shown to have a performance benefit. Or supplements that have been
shown to have a performance benefit. Now when we look at. The habits of young athletes,
it's pretty much in line with other teenagers that we see. They're not drastically
different and athletes notes not drastically different than than
a non athletic teenager. So when we look at these habits
inconsistent, breakfast is very common or missing breakfast
completely, poor hydration, poorly time snacking or no
snacking, low fruit and vegetable intake, inadequate
calcium and vitamin D supplementation, and then just
generally like not getting enough food over the course of
the day. Is really common. I put little boxes next to
these. You can see. Kind of how those relate to the
pyramid. But basically if we have. A standard, let's call it a
standard tea. An athlete that is missing out
on these pieces, we can make up a lot of ground. Not only in their health, but
also in their performance just by addressing these pieces of
the puzzle. And I'm going to really talk in
more depth on each of these tonight. So when we start off looking at
an athlete's nutrition needs, energy, total calorie need is
always where I start. That is really the foundation of
any diet we need to make sure that we're getting enough
calories plus protein, carbs and fat to be meeting the needs of
the athlete. If we're not doing that, then we are interrupting
normal growth and development and we're absorbing. Going to be performing our best.
So the chart that I've put up here today is the recommended
dietary allowance for athletes. This is very general, so it's
only an estimate and the what the numbers that you're seeing
in the chart is for just low activity levels. So like. Going to school, hanging out
with friends like no organized sports. So if you can see for our males
between the ages of 15 and 24, I know it's a little bit beyond
our age range. But basically our older teenag. About 3000 calories per day is
normal. Low activity energy needs, and if you have a boy in
that age range, I'm hoping you are seeing that amount of energy
go into their body and are like holy cow, this this human can
eat a lot. Females a little bit lower, but
still pretty high energy needs around 2200 calories. Again is a
low active energy level and if you look to the right of that
where I've put my estimates I'm seeing with activity depending
on the amount, the duration. The intensity of the activity
they're doing, I can see male athletes anywhere from 3000
level all the way up to 6000 calories a day, and female
athletes anywhere from 2200 up to about 4000 is pretty common. I've seen female athletes even
be a little higher than that. So basically, teen athletes have
really high energy needs. Now the breakdown of that energy
needs. I like to think of it in three buckets. So we have our resting metabolic
rate, which is in green. Resting metabolic rate is
essentially the amount of energy we need for normal organ
function. So this includes things like
just normal brain function, breathing, heart rate, blood
pressure management, muscle tone, body temperature, which
takes an exorbitant amount of energy. All of that adds up to be about
60 to 70% of our total energy expenditure for the day. As an
athlete. Now on top of that, in that dark Gray box, you see just
kind of like normal daily activities that someone might be
doing walking to the. Bathroom getting out of bed,
going and sitting on the couch, walking to school, all of those
things. And then our sport category is
that light Gray. So that's gonna vary just depending on the type
of sport that someone's doing. And again the amount, but
generally around 25% of total energy expenditure is coming
from sport and sometimes people are surprised to see that. Most of that energy expenditure
is still coming from rusting metabolic rate, but maybe not
now that you've seen the numbers ahead of time. So going into individual macro
nutrients or macro nutrients are the ones that provide us with
energy. We're gonna touch on these
briefly, and I'm just gonna expand into more of the athletes
base on these. Probably all of you are aware of
protein. You're probably aware that it's
a building block for muscle tissue. It also helps with building
basically any component of our body. So soft tissues bone is going to
be included in that and enzymes are all built by protein high
protein foods. I have a list of those here. The ones on that
first column, the fish, meat, poultry, tofu, those are your
more protein dense items. So they just have more protein
per volume, whereas things like whole grains, fortified cereals,
nuts, and seeds. Those absolutely have protein in them,
and they're great foods to add in. They're just a little less
dense. So if I have an athlete that
does need more protein, potentially we might be looking
at more of those denser options to increase their protein
intake. When we look at total protein needs, you can see that
I've broken down the size of different athletes and
approximately how much. Protein they're needing on on. Daily basis and so that is a
total for a day not per meal. And then those portion sites
that they gave you like the palm of the hand, the fist for
vegetarian protein options, those add up to about 20 grams
of protein. So if you think about what size
your athlete is, I'm going to use 140 LB athlete in in future
examples. But we'll take that 120 LB.
Athlete on the low end. That is still enough protein for normal
muscle development, strength development, bone growth like
that is. Of protein. For them, the reason
I have a higher range is that they're eating so much energy.
