Nutritional Habits and Performance in Male Elite Wheelchair Basketball Players During a Precompetitive Period

Abstract

Physical condition and an optimized diet are relevant to enhance performance and recovery. The diet composition and meal frequency of eleven elite wheelchair basketball players were estimated using a 3-day food-weighing diary in two months during the precompetitive-period. Performance was determined through a 20 m sprint test. The players consumed 4.2 ± 0.8 meals/day in May and 4.5 ± 0.9 meals/day in June, resulting in total energy intakes of 2492 ± 362 kcal/d and 2470 ± 497 kcal/d, respectively. The macronutrient distribution was 3.8 ± 1.3 g/ kg carbohydrates, 1.7 ± 0.6 g/kg protein, and 36 ± 5% of energy derived from fat in May, and 4.2 ± 1.9 g/kg carbohydrates, 1.5 ± 0.5 g/kg protein and 32 ± 5% of energy derived from fat in June. The maximum velocity of the sprint test improved from 4.77 ± 0.31 m/s in May to 5.19 ± 0.23 m/s in June. Our results revealed carbohydrate intake below and fat intake above recommendations, but improvements of dietary patterns. Further nutritional advice is necessary to ensure health and performance improvements.

Full text

295
APPLICATIONS
Adapted Physical Activity Quarterly, 2017, 34, 295 -310
© 2017 Human Kinetics, Inc.
https://doi.org/10.1123/apaq.2016-0057
The authors are with the Faculty of Physical Activity and Sports Science, Technical University of
Madrid, Madrid, Spain. Please address author correspondence to Amelia Ferro at amelia.ferro@upm.es
Nutritional Habits and Performance
in Male Elite Wheelchair Basketball
Players During a Precompetitive Period
Amelia Ferro, Guadalupe Garrido, Jorge Villacieros,
Javier Pérez, and Lena Grams
Technical University of Madrid
Physical condition and an optimized diet are relevant to enhance performance
and recovery. The diet composition and meal frequency of eleven elite wheelchair
basketball players were estimated using a 3-day food-weighing diary in two
months during the precompetitive-period. Performance was determined through
a 20 m sprint test. The players consumed 4.2 ± 0.8 meals/day in May and 4.5 ±
0.9 meals/day in June, resulting in total energy intakes of 2492 ± 362 kcal/d and
2470 ± 497 kcal/d, respectively. The macronutrient distribution was 3.8 ± 1.3 g/
kg carbohydrates, 1.7 ± 0.6 g/kg protein, and 36 ± 5% of energy derived from
fat in May, and 4.2 ± 1.9 g/kg carbohydrates, 1.5 ± 0.5 g/kg protein and 32 ±
5% of energy derived from fat in June. The maximum velocity of the sprint test
improved from 4.77 ± 0.31 m/s in May to 5.19 ± 0.23 m/s in June. Our results
revealed carbohydrate intake below and fat intake above recommendations, but
improvements of dietary patterns. Further nutritional advice is necessary to ensure
health and performance improvements.
Keywords: diet composition, nutrient timing, macronutrients, speed, kinematics
Interest in wheelchair sports has been growing over the last several years
(Krempien & Barr, 2011; Rastmanesh, Taleban, Kimiagar, Mehrabi, & Salehi,
2007), and the Paralympic Games have become one of the world’s largest sporting
events. Therefore, the rising competitive demands, external pressures, and the need
for high-performance levels are becoming more challenging for athletes (Krem-
pien & Barr, 2011; Rastmanesh et al., 2007). In wheelchair basketball, which is
one of the most popular wheelchair sports, performance is based on three factors:
the athlete, the wheelchair, and the interaction between the two (Goosey-Tolfrey,
2010). The adaptation of the wheelchair to the game has led to wheelchairs with
minimized weight (Cooper & De Luigi, 2014) and to improvements in propulsion
through biomechanical enhancements (Vanlandewijck, Theisen, & Daly, 2001),

296 Ferro et al.
APAQ Vol. 34, No. 3, 2017
both of which allow for higher levels of performance. Finally, the athletes’ physi-
cal condition plays an important role, and as such, they are undertaking training
programs that are comparable to those of their able-bodied counterparts (Broad &
Burke, 2014). To assess starting and sprinting performance of players on the court,
the 20 m sprint test is a common eld test in wheelchair basketball (De Groot,
Balvers, Kouwenhoven, and Janssen, 2012; Ferro, Villacieros, & Pérez-Tejero,
2016; Vanlandewijck, Daly, & Theisen, 1999; Yanci et al., 2015).
In addition to physical tness, optimal nutrition is required to achieve the goals
of performance in games and high-volume training (Goosey-Tolfrey & Crosland,
2010; Krempien & Barr, 2011; Rastmanesh et al., 2007) as well as to compensate
for the high energy expenditure of training (Kreider et al., 2010; Rodriguez et al.,
2009; Thomas et al., 2016). An optimal dietary intake of carbohydrates maintains
body weight and replenishes glycogen stores, protein builds and repairs tissue,
and fat provides essential fatty acids and fat-soluble vitamins (Kreider et al., 2010;
Rodriguez et al., 2009; Thomas et al., 2016). Existing recommendations from the
American College of Sports Medicine (ACSM) and the International Society of
Sports Nutrition (ISSN) for nutrient intake in relation to exercise intensity are based
on nondisabled athletes, and no specic recommendations for Paralympic sports
exist to date (Goosey-Tolfrey & Crosland, 2010; Kreider et al., 2010; Krempien &
Barr, 2011; Rodriguez et al., 2009; Thomas et al., 2016). Although some differences
have to be considered—such as a smaller muscle mass (Goosey-Tolfrey & Crosland,
2010), a limited sweating response (Price, 2006), and an altered maintenance of
bowel function in athletes with spinal cord injuries (SCIs; Levine, Nash, Green,
Shea, & Aronica, 1992)—the principles of sports nutrition can be transferred to
Paralympic athletes. However, existing studies have demonstrated inadequate
nutritional key points, such as low carbohydrate or high fat intake in Paralympic
and wheelchair basketball athletes (Goosey-Tolfrey & Crosland, 2010; Krempien
& Barr, 2011; Krempien & Barr, 2012). Because of these insufciencies and the
abovementioned differences to nondisabled athletes, meal frequency, including the
intake of snacks between meals, may play an important role in reaching nutritional
guidelines that has not yet been studied for wheelchair athletes.
Therefore, aims of this study were to (a) describe dietary patterns before and
after nutritional advice intended to reach sports nutrition recommendations during
a precompetitive period in wheelchair basketball, (b) evaluate the meal frequency
of the wheelchair basketball players on the Spanish men’s national team during two
training camps, and (c) determine improvements of performance between the camps.
Method
Participants
Eleven elite male wheelchair basketball players from the Spanish national team
participated in this study. The research was conducted during two high-intensity
training camps in the precompetitive period between May and June in one year.
None of the participants experienced injuries that had the potential to constrain
their ability to perform the research task. The Ethics Committee of the Technical
University of Madrid (Spain) approved the study, and it was undertaken in accor-
dance with the Helsinki Conference for research on humans (Williams, 2008). The