They need so much energy, it can almost be hard to keep protein
that low. So having 100 ish grams of
protein a day for an athlete, that side is is really normal. And if they're eating a very
diet and meeting their energy needs, that's generally pretty
easy for them to meet. Protein choices per meal. I'm not going to go in depth
here, but these are just some suggestions on where we could
get protein at each meal and I think this is one of the areas. Do see athletes struggling is if
we're skipping breakfast, if lunch is ramen and that's it,
right? Or Mac and cheese. Although Mac
and cheese could have some some good protein in it. If we're not
getting a dense protein choice. Or we're skipping meals. That's where we can see that
protein is not going to be spread throughout the day, which
is going to be more ideal for recovery, muscle building, bone
building. Now, in childhood and
adolescent, these are what we call positive nitrogen states
for for us as humans, pregnancy is another. Positive nitrogen. State it's basically an anabolic
state of our lifespan where we're building tissues, right? That makes sense. They're
growing. They're gaining muscle mass. We're building things so in you
can see in peak growth that males are putting down a lot. A lot higher lean mass accuril
than females, but females are still accruing quite a bit of
lean mass, and that's why we're targeting that slightly higher
protein amount. So you've probably heard the
recommended dietary allowance for protein for the average
adult is .8g per kilogram. In young athletes, it's 1.5g per
kilo, so it's significantly higher. But again, their energy
needs are also significantly higher. So it's relatively easy
to eat or to meet and eat the athletes that I will often see
again that are missing mills I'll see are a. Little bit lower on protein
needs sometimes. My vegan athletes that don't
have a very varied diet or vegetarian athletes with low
variability. Their protein intake might be
low, but generally my athletes are doing a pretty good job on
protein overall. In the same vein as protein, I
like to focus on a amino acid called leucine. Amino acids are building blocks
to protein. You may have heard of them before. Leucine is just
one in particular that turns on enabilism in the body. So from a recovery athlete
standpoint, this is a really important one to be
incorporating. So foods you can see on this
table you can see kind of total protein content. You can see portion size and you
can see Lucene content in that third category there. So our target per meal is really
that 2G of leucine at each meal and then post workout is another
important time to have that leucine content. This is only a a small snippet
of this whole table, but foods that are going to be highest in
leucine are going to include meats, fish, dairy products and
then soy products. Those are really your most bang
for your buck. While a vegetarian or vegan athlete
could eat. Nuts after a workout and get
enough leucine. It's gonna be something like 2
cups of nuts if I'm remembering correctly, which that's a lot of
nuts, and that's a lot of energy. And they're probably not
gonna be hungry for a meal after that, right? So if we think more in what
makes sense for the meal, what makes sense to make sure we're
meeting our nutrition needs totally those four foods I
mentioned are going to be a little bit easier to hit that
leucine target, especially if you've got like a snack after. A workout. OK, moving on to carbohydrate
next, I would argue that carbohydrates is one of the most
important nutrients for young athletes. This is the brain's favorite
nutrition source. So the brain prefers to run on
carbs. You're going to have better
focus, better attention if you're if you're eating adequate
carbohydrate. Same thing the body's preferred fuel source for
high intensity activity and endurance activity is
carbohydrate. It's a clean burning nutrients. So the byproduct of carbohydrate
metabolism is water. Whereas other nutrients have
other byproducts that are secreted after they've been
metabolized. So we want to make sure athletes
are getting plenty of carbs. These also provide lots of
vitamins and minerals for them to meet their very high
nutrition needs and high carbs foods are all over the place and
they're relatively varied. So it's going to include a wide
vari. Of fruits that's going to
include all of your grains all the way down to things like
desserts, sweet foods, sports drinks, all of those are going
to contain carbohydrate. So we'll see a variety of those
foods incorporated. To the diet to meet the
athlete's carb needs. So when we're thinking
practically about carbohydrates being added onto an athlete's
plate, it should generally be somewhere between 30 and 50% of
the plate for total energy needs. We're trying to get about
50% of our total calories from carbs. Specifically, that's what's been
shown to have best performance and best meat. The nutrition
needs of the young athlete carbohydrate before. A workout is ideal. We can top off energy stores. We typically see perceived
exertion being lower during exercise. There's also some research
that's pointing to that's helpful for bone health as well.
Having some carbs pre workout and then post workout we're
going to work on that combination of both carbohydrate
and protein after the exercise. So that protein that we just
talked about is going to help with muscle recovery, bone
recovery, more that tissue building, whereas carbohydrates
are going to help with. Restoring glycogen stores, which
is the storage form of carbohydrate in the body. It's also going to help with
anaerobic. Glucose storage. So restoring that glucose that's
available for a two second all out effort. So if someone's doing like a
hard weight lifting effort or sprinting 100 meters, building
those stores is important so that we can see that performance
improvement over time. One note that I like to put on
all my presentations is that things like cauliflower, rice,
and zucchini noodles are really not good substitutes for
athletes. These are great vegetable
sources. I love when my athletes want to
eat zucchini and cauliflower, but if they're using that in
replacement of regular rice. Or regular pasta noodles rice
noodles. Chickpea noodles. They're just
significantly lowering their carbohydrate intake and the
amount of volume they would need to eat to meet their
carbohydrate needs would be really, really high and probably
beyond what their appetite would allow them to eat. Not to
mention if they ate that volume of ca. Rice. It's probably going to be
a whole head of cauliflower. And so there's going to be some
digestive distress that's going to come up with that as well. From a carbohydrate standpoint,
we see in teens that their anaerobic carbohydrate
utilization is less efficient than in adults, and so we'll
continue to see their power and top and speed improving as
they're getting older. Endurance utilization of carbohydrate is
pretty similar to that as an adult and in. Obese versus non obese youth. It's pretty similar again to
adults as well. When we're exercising less than
an hour, carbohydrates not really necessary unless we're
going out for a really early morning workout. And we haven't eaten anything
pre workout. So having something to eat
before that workout is ideal. I do have some swimmers and some
runners who are getting up and going at 5:00 or 6:00 AM, and so
they're not always that interested in getting up early
enough to eat something which totally makes sense to me. But
in that case, having some fuel on their on. Their actual workout is going to
be helpful. Number one, to reduce perceived
exertion. #2 to again make sure we're
meeting that energy need during that workout somewhat and then
we can refuel after that workout. And then this just that last
point, just talked about kind of carbohydrate metabolism and
young boys. It's pretty similar to what we're seeing in, in
adults. We don't have the data on young
girls, unfortunately. So total amount of carbohydrates
that are needed. I just like to emphasize this point because I
feel like it's a lot more than what people expect. So before an event, typically
we're targeting about 1 to 4G of kilo or crumbs per kilo, about
one to four hours prior to that exercise. So. For a 140 LB individual who's
getting ready to compete, that's gonna be somewhere on the
minimum side of 60 grams of carbohydrate and on the high
side, 120 grams of carbohydrate. I know I'm using a lot of Graham
numbers, so to put that in like practical standpoint, a slice of
bread, regular bread, not altered in any way is about 20
grams of carbohydrate. So that individual that I just
mentioned is gonna need anywhere from three slices of bread to
six slices of bread. If we're just putting in. ICal terms. Now I don't
necessarily expect an athlete to eat half a loaf of bread in one
sitting before their event, so we would be mixing it up with
maybe oatmeal or granola or cereal or fruit, right? So there would be a a
combination of different foods that are contributing to that
carbohydrate for daily recovery. And just again meeting energy
needs. Overall carbohydrate needs are high. So for that same sized athlete,
140 ish pounds. If they're doing around one hour of exercise most
days of the week. Four to five days a week. Their carbohydrate needs are
around 300 grams for the day and that is normal and appropriate
for for a teen athlete. If they're doing higher levels of
training and extending more energy. So let's say closer to two hours
of exercise. Most days we're talking probably
closer to the 500 gram carbohydrate mark at that point.