Nutritional Habits and Performance in Wheelchair Basketball 297
APAQ Vol. 34, No. 3, 2017
volunteer participants were informed about the purpose of the study and gave their
written consent before taking part in it.
Anthropometrics
Height was determined to the nearest 0.1 cm using a stadiometer (DKSH Switzer-
land Ltd., Switzerland) in a standing position if possible, and the formula recom-
mended by Canda (2009) was applied to estimate height based on arm span and
seated height for athletes who were unable to stand. Body weight was measured to
the nearest 0.1 kg with athletes wearing minimal clothing using a calibrated scale
(Kern, Twister Medical, Spain).
Diet Composition
Diet composition was estimated using a food-weighing diary (1 g accuracy; Mettler-
Toledo S.A.E, Barcelona, Spain) over three consecutive days in May and again in
June. The weighing of each individual food item was performed by researchers
during main meals: breakfast, lunch, and dinner. All foods and energy-containing
drinks consumed outside the main meals were considered as snacks. Snacks were
taken from the buffet or from vending machines at the training site and were also
weighed and noted as snacks. Before the next measurement, possible leftovers
of the snacks were collected and weighed. Food and beverages from the vending
machines, which were not free of charge, were reported, and players provided
leaets of consumed food and drinks, which consisted of cookies, prepared cakes,
and isotonic drinks. All players ate together and chose their food freely from a
buffet at the Higher Sport Council in Madrid (Spain); the buffet included starters,
main courses, salads, fruits, deserts, and a variety of bread. As it is common for
national teams to hold training camps in the precompetitive period and during
championships, it seems likely that their food selection represented their normal
habits for these important periods. The buffet offered the same food choices during
the second evaluation. The recipes of each meal were provided by the kitchen staff,
and recipes not already included in the food composition database were added.
To determine supplement intake, the players reported the daily amounts taken and
provided leaets, labels, or packaging information of each supplement, which were
also included in the database. DIAL v.2 software (Alce Ingeniera, Madrid, Spain)
was used to determine daily nutrient intake, including the macro- and micronutri-
ent composition.
After the rst period, a nutritionist provided individual written reports,
including nutritional modications with specic food intake recommendations,
to optimize each player’s diet composition, based on anthropometric data, energy
expenditure, and personal intentions, such as gaining or losing weight, estimated
through a questionnaire before the rst period. Additional individual feedback was
given before the second period, and the importance of meal frequency and snacks
was also emphasized. All nutritional pieces of advice applied to recommendations
for able-bodied athletes because of the lack of specic recommendations for Para-
lympic athletes (Kreider et al., 2010; Rodriguez et al., 2009; Thomas et al., 2016).
Therefore, macronutrients were expressed in grams per kilogram of body weight
to give the player more practical advice: carbohydrates 5–8 g/kg, protein 1.2–2 g/

298 Ferro et al.
APAQ Vol. 34, No. 3, 2017
kg, and fat 0.5–1.5 g/kg (Kreider et al., 2010; Rodriguez et al., 2009). Because the
study was conducted before the updated recommendations from the ACSM were
published, we used the ACSM recommendations published in 2009 for nutritional
optimizations (Rodriguez et al., 2009; Thomas et al. 2016).
Energy expenditure during each training camp was estimated through a 24 hr
written activity protocol. Resting energy expenditure was estimated according to
Abel, Platen, Rojas Vega, Schneider, and Struder (2008) to determine the energy
cost of physical activities; the compendium of Collins et al. (2010) was used for
athletes with spinal cord injuries; and Bernardi et al. (2010) or Abel et al. (2008)
was used for other athletes, such as amputees. The estimated energy expenditure
was used to compare the intensity of each training camp, both of which took place
during the precompetitive period.
Sprint Test
On the second day of each period, the players performed two series of 20 m
sprint tests. They used their own game wheelchairs and prepared before the test
as they normally would for a competition. The test started with a 15 min warm-
up, and between the two series, a rest of 5 min was given. The players waited at
the starting line with the front wheels on the line and their trunk behind. They
could independently carry out preparatory driving movements and start when
they were ready. A type 1 laser sensor (LDM301, Jenoptik, Jena, Germany)
integrated into a kinematic analysis system in real time for the training and the
sports competitions by Ferro and Floría (2010), BioLaserSport® (Ferro, 2012),
was used to measure the players’ displacement along the test. The laser beam hit
the backrest of the wheelchairs at a height of 0.63 m, with the horizontality of
the beam being controlled. Position data were recorded at a sampling frequency
of 2000 Hz with an accuracy of ±0.06 m and a resolution of 0.001 m and were
processed with a routine developed with DasyLab v.10.0 (National Instruments,
Austin, TX, USA). The data were ltered at a frequency of 3 Hz, with a second-
order Butterworth low-pass lter. The maximum velocity (Vmax) and average
velocity (Va) were calculated in ve sections (0–3 m, 3–5 m, 5–10 m, 10–15 m,
and 15–20 m) so that a more accurate assessment of the kinematic data could be
obtained. The average of the two attempts was recorded. The intraclass correla-
tion coefcients (ICC) were ≥ 0.94 for Vmax and ≥ 0.97 for Va.
Statistical Analysis
Normal distribution was tested with the Shapiro-Wilk test. To establish possible
differences in the distribution of meals and in the velocities of the sprint tests,
analysis of variance with repeated measurements was performed with post hoc tests
corrected by Bonferroni and with η2 as effect size. For comparing the two periods,
May and June, paired two-sided Student t tests for parametric and Wilcoxon tests
for nonparametric data were performed. Cohen’s d was determined to estimate the
effect size. Fisher’s exact tests were used to test the proportion of players reach-
ing the recommendations between the two periods. All data are given as the mean
± SD. Signicance was accepted at p < .05. All tests were performed with SPSS
Version 22 (IBM Corp., Armonk, NY, USA).