And then during sport, again when we are getting beyond that
one hour mark, we would want to make sure that we're adding in
sport strength that has carbohydrate and also salt. And then when we have more
extended periods of exercise, we're generally targeting about
30 to 60 grams of carbohydrate per hour. OK, for fat, fat is our last
macro nutrient. Fat aids in a lot of different
metabolic processes, including regulating body temperature,
hormone production, vitamin absorption, and can help with
reducing inflammation. Foods with fat are listed there
on the side with the oils and avocado. Those are foods that
are mono and polyunsaturated fat, so they're typically liquid
at room temperature. Aside from the nuts and avocado. And the ones that are more solid
at room temperature are considered saturated fats. And that's the other column that
you're seeing. Athletes need a mixture of all
of these, and so there's none of these that we should be
completely avoiding. But there is research that shows
getting more of the ones from the oil seeds avocado side that
can help with lowering inflammation a little bit more. That can also help with heart
disease risk factors. That helps with joint health. So overall, we try to focus a
little bit more heavily on that side and then sprinkle in the
the favorite ones from the other side. Fat prescription needs are a
little bit different than carbohydrates and protein. There's not necessarily a
specific amount of fat that we're looking for on a daily
basis. So generally we look at like 20
to 30 fiveish percent of total energy needs for fat. I like to think of it as adding
it as a compliment to the meal. So if you're having a potato,
you're putting butter or sour cream or cheese on it. If you're
having a salad, you're putting dressing or cheese or nuts, or a
combination of all of those things on it, right? I would say generally, teens are
poor at getting an omega-3 fat, which is coming either from
fish. Sources like mackerel, herring,
tuna and salmon, if you can eat those two times a week, that
gives you your Omega threes for the week. I find most of my
athletes don't meet that target. You can also get it from plant
based sausage which includes walnuts, chia seeds and ground
flaxseed. You do need to eat at least 2
tablespoons of those every single day in order to meet
those omega-3 needs. But that's a really good fat for
athletes to be incorporating for all of those reasons. But then it's also been. Shown to be protective with the
brain. And so if your child is in a sport that is high risk for
concussion, incorporating more of these foods and getting more
Omega threes is really important for just brain health in
general. So how do we structure this
logically when we're actually looking at a play and building a
play? How do we put all of this into
practice? Yes. And so I think these are
the best tools that can help both athletes and parents long
term when we have more of that moderate training and take this
with a little grain of salt because if I have a smaller
athlete versus a larger athlete, I may start. With a different plate, just
depending on their nutrition needs. But say we're exercising
about one hour a day. This would be the plate. I would generally
choose for an athlete with a third of their plate grains, a
third of their plate from a colorful food, 1/4 from. Protein and then some fat added
in on the side and then as exercise goes up, as I
mentioned, carbohydrate needs will go up. So now we have half of that
plate from our grain portion, 1/4 from protein, 1/4 from our
colourful foods, and you'll notice that fat portions also. Increase to help meet our
increased energy demands. This is still assuming that the
athlete is eating the same amount of snacks because our
goal is really to increase total energy intake. Now I threw some sample size in
here and my understanding is you guys are going to get the slides
as well so that you have some resources on what are good
choices. Pre workout post workout and
such. So pre workout snacks again we
want to focus on more easy to digest carbohydrates, granola,
granola crackers. Fruit cereal. Those are all
really good options pre workout. They're mostly carb. They're going to digest really
fast things like crackers with cheese, yogurt, PB and J
sandwiches. Trail mix. Those can also be really great
choices, but I would say if you have a kiddo who their stomach
just doesn't feel super great when they exercise or there's
more prone to that GI distress, I would I would probably avoid
those. Those food items that just have a little. Bit higher protein and fat
content. They just take a little bit
longer to digest. On the post work outside again,
we want that combination of protein and carbohydrates after
the workout. This could be a snack post workout or it could
be a meal. If they're coming home from practice. One thing I
would say is that there's going to be a delay from. The end of practice until a meal
that's like 2 hours or three hours long. Then I would still try to get
that snack item in immediately after an exercise. Within an hour, ideally so that
could be chocolate milk, a Turkey sandwich. Salmon with rice and veggies. Some string cheese. Fruit or crackers? Any of these options could be
great options to meet both of those needs. And then if we look at the
sample menu here, you can see that I tried to keep it really
simple from a food choice. So that hopefully it's mostly
teenager accepted here and this is just one sample plan and to
be perfectly honest, the portions are a little trivial
because it's gonna it's gonna change based on the athlete,
their sport and how much energy they need. But generally toast
with peanut but. Greek yogurt and granola in the
morning. Maybe a deli meat wrap with
apples and chips on the side for lunch. A banana and granola bar. Pre
practice chicken Alfredo with Sal with salad and garlic bread
for dinner and then some nuts and berries. Before bed snack. So hopefully this seems like
something that's relatively doable. It doesn't have to be. A crazy meal plan to be able to
meet the nutrition needs of our teen athlete. So what does poor fueling look
like? I get asked this question quite
a bit and one of the things I'm really looking for is is the
athlete needing their daily nutrition needs and if they're
not then I have lots of questions and probably some
adjustments. I'd like to make. So the the categories that I
typically see athletes fitting into. They are back loading their
nutrition intake. They're under fueling. They're restricting their food
intake or they tons of fast food for all their meals, right? So
with a back loading type of fueling pattern, I see kind of a
standard practice where athletes aren't eating breakfast 'cause
they're in a hurry to get out the door they're having a. Pretty small lunch. They're not having a snack
before practice, and then they're starving, right? And that makes total sense. And they eat a boatload of food
at dinner, and they eat a boatload of food after dinner
because they are starving. And it's good that they're eating
that amount of food because they are hungry and they need to be
eating their energy needs. But we can make a lot of
adjustments to this. Which is going to help them have
more energy during the day. It's going to help them recover from
exercise better. It'll help them play better
during their sport or run better, whatever their sport is. And they should feel a lot more
comfortable by the time they're actually going to bed at night. For my under fuelling athlete,
it's kind of similar to backloading, except they don't
backload, they just eat small portions all day long. There can be a variety of
reasons why this is happening. Sometimes athletes hunger cues
are poor and so we need to work on just getting them to
consistently fuel more adequately. Sometimes there's intentional
restriction going on where an athlete doesn't want to eat too
much for fear of what might happen with their weight. But this is putting an athlete
at pretty high risk of injury long term and we're going to
talk about that in a minute. But we would. We would correct this by adding
more fuel across the day. A restrictive eating pattern is
when an athlete is cutting out one nutrient group or one whole
food group. So hopefully you can see from
that pattern there that the athlete is lowered their
carbohydrate intake pretty significantly. Replacing regular pasta noodles
with Zoodles doing mostly protein foods and in fats
throughout the rest of the day. They may be meeting their energy
needs, but without that carbohydrate again the brain is
having to change the way that it processes fuel, which can be
really hard for con. And focus. And there has been a correlation
with low carbohydrate diets on increased bone risk factors, so
increased risk of stress fractures. And there's been
correlations with that in. Irregular menstrual cycles in
female athletes, too. So low carbohydrate diets
leading to. Periods of amenorrhea, or lack
of a menstrual menstrual cycle. So hormone adjustments finally
for fast food. Pretty straightforward. They're seeing fast food at each
meal, and so we get worried that they're just not getting enough
variety of nutrients, specifically colorful foods,
specifically, fiber from whole grains. And so I don't. I absolutely don't mind if my
athlete is eating out. I think that's pretty expected with the
type of schedules that they have. But we need to be bringing some
foods from home or we need to be intentional about the
restaurants that we're choosing so that we can get a wide
variety of foods incorporated. OK, moving on to hydration,
hydration water is another essential nutrient and our
bodies are anywhere from 60 to 70% water, which is pretty
incredible when you actually think about it. We're mostly
liquid. Fluid sources that I like
athletes to be choosing are things like water, sparkling
water, unsweet black and green tea or milk. Things like black coffee sports,
drink, sweetened beverages, diet drinks, juices, all of those can
be incorporated in. I just ask that my athletes
don't drink those. The majority of the time. That's something like fun and
delicious that they want to add in. The only drinks I drinks, I
ask my athletes to avoid our energy drinks and alcohol. Alcohol hopefully is pretty
straightforward, has no benefits from it for performance or for
health, whereas energy drinks. They the labeling on energy
drinks used to be that they were all labeled as supplements. We'll talk about that in a
little bit, but that was that's not ideal. Now they've moved to more food
based labeling. Caffeine is disclosed on the label, but a
lot of them still have pretty high caffeine levels. The American Academy of
Pediatrics recommends that all teen athletes have 100
milligrams or less of caffeine a day. Most of them have about two. Oh,
oh, milligrams of caffeine. Often they will contain banned
sources of stimulants. There's a popular one in
particular that contains guarana and that one is banned at the
collegiate level for high level athletes. And then they often will contain
really big doses of vitamins in them as well, which which
athletes don't need. And so the risk of an athlete taking this
and then going into a high stress situation on their body
when they're playing sports. Is not worth it. And so my question is always to
ask the athlete why they're drinking those and if they feel
like they need a pick up from the stimulant, we really need to
investigate what's going on with their nutrition, what's going on
with their sleep and their recovery. And if if all of that is looking
pretty good, which usually there's some adjustments we can
make, then we can go towards more natural sources like tea or
coffee or some dark chocolate to get some caffeine in. So how much water do athletes
need? You've probably heard the
general like half your body weight in ounces. That's a good rule of thumb for
an inactive person. Inactive person and when we
start to add exercise on adding somewhere between 10 and 30 oz
per hour of exercise is appropriate. If an athlete is really working
on that 30 oz per hour, they don't need to drink all of that
during practice, but it should be generally. If they drink 16
ounces during practice, they should be replacing with an
additional 16 ounces. After practice. A really simple tool is just
have them look at their pee when they're going to the bathroom
throughout the day. Ideally, their pee would be out
of Level 3 on this chart or or higher, so 1-2 or three is
considered hydrated when we start to get lower than that,
that darker urine is indicating that we're less hydrated, which
is normal for our first morning urine or right. After a multivitamin. But if it's happening all day
long, they're probably just not very well hydrated. Sweat rates can be super high in
athletes. Especially larger athletes. So really tall guys, especially
if they're wearing pads for football and they don't get
normal evaporation, they can lose a whole lot of sweat up to
somewhere around 2 liters in an hour. So if you think about a two
liter bottle, that's how much some athletes will lose in an
hour sweating. That's a lot of fluid to replace. If someone is not taking drink
breaks and hydrating throughout practice, that will
significantly impair their performance and then also can
become dangerous if practice is long enough. So general hydration guidelines
for our younger athletes 9:00 to 12:00, about four to 8 oz every
20 minutes. Our older athletes, again around
a leader, maybe a leader and 1/2 for that hour of exercise. I
don't expect that athletes are going to start drinking that
during their exercise immediately, but working to
replace that after exercise and working on sips of fluid during
exercise is import. And then on the bottom, those
guidelines for. For during exercise hydration,
type again water under an hour. Is great, unless it's maybe
competition or an all out effort. And then sports drink is
appropriate. If we're over that hour Mark, then we're going to
switch to sports drink. If we're over the hour and a half mark,
then we're going to be really intentional about making sure
we're getting a specific amount of carbohydrate and to sustain
activ. OK. So we're gonna switch gears and
go into weight control in, in adolescent athletes and adequate
fuelling. So I'm first going to talk about
weight control and this comes up a lot in my office where
athletes are worried that their weight is too high or that they
need to bring weight down to help with performance or to help
with a certain aesthetic if their SP. Is aesthetically based and
really in developing athletes, weight loss is not recommended. And so I'm not manipulating a
diet to help an athlete lose weight. I will look at their overall
nutrition and see where it is in terms of adequacy for all of
those nutrients we just talked about and if it appears that
we're having larger portions at some time and lower portions at
another time, we might make some changes to that. Which is going to help them
better produce muscle mass. Better utilize their metabolism. It may not help them lose
weight, but it will help with their performance. So I really
try to talk about let's change your nutrition to manipulate
performance. Health as opposed to
manipulating your weight, which is typically not very helpful
for most people. We have a pretty high risk of low energy
availability or not meeting calorie needs in very active
populations, and hopefully that makes a lot of sense based on
one of those first SL. That I showed you. Beaumont's risk is high if we
restrict in calories and disordered eating and eating
disorder. Behavior goes up if we're
restricting energy as well, and just on in that same line
there's data that shows up to 81% of 1010 year olds are afraid
of being fat. And those thoughts and beliefs
about body image can start as young as six. And so we want to
make sure that we're really raising these determined, smart,
strong individuals to feel comfortable and confident in
their body image and comfortable and confident in their food
choices so that they. Can maximize their performance
and not worry about weight or anesthetic. And that can be really hard in
those aesthetically based sports, I understand as well. On the opposite end, I will also
see athletes who desire to gain more weight so they may be on
the high end of the typical like weight, BMI skills that we look
at. They may want to gain more weight, thus not uncommon. One of the things that I will
also educate families on is that we need adequate androgens
available. So adequate testosterone
available if we're wanting to gain size, however, we can
manipulate getting stronger by changing nutrition training
patterns and sleep patterns. And so again, we want the
athlete to stay within a healthy range for themselves. We want to help support their
goals as much as possible, but we also need to let their body
progress through puberty. Normally in order for them to be
able to achieve those things. Any weight changes again ideally
would take place in the offseason and only when age
appropriate, and having a discussion with your medical