Nutritional Habits and Performance in Wheelchair Basketball 299
APAQ Vol. 34, No. 3, 2017
Results
Participants
Characteristics of the participants are shown in Table 1. Their body weights and
body mass indexes (BMI) remained stable during the two training camps (Table
1). The intensity of the camps showed no signicant difference (p > .05; Table 2).
Diet Composition
Total e ne rgy i nt ak e was 34 .8 ± 9.8 k ca l/ kg in Ma y an d 34.7 ± 12.6 k ca l/ kg i n June
(p > .05). Energy intake and distribution of macronutrients showed no signicant
differences for main dishes between May and June (Table 2). Six players reached the
recommendations for carbohydrates in May, and nine in June (p > .05); for protein,
six in May and seven in June (p > .05); and for fat, four in May and nine in June
(p > .05). There was a signicant difference between May and June in the energy
intake of the main dishes (p < .001, η2 = .80), with lunch being the highest-energy
meal in both May and June in terms of energy distribution (p < .001, η2 = .74),
carbohydrate distribution (p < .001, η2 = .78), protein distribution (p = .002, η2 =
.46), and fat distribution (p < .001, η2 = .72). The signicances of the post hoc tests
are shown in Table 2. The distribution of energy intake from lunch was signicantly
higher in June compared with May (p = .020, d = 0.46; Table 2). Daily water intake
did not differ signicantly between May (2565 ± 917 ml) and June (2640 ± 697 ml).
The combined energy intake and the distribution of macronutrients of all three
snacks showed no signicant differences between May and June (Table 2).
Macronutrient intakes in gram per kilogram of body weight for all six meals
are shown in Table 3. The amount of carbohydrates consumed at breakfast was
signicantly higher in June than in May (p = .044, d = 0.29).
Figure 1 provides the prole of fat intake and shows a signicant increase of
polyunsaturated fat (p = .034, d = 1.02) and a signicant reduction of saturated
fats (p = .045, d = 1.05), with two players under the recommended 10% in May
and seven in June (p = .080). Cholesterol intake was likewise signicantly reduced
in June (322 ± 94 mg) compared with May (478 ± 215 mg, p = .026, d = 0.94).
One player in May was under the recommended amount of 300 mg, and six were
under in June (p = .063).
Meal Frequency
From the six possible meals per day, the players consumed 3.8 ± 0.8 meals in May
and 4.0 ± 0.8 in June, with 9 players eating all three main dishes in May and 10 in
June. No player consumed three snacks per day; the average was 0.8 ± 0.8 in May
and 1.0 ± 0.8 in June. In addition, the players drank only water outside the main
dishes 0.5 ± 0.5 times a day in May and 0.5 ± 0.4 times in June.
Sprint Test
The overall time of the 20 m sprint test was signicantly higher in May (5.34 ±
0.29 s) compared with June (5.09 ± 0.26 s, p = .002, d = 0.91). Figure 2 shows the
results of the sprint tests by sections, which showed signicant interaction effects

300 APAQ Vol. 34, No. 3, 2017
Table 1 Characteristics of the Participants
May June
Amputee or
SCI Age
(years) Body
height (cm) Body
weight (kg) BMI (kg/m
2
) EI (kcal) Body
weight (kg) BMI (kg/m
2
) EI (kcal)
Amputee — — 102.0 — 2564 102.0 — 2486
Amputee — — 88.5 — 2437 88.5 — 2558
Amputee — — 75.0 — 2849 75.7 — 2386
SCI — — 72.0 — 2111 81.5 — 2437
SCI — — 61.9 — 2939 61.9 — 2424
SCI — — 73.5 — 2004 73.5 — 2195
SCI — — 68.0 — 2183 68.0 — 1910
SCI — — 47.0 — 2524 47.5 — 3000
SCI — — 69.0 — 3127 69.0 — 3446
SCI — — 75.0 — 2191 72.0 — 2732
SCI — — 90.6 — 2479 86.4 — 1597
Mean ± SD 30 ± 6 179 ± 6 74.8 ± 14.9 23.3 ± 4.0 2492 ± 362 75.1 ± 14.5 23.4 ± 3.9 2470 ± 497
Note. BMI = body mass index; EI = energy intake; SCI = spinal cord injury (including spina bida).

301APAQ Vol. 34, No. 3, 2017
Table 2 Daily Energy Intake and Macronutrient Distribution for Main Meals and Combined Snacks and Calculated Energy
Expenditure
May June
Type of
meal Energy
(kcal) Energy (%) CHO (%) Protein
(%) Fat (%) Energy
(kcal) Energy (%) CHO (%) Protein
(%) Fat (%)
Breakfast 406 ± 208a, b 16.0 ± 7.5a, b 57.0 ± 13.2a, b 15.0 ± 4.9a27.3 ± 12.4b430 ± 187a, b 16.7 ± 6.0a, b 66.8 ± 12.2a, b 13.4 ± 4.9b17.2 ± 10.8a, b
Lunch 1022 ± 252a, c 41.4 ± 10.1a, c, *42.2 ± 9.7a20.8 ± 4.6a35.7 ± 6.4c1144 ± 228a, c 47.3 ± 10.3a, c, * 45.5 ± 10.2a17.7 ± 3.0 35.1 ± 7.9a
Dinner 835 ± 184b, c 33.5 ± 6.0b, c 34.9 ± 12.4b19.9 ± 5.7 43.8 ± 8.3b, c 704 ± 230b, c 28.6 ± 7.6b, c 35.0 ± 12.1b20.3 ± 6.7b42.4 ± 10.5b
Snacks 227 ±251 9.0 ± 9.6 44.4 ± 28.1 12.3 ± 14.5 22.0 ± 18.4 191 ± 165 7.3 ± 6.2 48.1 ± 31.7 15.3 ± 17.3 16.8 ± 12.3
Total 2492 ± 362 —45.3 ± 7.3 19.1 ± 4.8 35.5 ± 4.7 2470 ± 497 —49.3 ± 8.2 17.0 ± 2.8 32.1 ± 5.3
EE 3591 ± 711 — — — — 3791 ± 732 — — — —
Note. CHO = carbohydrate; Total = total energy intake, including main dishes and snacks; EE = energy expenditure. *p < .05, May vs. June.
aBreakfast vs. lunch, bbreakfast vs. dinner, clunch vs. dinner, p < .05.

302 APAQ Vol. 34, No. 3, 2017
Table 3 Macronutrient Intakes for All Six Meals
May June
Type of meal CHO (g/kg) Protein (g/kg) Fat (g/kg) CHO (g/kg) Protein (g/kg) Fat (g/kg)
Breakfast 0.83 ± 0.46* 0.20 ± 0.11 0.18 ± 0.15 0.97 ± 0.49* 0.22 ± 0.14 0.13 ± 0.09
Morning snack 0.11 ± 0.12 0.07 ± 0.12 0.06 ± 0.09 0.18 ± 0.29 0.07 ± 0.10 0.02 ± 0.04
Lunch 1.53 ± 0.68 0.73 ± 0.28 0.56 ± 0.17 1.91 ± 0.92 0.69 ± 0.20 0.61 ± 0.20
Afternoon snack 0.20 ± 0.25 0.05 ± 0.10 0.03 ± 0.05 0.22 ± 0.25 0.03 ± 0.05 0.04 ± 0.07
Dinner 1.05 ± 0.64 0.57 ± 0.20 0.56 ± 0.17 0.92 ± 0.62 0.46 ± 0.13 0.43 ± 0.12
Evening snack 0.03 ± 0.06 0.07 ± 0.19 0.01 ± 0.01 0.04 ± 0.08 0.01 ± 0.02 0.01 ± 0.02
Total 3.76 ± 1.30 1.68 ± 0.64 1.39 ± 0.43 4.24 ± 1.92 1.48 ± 0.45 1.23 ± 0.41
Note. CHO = carbohydrate.
*p < .05, May vs. June.

Nutritional Habits and Performance in Wheelchair Basketball 303
APAQ Vol. 34, No. 3, 2017
of periods and sections for Vmax (p < .001, η2 = .49) and for Va (p < .001, η2 = .81).
The post hoc tests revealed signicant differences for Vmax and Va in all sections
except the rst two, 0–3 m and 3–5 m, when comparing the May and June results
(Vmax: 5–10 m: p = .009, d = 1.08; 10–15 m: p = .010, d = 1.12; 15–20 m: p <
.001; d = 1.54, and Va: 5–10 m: p = .006, d = 0.74; 10–15 m: p < .001, d = 1.13;
15–20 m: p < .001; d = 1.52).
Figure 2 — Maximum velocity (Vmax) and average velocity (Va) by sections.
Figure 1 — Fat intake proles in relation to total energy intake.