provider, a sports MDI think would be a really great choice. And then if you have a
dietitian, they they can also contribute to that conversation. So what we get worried about
with weight manipulation is a condition called relative energy
deficiency in sport. It's shortened to Reds and
basically when an athlete is taking in too little calories,
we start to see adjustments in the Physiology of the body to
accommodate the lower energy intake. And so how I describe it
to my athletes is that we continue to exercise. So we're
ex. Energy there, we continue to
wake up and move about through our day. So we continue to
expend energy there. So where the energy gets taken
away from is the RMR, the resting metabolic metabolic
rate. Normal organ function, so we can
often see adaptations like lowering hormone levels where
some female athletes may lose or have inconsistent periods. We see bone metabolism declining
and in teen athletes, bone metabolism is the highest rate
it's going to be in their entire lives. So we don't want to see that. Slow down. We want to keep that going very
quickly. We can see thyroid hormone
declining and just overall metabolism decreasing. We can see red blood cell
production decre. And so it can have some really,
really big effects on the Physiology of the body. If we're
not getting enough calories. The sport prevalence of Reds as,
as you might imagine, sports that are focused on aesthetics,
sports that are focused on a power to weight ratio. So more of your endurance based
sports and sports that are anti gravitational. So think of climbing and
gymnastics. Those tend to be the highest
risk sports, but I have worked with athletes at. Again, all levels in a wide
variety of sports, and I've seen under fueling in every single
sport, even things like football, where I think a lot of
people don't necessarily suspect that an athlete would be under
fueling. So the overall prevalence of low
energy availability is 22 to 58% in all sports. Four year
athletes. These are the performance changes that they're
going to experience. They're going to see a decrease
in endurance. They're going to see a decrease
in concentration. They're gonna see a decrease in
power, a decrease in speed. All of those things are declined
and for any athlete, they're generally not very excited to
see a decrease in anything performance related. Often these athletes will
present as they've increased their training and they haven't
increased their fueling and so paying attention if your athlete
is going from not doing anything to doing a lot, their food
intake should also be increasing. So that can be a red flag if
it's not continued exercise through injury or overtraining
with an injury. Loss of menstruation is a big
red flag, a preoccupation with food or highly restrictive
diets. Continued training with
decreasing performance, so maybe you don't necessarily notice
anything, but they're still working really hard and. They're just getting slower and
slower, or they're having a hard time keeping up in practices and
an emphasis on a certain aesthetic or look, not one must
have with their sport. Functional hypothalamic aminoria
is the technical term for a loss of of menstruation related to
not getting enough calories. We have a good amount of data on
this. This is called the athlete
triad. This is clearly since it's
related to periods related to female athletes. Male athletes also experience
it. We just have lower data on them
since we we don't see the the menstrual cycle happening like
we do in women. But when we have normal energy intake we can we
see normal estrogen levels and we see normal bone health. All
three of those things are related, so. If calorie intake goes down, we
see a slowing of the bone growth factors. If estrogen is is too
low and we're not able to build the lining of the uterus. We see that directly correlated
in in women who have gone through menopause when estrogen
drops. Bone health starts to drop
pretty rapidly. We see the same thing in teen
athletes. If they stop having periods at a time in their life
where they're supposed to be having very rapid bone growth.
And again in boys, what we're seeing is more related to
testosterone. So we'll see that testosterone
level dropping. We still see that impact on bone
health from the lack of energy intake as well. Relative energy deficiency does
not just happen in teen athletes. It happens at all level of
athletes. So Sean Johnson, she went to the
Olympics in 2008, won a gold medal. She was 12 at the time. She was taking in a 700 calorie
diet reports not having grains at that time, and she performed
so at a very high level, but also reports the amount of
dizziness that she had in a very scary sport where she's going
upside down. On a very small apparatus. And how long it took her to
regain her healthy relationship with her body and her food? Missy Copeland is a dancer. She's a ballerina. She didn't even start her period
until she was 19. What's considered normal is
under the age of 15. She was reportedly asked to lose
weight a lot and admittedly was binging after performances. And
then Mary Kaye is a distance runner. Most people heard about her. This was a while ago. Now it was 2018. That her story came out. She was a high level high school
runner, went professional right after high school, encouraged to
lose weight. How to negative relationship
with the coach lost her period and ended up with five
fractures. Fractures. So all of these
ladies have struggled with energy deficiency in sport. The stories about males are
fewer and further between, but they're starting to come out a
little bit more. But I think it's helpful for
athletes to hear teen athletes, especially to see these stories
that have happened and know that people at the highest levels are
also. Was struggling so low energy
availability exists on a spectrum from just under
fueling. So like the athlete, I said that just doesn't get
normal hunger cues. They're not taking in enough,
but they don't mean to not take in enough. That's a pretty for the most
part, easy case to fix to disordered eating, where an
athlete is maybe experimenting with some fad diets. They're intentionally
restricting their food or changing their food for whatever
reason, at two of full blown eating disorder where we would
include diagnostic criteria for anorexia or bulimia. All of
these are treated similarly and that we need to probably
increase and regulate their food intake so that they. Meeting. They need for their normal
exercise output, but the amount of people involved in the team
and the approach are all going to vary slightly. Development. I like to talk
about disordered eating and eating disorders in sports
because athletes just have a higher risk than the normal
population. As I mentioned earlier, athletes, especially
high level athletes, tend to have some of the personality
traits that do put them at higher risk for eating. Disorders. So they tend to be
very determined. They tend to be able to. Move through pain at a higher
rate than most individuals. They tend to be very independent and
strong willed, all of which are great traits to be a high
performing athlete and also they can be great traits to restrict
food and maintain discipline with food and potentially get a. Little too niched in with food,
right? So it's important just to pay
attention and again make sure that we are supporting our
athlete to include all foods in their diet and have that healthy
relationship with. Their body, as they're
continuing to move forward with their performance. OK. Last slide that I have on wait,
I love this graph. This study was done a few years
ago at this point, but this study was done on the top 100
runners in each event across the world, and they looked at what
are the size of these athletes. Who are the fastest 100 people
in the entire world? And I think it's really cool to
see we have the distance all the way up to the marathon, which is
26.2 miles. Down to the 100m, so if you can
see something like the marathon with the gold line, you can see
maybe the mid range there is around abmi of 20 but the range
is anywhere from like a 15 to. I don't know 2627 total. So there's a huge range and
these people are all very, very fast, right? And if we go down to the 100
meter, the range grows a little bit more and you can see the
shift up in BMI, which makes sense to me because they need
more. Powerful units on their body,
right? So we have more muscle mass, we
have more mitochondria available to ramp up the speed for a
shorter period of time. That makes a lot of sense. But again, the range is huge.
So. Maybe a 1718 on the low end up
to a 3132 on the high end. So I like to show my athletes
this to say like, look, these people are all incredibly fast
and they're all different in size. We're not seeing everyone just
kind of narrow into one specific area. Obviously there's peaks, but
there is a big range there too, and we're talking the highest
level performers in the world, which is pretty incredible too. OK. We're gonna switch gears and
go to micronutrients next for the teen athlete from a bone
health perspective, we talked a lot about this. I feel like
already, but calcium invited. We are going to be incredibly
important. Calcium needs for teenagers are
the highest that they'll ever be in their life. They need 1300 milligrams of
calcium per day, which is the equivalent of about four high
calcium foods per day. Often in my teen athletes that
they're moving a little bit away from dairy milks and going more
towards non dairy alternatives, which can be fine, but they're
not all equal. Dairy Milk is naturally high in
calcium. Plant based milks are not and so we need them to be
fortified if they're using them that as their calcium source. So making sure you're looking at
the label on your milk, make sure it has 30% or 300
milligrams minimum of calcium in it. If your kiddo is going to be
using that as their calcium source. Vitamin D. Lots of athletes are not
adequate in vitamin D. We can see this being linked to
muscle pain, bone pain, muscle weakness, a slower rehab rate. We consider lots of things when
we're looking at vitamin D and it can be helpful to get blood
work done and we make adjustments on supplementation
if needed at that point. But generally, just adding in
those beverages that are high in calcium often they're also
fortified with vitamin D so you can look for that as well. Vitamin D foods include things
like egg yolks, which have a little bit of vitamin D in them. The best vitamin D source is
salmon. And so if you're a kiddo, if
your kids like salmon, like you're in a good spot, just
serve it to them more often for sure. Food sources we just talked
through this. The other ones I didn't mention
are tofu and edamame are great sources of calcium for our
vegetarian vegan athletes, and then green leafy vegetables. I'm seeing those comment pop up
more sushi. Absolutely. Green leafy veggies
are also another good source. It is 2 cups for one high
calcium food, so a lot of my athletes are like oh, I eat
green. So that's my. That's good for calcium. We're talking like half a tub of
one of those big things of spinach a day to meet. Calcium needs, so don't think
that's the most effective way to get all of your calcium in. Iron is another super important
nutrient for growth, development and athletic performance. Post puberty females. So those who are menstruating
have high needs at around 18 milligrams per day. Vegetarian vegan athletes also
have higher needs. They need about 1.8 times what
an omnivore athlete needs just because of the amount of fibre
and phytate and other. Food substances. From a vegan and vegetarian
diet, they just don't absorb the iron as well as athletes who are
getting more of an omnivore diet, so their needs are very
high. Things like meat, fish, those type of proteins are very
high in iron and it's the most absorbable form of. Iron in the body for our bodies,
but things like whole grains, fortified cereals, beans,
legumes, nuts, green leafy vegetables, seeds. Those are all really good
sources as well. I would say generally the kids
that I see that have the best iron profile. Are getting adequate energy
intake, and they also often eat fortified cereal on a pretty
regular basis. I feel like that's one of your best bangs
for your book from an iron standpoint, adding things that
are high in vitamin C has been directly correlated with higher
iron absorption and. Higher iron stores, so adding
oranges to breakfast or lemon on your chicken at dinner. Strawberries with lunch. All of those are really. Efficient ways of adding a
little bit more iron. Absorption, at least to your
day. And finally, from a
micronutrient standpoint, potassium and folate tend to be
lower in our teens, especially teen athletes as well. And just getting a higher dose
of antioxidants can be helpful for them because of the the
higher amounts of damage they're putting their body through. Exercise is damaged. That's how we build it and get
it stronger. That's how we get better at our
sport, but we also want to make sure we're addressing that
through our diet. Most of my athletes are not
getting enough. Fruits and vegetables targeting
3 pieces of fruit per day and two plus cups of veggies per day
is generally what I want them to be doing. That can feel like a
really overwhelming number to an athlete who is not even getting
one piece of fruit a day or. One vegetable a day. And So
what? I encourage my families to do is
start by adding one right so we can get one banana in a day. If
we can get one apple in a day. If we can get one serving of
spinach in a smoothie a day, that is a really big. And then if we can kind of start
to build on that over time, it's huge. If your athlete is dealing
with pickiness and just needs exposure to things working with
a dietitian can be really helpful to kind of triage that.