304 Ferro et al.
APAQ Vol. 34, No. 3, 2017
Discussion
This study describes the meal frequency and meal composition of elite male
wheelchair basketball players twice in the precompetitive phase. During the stud-
ied days in May and June, players ate 3.8 ± 0.8 and 4.0 ± 0.8 meals per day, with
82% consuming all three main meals in May and 91% in June. Only 27% of all
possible snacks were eaten in May and 34% in June, which showed a tendency for
an increased snack frequency but without signicant differences. Together with the
fact that approximately one-third of all foods and drinks consumed outside the main
dishes were merely uids, it seemed likely that the players were more aware of uid
replacement and not of the possible benets of snacks containing carbohydrates
and protein during, before, and after exercise (Kreider et al., 2010; Price, 2006). It
is rather unlikely for highly organized sports teams to not consume snacks during
exercise (Erdman, Tunnicliffe, Lun, & Reimer, 2013). However, keeping in mind
that access to a toilet can be difcult for wheelchair users, it might be an individual
strategy not to consume snacks or drinks to avoid interrupting training sessions or
games. On the other hand, for athletes with SCIs gastrointestinal conditions, their
digestion system may have tremendous inuence on their eating habits because of
longer digestion time (Lin, Kim, Hsiao, & Brown, 2002), which makes their timing
of nutrition more difcult than that of able-bodied athletes.
Regarding our biomechanical measurements, we observed improvements in
Vmax and Va except in the starting phases (0–3 m and 3–5 m sections). This could
be explained by the fact that the training between May and June focused more on
tactics and technics than on strength or explosive strength training and that the
energy of the rst few seconds depends on adenosine triphosphate and creatine.
In the 5–10 m section, the players performed at higher velocities in June than in
May, with a 5% higher Vmax and a 4% higher Va. In the 10–15 m section, the values
were 6% higher for both Vmax and Va, and in the 15–20 m section they were 8%
higher for both Vmax and Va. Concerning nutrition in general, the distribution and
contribution of the breakfast or dinner before the test day, with tests performed in
the morning, could have inuenced the performance of the players. Vanlandewijck
et al. (1999) developed a eld test battery for coaches to evaluate the wheelchair
basketball skills of players, including a 20 m sprint test. They obtained an average
velocity of 3.37 m/s over 20 m (Vanlandewijck et al., 1999), while the participants
achieved velocities of 3.76 ± 0.20 m/s in May and 3.94 ± 0.20 m/s in June. This
difference could be explained partly by the fact that the participants were elite
athletes and that improvements in wheelchair design and biomechanics, together
with improved training, had occurred since the study of Vanlandewijck et al. (1999).
The athletes’ daily energy intake and the intensity of the training camps, which
took place in the precompetitive period, did not differ. Their energy intake was
higher in both May and June (2497 ± 362 kcal and 2470 ± 497 kcal, respectively)
compared with other elite male wheelchair basketball and tennis players (2060
kcal; Goosey-Tolfrey & Crosland, 2010) but lower compared with elite able-bodied
basketball players (4284 kcal; Bescos-Garcia & Rodriguez-Guisado, 2011).
The contribution of macronutrients was at the lower limit of the carbohydrates
intake (45–65%) and at the upper limit of the fat intake (20–35%), based on cur-
rent recommendations (Kreider et al., 2010). The same tendency was shown by
Goosey-Tolfrey and Crosland (2010) and by Krempien and Barr (2012), but other

Nutritional Habits and Performance in Wheelchair Basketball 305
APAQ Vol. 34, No. 3, 2017
training intensity recommendations would suggest a higher amount of carbohy-
drates and a lower fat intake (Kreider et al., 2010). Although there are no nutritional
recommendations for disabled athletes to date, the existing recommendations for
able-bodied (Kreider et al., 2010; Rodriguez et al., 2009) can be applied to disabled
athletes if their impairment is taken into account. In the case of SCIs, no strong
evidence exists that the muscles of these athletes responded differently than those
of able-bodied athletes, and substrate oxidation rates are comparable (Knechtle,
Muller, Willmann, Eser, & Knecht, 2003). However, the muscle mass of disabled
athletes is smaller because of paralysis and a reduced sympathetic nervous system
activity below the level of lesion, which leads to a reduced aerobic capacity (Leicht,
Bishop, & Goosey-Tolfrey, 2012). Therefore, energy expenditure and requirements
for athletes with SCIs are lower than those for their able-bodied counterparts (Croft,
Dybrus, Lenton, & Goosey-Tolfrey, 2010). But how much lower is difcult to assess,
because the calculation of energy expenditure by existing estimations—such as the
compendium by Collins et al. (2010), used in this study to calculate the intensity
of the training camps—could not be easily transferred to wheelchair athletes, since
even the experience of wheelchair propulsion can reduce energy expenditure in
trained compared with novice wheelchair users (Croft et al., 2010).
To date, no recommendations for meal frequency other than before, during,
and after exercise exist (Kreider et al., 2010; Rodriguez et al., 2009). Nevertheless,
more meals per day seem to be a logical strategy to increase energy intake without
the side effects of gastric discomfort from larger meals (Broad & Burke, 2014).
Burke et al. (2003) showed a moderate correlation between eating intervals and
energy intake in able-bodied male Australian endurance athletes, with an intake
of 3033 ± 979 kcal divided into 5.6 ± 1.1 meals. The same eating habits with 5
meals per day were also determined in able-bodied male Canadian (3055 ± 947
kcal) and Brazilian (3678 ± 1075 kcal) athletes (Erdman et al., 2013; Nogueira &
Da Costa, 2004). The eating habits of wheelchair athletes of one main meal does
not seem uncommon, as other studies have discovered similar results, and only
the time of day—that is, lunch or dinner—varied (Burke et al., 2003; Erdman et
al., 2013; Garrido, Webster, & Chamorro, 2007; Nogueira & Da Costa, 2004). The
energy intake for lunch was comparable between the participants and the Brazilian
athletes, whose total energy intake was the highest of all studies analyzed (Burke
et al., 2003; Erdman et al., 2013; Nogueira & Da Costa, 2004). This could be due
to the buffet-style diet at training camps, which contained a great variety of food
(Garrido et al., 2007). However, we believe that the participants’ eating habits during
these intensive weekends were comparable to those at international competitions, so
the choice of meals should be representative. In fact, during both periods, they had
the possibility to choose their food freely from a buffet offering the same choices
that were available at the training site.
Recommendations for able-bodied athletes regarding dietary intake in rela-
tion to exercise intensity took only two macronutrients, carbohydrates and pro-
tein, into account, with daily amounts of 5–10 g/kg carbohydrates, depending on
exercise intensity, relative to 1–2 g/kg protein (Kreider et al., 2010; Rodriguez et
al., 2009). Regarding the lower energy expenditure in wheelchair basketball, we
expected that the participants’ carbohydrates needs would be at the lower limit of
the recommendations (Croft et al., 2010; Kreider et al., 2010; Rodriguez et al.,
2009). This consideration was supported by Goosey-Tolfrey and Crosland (2010)

306 Ferro et al.
APAQ Vol. 34, No. 3, 2017
and Krempien and Barr (2012), who showed dietary intakes of 4.3 g/kg and 4.4
g/kg of carbohydrates, respectively. In addition, calculating an intake of 5 g/kg of
carbohydrates, which is at the lower limit of the recommendations of the ACSM
for healthy active people (Rodriguez et al., 2009), would result in 1,500 kcal for a
body weight of 75 kg, leading to a high contribution of 60% carbohydrates by an
assumed energy intake of 2,500 kcal. Interestingly, the athletes did not reach these
smaller amounts of carbohydrates in either May (3.8 ± 1.3 g/kg) or June (4.2 ± 1.9
g/kg), except for one athlete in May and three in June, which is attributed to their
high fat intake during the training camps that was at the upper limit of recommen-
dations and could have been reduced in favor of carbohydrates. In contrast, their
protein intakes in May and June were 1.7 ± 0.6 and 1.5 ± 0.5 g/kg, respectively,
which were well within the recommendations. Even if the participants reached
protein recommendations for optimal recovery as a group, special care should be
taken for each individual because a higher intake of protein might be necessary
to support and promote the healing of pressure ulcers or wounds, which are often
seen in wheelchair athletes (Lee, Posthauer, Dorner, Redovian, & Maloney, 2006).
In addition to the amount of carbohydrates consumed per day, the timing of
consumption in relation to trainings sessions is also important, and the training
sessions were held twice per day, once in the morning and once in the afternoon.
In able-bodied athletes, limited glycogen stores lasted from 90 min up to 3 hr,
depending on exercise intensity, so carbohydrate intake of between 1 and 4 g/kg is
recommended before exercise (Kreider et al., 2010; Rodriguez et al., 2009). Our
results showed a signicant increase in carbohydrate intake at breakfast from May
to June, from 0.8 ± 0.5–1.0 ± 0.5 g/kg, which reached the lower limit of the rec-
ommendations. On an individual level, approximately half of the players achieved
1 g/kg, but after an overnight fast, with depleted glycogen stores, particularly in
the liver, and training sessions in the morning, it should be favorable for all play-
ers to reach at least the lower limit of the recommendations (Kreider et al., 2010;
Rodriguez et al., 2009).
Another important component to discuss is the avoidance of fatigue and hypo-
glycemia of more than 60 min during exercise because of low liver and muscle
glycogen stores. Therefore, a 30–90 g/h carbohydrate intake during exercise is
recommended (Kreider et al., 2010; Rodriguez et al., 2009; Thomas et al., 2016).
Because the participants consumed only half of the possible snacks during exercise,
the amount of carbohydrates was below this recommendation. Reasons could be
less intensive training sessions than assumed or the strategy to avoid using the
toilet during training.
Finally, to recover from exercise, refueling of glycogen stores with 1–1.2 g/
kg carbohydrates is recommended between training sessions (Kreider et al., 2010;
Rodriguez et al., 2009). During lunch, the participants consumed higher amounts
of carbohydrates in May and in June (1.5 ± 0.7 and 1.9 ± 0.9 g/kg, respectively),
with 8 athletes above the upper limit in May and 7 in June. One to 1.5 g/kg carbo-
hydrates should be ingested to refuel after exercise (Kreider et al., 2010; Rodriguez
et al., 2009). At dinner, we found a carbohydrate intake of 1.1 ± 0.6 g/kg in May
and 0.9 ± 0.6 g/kg in June, with 7 athletes in both May and June below the recom-
mendations. This amount could have easily increased with an appropriate evening
snack. In fact, besides common reasons to avoid an evening snack, such as over-
consumption at dinner or being exhausted and going early to bed, digestion time

Nutritional Habits and Performance in Wheelchair Basketball 307
APAQ Vol. 34, No. 3, 2017
differs widely among individuals with SCIs, and therefore individual solutions for
disabled athletes seem essential to overcome these difculties.
Overall, the ratio between carbohydrates and fat was insufcient, with fat
consumption above the recommendations. Although the composition of breakfast
improved signicantly, both the total amount and the distribution of fat at lunch
did not change despite our written and oral feedback. A reduction of fat at lunch
should have led to higher carbohydrate amounts, reaching recommendations of 5
g/kg carbohydrates (Kreider et al., 2010; Rodriguez et al., 2009). In contrast, the
recommended protein intake could be reached with a normal diet without supple-
ments, as previously shown by Goosey-Tolfrey and Crosland (2010) and Krempien
and Barr (2012). One-third of the participants failed to reach the recommenda-
tions, which was comparable to the ndings of Ribeiro, da Silva, de Castro, and
Tirapegui (2005), who reported that 35% of wheelchair athletes had below-normal
levels of the serum insulin-like growth factor-1 (IGF-1), a sensitive indicator of
protein nutritional status. Our advice between the two training camps regarding
the personal intentions were successful, and the two players who had an intention
reached their goal to gain and lose weight, respectively.
Our results revealed the limited usefulness of calculating energy expenditure
of wheelchair athletes with existing estimations. The energy intake of ours athletes
was greater than their energy expenditure by about 1,000 kcal/day, calculated
according to Collins et al. (2010), which is probably an overestimation, since their
body weights remained stable from May to June, indicating that their real energy
expenditure was much closer to their energy intake than that 1,000 kcal/day gap
implies. However, because we expected an overestimation, we used the compendium
from Collins et al. (2010) only to compare the intensity of the training camps. Sprint
measurements of nondisabled athletes by laser technology have been shown to be
less accurate during the start of the sprint, because the center of mass moves in
relation to the lower back (Simperingham et al., 2016). But these limitations affect
only the start, and the measurement of distances over 10 m showed high validity
(Simperingham et al., 2016). Together with the fact that the laser hits the backrest
of the wheelchair and not the moving lower back, our measurement of the average
velocity over a 20 m sprint should be accurate.
Wheelchair basketball players showed a lower meal frequency than able-bodied
athletes. Although their energy expenditure is lower, their low snack frequency
leads to higher energy intake during main meals in relation to total energy intake.
Therefore, nutritional advice for wheelchair players seems to be necessary to correct
imbalances, such as carbohydrate intake below recommendations and fat intake
above recommendations. As this is the rst study that investigated meal frequency
in wheelchair basketball athletes, our results could not be compared with other
investigations, such as Burke et al., 2003; Erdman et al., 2013; Garrido et al., 2007;
and Nogueira & Da Costa, 2004. Although training camps during precompetitive
phases and championships are common for elite athletes, future studies should
investigate meal frequency of wheelchair basketball players at home.
In conclusion, the current study observed on the one hand a lower energy
expenditure of wheelchair basketball players compared with their able-bodied
counterparts, and on the other, a high energy intake in main meals in relation
to total energy intake. Therefore the strategy to reach energy balance through
higher meal frequency and lower energy intake during the main meals might