And often there's other support people that can. Help with those things too. Over consumption of fruits and
vegetables does happen and often leads to underconsumption under
consumption of total energy intake. So I typically see grains and
fats being under consumed. If I'm seeing really large portions
of fruits and veggies. So I'm talking like if an
athlete's having a really big salad at lunch. Awesome. Glad you're getting
lots of veggies in, but if you're not adding quinoa or
beans or corn or rolls on the side to that, you're not getting
enough carbs and it would be really hard to get enough
calories out of that unless you're adding a lot of differe. Fats and those carbohydrates in.
So it's all about balance, right? So too much fruits and veggies
can actually be a bad thing for athletes. But at least getting that that
5:00-ish servings a day is what we're really trying to target. OK. Finally, I talk a little bit
about supplements and then. We can open it up for questions
from there. Supplement use in athletes young
athletes is quite common. The the tricky thing with
supplements is that supplements are not regulated in the United
States. And so if you pick up a
supplement label and you're not seeing any of these additional
little marks that I I have added to my slide on there, there is
no way to tell if what is on the label of that supplement is
actually what's in the product. When independent research
studies have been done on supplements, something of the
tune of like 80% of supplements are outside of the 10%
recommendation from what's on the label to what's actually in
the product. And there's a high amount of
contamination in three types of supplements specifically, which
can be more commonly used in sport. Weight loss supplements
tend to be more highly contaminated. Often we're
finding. Medication called zybutramine in
it, which is a weight loss medication in a supplement which
may or may not be on the label. Muscle building supplements are
often contaminated and can have pro hormones or other banned
substances in them, and then sexual enhancement. Supplements
are also often contaminated, so these are three highest risk
categories of supplements. And as you can imagine, for young
athletes, the muscle building supplement can be quite. Popular. So we need to make sure
that we're being safe if an athlete is taking supplements. So my recommendation is always
if an athlete's wanting to take something. Hopefully they're discussing it
with their parent first. Or they need to be talking to
their pediatrician. Or, better, a sports sports
doctor. And if they can get a sports
scientifician in conjunction with that, I think that can be
really helpful because I find a lot of my sports M DS just
haven't had the time to really dive into the world of sports
supplements, which is a lot of my role. As a sports scientitian, So what
we can do to be safer with these things is look for 3rd party
verification. So those labels that you're
seeing, the USP NSF, BSCG and information. Those are third party
verification. So if you're at home, you have
the luxury of grabbing your supplements from the cabinet. And you can start checking out
the label to see what's on there. But if you're seeing one of
these labels on your supplement, it means it's been sent to a
third party. Verified that. What's on the label is actually
what's in the product, so that is one safety net. And that's
really, really helpful. The second safety net is. If it is verified, looking
through and making sure there's no proprietary blends, that's
often a way that. Ingredients are hidden on a
label. Reading through the label and seeing. Are there any band
ingredients on there? Are there pro hormones? Are there? You know, NCAA banned
ingredients on the label and I think that's where a medical
professional can help to kind of tease out those things. But this is a really good place
to start if your supplement doesn't have one of these
labels, don't purchase it. To be perfectly honest, and you just
don't know that you're actually getting anything out of that
product and you don't know that you're not getting anything that
you. Don't want. In that product, the list that I
have here is are common supplements that I see from my
teen athletes. The three that I circled I think can be really
valuable as long as they have that third party certification.
A multi vitamin is the first one I think that. Can be a really nice kind of
insurance for teen athletes who are very highly active and have
very high nutrition needs. Carbohydrate supplements for
more endurance athletes. I think those can be really useful and
and necessary in that type of sport. And then omega-3, if you have an
athlete who's really picky about eating fish or struggling with
the the plant based sources of omega-3's, that can be another
one to add in. Although I will say there are contraindications
for Omega threes. So if your child does have any
health history, any type of medical conditions, if they're
taking any medications, it is really important to make sure
you're checking with their doctor 1st to make sure that is
an appropriate supplement for you to add. So don't just take my word for
it. Please make sure you're talking
to their doctor or schedule. Again an appointment with the
dietitian who kind of helped can help to navigate that. The other supplements on this
list, the ones that have been. Researched well, excuse me. For performance specifically
include creatine and includes caffeine, beta alanine and
sodium bicarbonate. Those have been researched
mostly in adults, so I don't use them a lot in my teen
population, and also because the amount of performance change
we're seeing from those things is so small in comparison to
what we can see from a. Total, Dieter. That I really want my athletes
to know that they can eat normal foods and still meet their
nutrition needs and still crush their performances, right? We
can absolutely do that. These other things can be a little
icing on the cake. Food puns are my favorite, but
they can help in those really highest tier athletes who are
competing. With like within tenths of
seconds, right? That can make a difference, but
we're really talking like that is the that's the difference,
right? Tenths of a second and so
overall where we're going to see the most performance changes is
going to be from these larger scale dietary changes. So I will go ahead that, oh, I'm
just going to do a little summary here just to kind of
keep you in mind with all that information. So basically we're encouraging
regular balanced meals for athletes. Three meals a day, one to three
snacks a day. Definitely a snack before we
exercise. Definitely a snack afterwards if
if dinner or whatever meals going to be more extended. Three to five fruits and veggies
per day for high calcium foods per day. Focus on foods with
high iron content supplements. Make sure you've got third party
verification, and ideally you're consulting with a pediatrician,
a sports doctor, and or a dietician to make sure that
you're safe in those choices that you're making. So thank you guys for having me
and Julie. I'll open it up for any
questions that might be available. Thank you, Amanda. Yes, if you guys have questions,
please post them in the Q&A section so that she can answer
them for you all. That was great, Amanda. Thank you. Or in the chat if you can't
access the Q&A, you can also post it in the chat and then
also we posted a survey too. And that's just really helps us
with future pairing academies. And then the questions come up a
few times about the slides. We will post the slides along
with the recording in about a week on our District 20 website
under the parent academies. But please just post if you have
questions. Just put them either place in the chat or the Q&A
if you have any questions for AM. We just have one that says thank
you. Fantastic. Welcome. My kids have GI problems and we
avoid. Sorry. Let me. I don't know if you can see that
one. See it my kids have GI problems
and avoid eating before competitions. Is this bad? Any way to provide food without
upsetting the stomach? This is a tough situation and I
do have a lot of athletes who experience that and I think it
can be a combination of just the sensitivity within the kid. There could be other things that
we need to address and then pre match pre race pre competition.