308 Ferro et al.
APAQ Vol. 34, No. 3, 2017
be one possible solution to enhance performance. Following sports nutrition
principles for nutrient timing, particularly for carbohydrates in relation to train-
ing sessions, could improve wheelchair basketball players’ performance and
their macronutrient contribution because of more balanced main dishes and
more frequent snacks. The individual requirements always have to be taken into
account, and longer nutritional interventions are required to correct imbalances
and improve dietary habits of male wheelchair basketball players, as shown in
our study. Basic knowledge about sports nutrition should be improved to ensure
health and performance improvements. Nevertheless, further studies should be
conducted to conrm these hypotheses.
Acknowledgments
To the Ministry of Economy and Competitiveness (MINECO) for the project funding through
the National Plan R&D&I (DEP2012-38785); to the High Council for Sport (CSD) for their
support; and to the Spanish Sports Federation for People with Physical Disabilities (FEDDF)
and their wheelchair basketball players for participating in this study.
References
Abel, T., Platen, P., Rojas Vega, S., Schneider, S., & Struder, H.K. (2008). Energy expendi-
ture in ball games for wheelchair users. Spinal Cord, 46(12), 785–790. doi:10.1038/
sc.2008.54; 10.1038/sc.2008.54
Bernardi, M., Guerra, E., Di Giacinto, B., Di Cesare, A., Castellano, V., & Bhambhani, Y.
(2010). Field evaluation of Paralympic athletes in selected sports: Implications for
training. Medicine and Science in Sports and Exercise, 42(6), 1200–1208. PubMed
Bescos Garcia, R., & Rodriguez Guisado, F.A. (2011). Low levels of vitamin D in profes-
sional basketball players after wintertime: Relationship with dietary intake of vitamin
D and calcium. Nutricion Hospitalaria, 26(5), 945–951. PubMed
Broad, E., & Burke, L. (2014). Principles of sports nutrition. In E. Broad (Ed.), Sports nutri-
tion for Paralympic athletes (pp. 23–66). Boca Raton; FL: CRC Press. doi:10.1201/
b16375-4
Burke, L.M., Slater, G., Broad, E.M., Haukka, J., Modulon, S., & Hopkins, W.G. (2003).
Eating patterns and meal frequency of elite Australian athletes. International Journal
of Sport Nutrition and Exercise Metabolism, 13(4), 521–538. PubMed doi:10.1123/
ijsnem.13.4.521
Canda, A. (2009). Stature estimation from body segment lengths in young adults—Appli-
cation to people with physical disabilities. Journal of Physiological Anthropology,
28(2), 71–82.
Collins, E.G., Gater, D., Kiratli, J., Butler, J., Hanson, K., & Langbein, W.E. (2010). Energy
cost of physical activities in persons with spinal cord injury. Medicine and Science in
Sports and Exercise, 42(4), 691–700. PubMed doi:10.1249/MSS.0b013e3181bb902f
Cooper, R.A., & De Luigi, A.J. (2014). Adaptive sports technology and biomechanics:
Wheelchairs. PM & R, 6(8, Suppl.) S31–S39. PubMed doi:10.1016/j.pmrj.2014.05.020
Croft, L., Dybrus, S., Lenton, J., & Goosey-Tolfrey, V. (2010). A comparison of the physio-
logical demands of wheelchair basketball and wheelchair tennis. International Journal of
Sports Physiology and Performance, 5(3), 301–315. PubM ed doi:10.1123/ijspp.5.3.301
De Groot, S., Balvers, I.J.M., Kouwenhoven, S.M., & Janssen, T.W. (2012). Validity and
reliability of tests determining performance-related components of wheelchair bas-
ketball. Journal of Sports Sciences, 30(9), 879–887. PubMed doi:10.1080/0264041
4.2012.675082