Nerves can also play a role in that. It's not ideal for sure. I mean we we definitely get the
most out of competitions when we're eating before them, so
there can be a training effect that if we're eating a couple
hours before and starting with something small like saltine
crackers, right, we can start to train the gut to tolerate a. Little bit more I would probably
recommend just because all of my kids with GI issues are
different and tolerate different things. Seeing a sports
psychician is helpful just because you can get specific
recommendations, but we can train the guy. Ideally, we would train it so
that we can tolerate something before competition and they will
feel better and we might be able to actually improve their gut
symptoms as well. OK. Next question. You're welcome,
Amanda. You're welcome, Linda. S. Rusler. Yep, I love my
wrestlers. Next question was, what about
multivitamins? Should I look for a third party verification? Yes. So on multivitamins, you're
going to see that USP symbol. So the black with the gold. But yes, they do have. You do want third party
certification on those as well. They they are generally less
risk. I will say, but I've seen
multivitamins that have caffeine at it. I've seen multivitamins with
herbal. And that study I was quoting
about the 80% misinformation on the label that was specifically
in, in supplements that have herbal ingredients. So I would definitely look for
USP on multis. Dance teacher struggling with
athletes avoiding eating. Are there some quick comments or
conversations I can have with them to encourage proper
fueling? Yes, we also do presentations
for dancers and dance athletes as well. So if you need someone else to
come out a third party, talk more about it. We can also set that up as well,
but I think generally letting them know these risk factors
that we've talked about telling them what relative energy
deficiency is telling them how that's going to impact their
bones long term. I focus on a lot of things, but
when an athlete is loving their sport so much, the thought of
them going out of their sport because they land on their foot
and they break their foot or they break a bone in their leg
because their bone health is. Poor because they've been
restricting food. That's pretty scary to most
athletes, and they're not out for a short period of time. It's generally anywhere from 6
to 12 weeks, depending on the degree of the injury. So letting them know that that's
impacting their bone health now and. Potentially as they grow older
as well. I think that can be really
motivating, but then I think also like demonstrating like how
do we do this? I assume you're not a dietician,
but like actually having someone who can say, OK, this is how we
do this. Expressing concern to parents if you're noticing it in
individuals so that they can get the help of a dietitian if
there's more going on under the surface as. To why they're not eating a
tough sport with the aesthetics with it. Question on sleep. How much sleep to get and should
they be eating before bed? That's such a great question. I think the general
recommendation for sleep for teen athletes is around 9 hours
per night, which is so if they're not getting that much
working towards getting closer to that amount. Should they be eating before bed
is a tricky question. I think if it doesn't impact the athletes
sleep, I have no problem with them eating before bed. My question is if they're
starving right before bed. They probably haven't eaten
enough throughout the rest of the day, and so the goal would
be yes on that day, eat before bed, like get adequate energy
intake for the day, and let's also make an adjustment the next
day so that we can get more fuel in at. More productive times during the
day, but eating right before bed, especially if their
exercise is later in the day. That still acts as a refuelling
period. We we have a heightened
absorption response to food for about four hours, four to six
hours after exercise. And so they're still getting
that and absorbing it really well and incorporating into
their tissues well. So don't be afraid that them
eating that is going to waste. It's not going to waste, but we
can probably time it a little bit more efficiently so they're
not so starving right before bed. Stands on MMCMCTI think oil and
how to incorporate into an athlete. Sorry, MCT oil is. It stands for medium train chain
triglyceride and it's typically found in coconut based products.
So like the coconut oil is a rage for more endurance type
athletes that specific fat can be absorbed directly through the
stomach wall as opposed to going through what we call the portal
system. Through the small intestine and
so it's absorbed and it can be used as an energy source pretty
immediately. So it's nice for endurance
athletes because they can use that in conjunction with their
carbohydrate intake. And fatty acids floating around
in their bloodstream too. I don't use it a lot with my
teen athletes because most of them are not at that level of
endurance athletics like they're not doing half marathons
typically or marathons, and that's usually the distance
where I'll start using it more. If an athlete wanted to
incorporate in some. Coconut, like coconut flakes,
coconut oil into like a Curry dish or things of that nature. I support them adding it in that
way, but I'm not using like a specific MCT oil as a supplement
adding in. And then the question is
thoughts on protein drinks and bars? So there can be a wide variety
of these products. Some of them are classified as food, some of
them are going to be classified as a supplement. So I would first look at the
label and see does it have a nutrition facts label or does it
have a supplement facts label? If it has a nutrition facts
label, it's been labeled as a food. So again, what we see on the
product should be what's in the product. If it's a supplement
fax, we need to be looking for 3rd party verification. Generally, when I'm looking for
protein drinks and protein bars. The place that I'm using those
is for convenience, right? So we may be adding protein to a
smoothie in the morning because the athlete is like running out
the door needs a source of protein and they're smoothie and
maybe they don't like Greek yogurt or whatever the reason is
or protein bars for like a fast something in. The middle of the day can be
helpful. But adding it in if the
athlete's diet is already pretty varied and adequate in protein
sources, I don't think it's necessary, but I think it can be
a convenient option. And then the next question is,
are there different nutrition recommendations for a child
athlete with delayed growth? That's not related to growth
hormone deficiency. So this can be a byproduct of
that relative energy deficiency in sport that I was talking
about earlier. So we're just not providing
enough calories in order to support normal growth in the
athlete. And so that's generally what I'm
looking for, as well as micronutrients that contribute
to growth. Low iron stores those things of
that nature. An adequate protein intake and
just kind of adequacy of the diet. So I would say yes,
nutrition plays a role in that. And so if you haven't seen a
dietitian seeing someone who specializes either in sport for
your athlete or. In growth like we have a gap
clinic in at Children's Hospital and they're really good at being
able to determine where the deficiency is and what could be
impacting that growth. Any other questions before we
wrap up? That might be. OK. Well, just once again, if you
haven't played the survey, please complete the survey. That really helps us with future
ideas. And like I said at the beginning, Children's Hospital
is phenomenal with us with partnering with us and offering
all these parent academies. So thank you again, Amanda. We appreciate you so much doing
this. This was fantastic. Thanks for having me. Best of luck to all of you guys
out there feeding your kids. Thank you. Yeah. Have a good day. Have a good night everybody. Thank you for joining us.