Nutritional Habits and Performance in Wheelchair Basketball 309
APAQ Vol. 34, No. 3, 2017
Erdman, K.A., Tunnicliffe, J., Lun, V.M., & Reimer, R.A. (2013). Eating patterns and
composition of meals and snacks in elite Canadian athletes. International Journal
of Sport Nutrition and Exercise Metabolism, 23(3), 210–219. PubMed doi:10.1123/
ijsnem.23.3.210
Ferro, A. (2012). BioLaserSport®. Trademark n° 3019808/9. Ofcial Bulletin of Industrial
Property (B.O.P.I.):12.06.2012.
Ferro, A., & Floría, P. (2010). Kinematic analysis system in real time for training and sports
competitions. Patent ES2331170A1 (A61B 5/11-G01S 11/00). BOPI: 22.12.2009.
Ferro, A., Villacieros, J., & Pérez-Tejero, J. (2016). Sprint performance of elite wheelchair
basketball players: Applicability of a laser system for describing the velocity curve.
Adapted Physical Activity Quarterly, 33, 358–373. PubMed doi:10.1123/APAQ.2015-
0067
Garrido, G., Webster, A.L., & Chamorro, M. (2007). Nutritional adequacy of different menu
settings in elite Spanish adolescent soccer players. International Journal of Sport Nutri-
tion and Exercise Metabolism, 17(5), 421–432. PubMed doi:10.1123/ijsnem.17.5.421
Goosey-Tolfrey, V. (2010). Supporting the Paralympic athlete: Focus on wheeled sports.
Disability and Rehabilitation, 32(26), 2237–2243. PubMed doi:10.3109/09638288.
2010.491577
Goosey-Tolfrey, V., & Crosland, J. (2010). Nutritional practices of competitive British
wheelchair games players. Adapted Physical Activity Quarterly, 27(1), 47–59. PubM ed
doi:10.1123/apaq.27.1.47
Knechtle, B., Muller, G., Willmann, F., Eser, P., & Knecht, H. (2003). Comparison of fat
oxidation in arm cranking in spinal cord-injured people versus ergometry in cyclists.
European Journal of Applied Physiology, 90(5-6), 614–619. PubMed doi:10.1007/
s00421-003-0920-5
Kreider, R.B., Wilborn, C.D., Taylor, L., Campbell, B., Almada, A.L., Collins, R., . . .
Antonio, J. (2010). ISSN exercise & sport nutrition review: Research & recom-
mendations. Journal of the International Society of Sports Nutrition, 7, 7-2783-7-7.
doi:10.1186/1550-2783-7-7
Krempien, J.L., & Barr, S.I. (2011). Risk of nutrient inadequacies in elite Canadian athletes
with spinal cord injury. International Journal of Sport Nutrition and Exercise Metabo-
lism, 21(5), 417–425. PubMed doi:10.1123/ijsnem.21.5.417
Krempien, J.L., & Barr, S.I. (2012). Eating attitudes and behaviours in elite Canadian ath-
letes with a spinal cord injury. Eating Behaviors, 13(1), 36–41. PubMed doi:10.1016/j.
eatbeh.2011.11.005
Lee, S.K., Posthauer, M.E., Dorner, B., Redovian, V., & Maloney, M.J. (2006). Pressure
ulcer healing with a concentrated, fortied, collagen protein hydrolysate supplement:
A randomized controlled trial. Advances in Skin & Wound Care, 19(2), 92–96. PubMed
doi:10.1097/00129334-200603000-00011
Leicht, C.A., Bishop, N.C., & Goosey-Tolfrey, V. (2012). Submaximal exercise responses
in tetraplegic, paraplegic and nonspinal cord injured elite wheelchair athletes.
Scandinavian Journal of Medicine & Science in Sports, 22(6), 729–736. PubMed
doi:10.1111/j.1600-0838.2011.01328.x
Levine, A.M., Nash, M.S., Green, B.A., Shea, J.D., & Aronica, M.J. (1992). An examination
of dietary intakes and nutritional status of chronic healthy spinal cord injured individu-
als. Paraplegia, 30(12), 880–889. PubMed doi:10.1038/sc.1992.165
Lin, V.W., Kim, K.H., Hsiao, I., & Brown, W. (2002). Functional magnetic stimulation
facilitates gastric emptying. Archives of Physical Medicine and Rehabilitation, 83(6),
806–810. PubMed doi:10.1053/apmr.2002.32644
Nogueira, J.A., & Da Costa, T.H. (2004). Nutrient intake and eating habits of triathletes on
a Brazilian diet. International Journal of Sport Nutrition and Exercise Metabolism,
14(6), 684–697. PubMed doi:10.1123/ijsnem.14.6.684

310 Ferro et al.
APAQ Vol. 34, No. 3, 2017
Price, M.J. (2006). Thermoregulation during exercise in individuals with spinal cord injuries.
Sports Medicine (Auckland, N.Z.), 36(10), 863–879. PubMed doi:10.2165/00007256-
200636100-00005
Rastmanesh, R., Taleban, F.A., Kimiagar, M., Mehrabi, Y., & Salehi, M. (2007). Nutritional
knowledge and attitudes in athletes with physical disabilities. Journal of Athletic Train-
ing, 42(1), 99–105. PubMed
Ribeiro, S.M.L., da Silva, R.C., de Castro, I.A., & Tirapegui, J. (2005). Assessment of
nutritional status of active handicapped individuals. Nutrition Research (New York,
N.Y.), 25(3), 239–249. doi:10.1016/j.nutres.2004.12.006
Rodriguez, N.R., DiMarco, N.M., Langley, S. (2009). Position of the American Dietetic
Association, Dietitians of Canada, and the American College of Sports Medicine:
Nutrition and athletic performance. Journal of the American Dietetic Association,
109(3), 509–527. PubMed doi:10.1016/j.jada.2009.01.005
Simperingham, K.D., Cronin, J.B., & Ross, A. (2016). Advances in sprint acceleration pro-
ling for eld-based team-sport athletes: Utility, reliability, validity and limitations.
Sports Medicine (Auckland, N.Z.), 46(11), 1619–1645. doi:10.1007/s40279-016-0508-y
Thomas, D.T., Erdman, K.A., & Burke, L.M. (2016). Position of the Academy of Nutrition
and Dietetics, Dietitians of Canada, and the American College of Sports Medicine:
Nutrition and athletic performance. Journal of the Academy of Nutrition and Dietetics,
116(3), 501–528. PubMed doi:10.1016/j.jand.2015.12.006
Vanlandewijck, Y., Daly, D., & Theisen, D. (1999). Field test evaluation of aerobic, anaerobic,
and wheelchair basketball skill performances. International Journal of Sports Medicine,
20(8), 548–554. PubMed doi:10.1055/s-1999-9465
Vanlandewijck, Y., Theisen, D., & Daly, D. (2001). Wheelchair propulsion biomechanics:
Implications for wheelchair sports. Sports Medicine (Auckland, N.Z.), 31(5), 339–367.
PubMed doi:10.2165/00007256-200131050-00005
Williams, J.R. (2008). The Declaration of Helsinki and public health. Bulletin of the World
Health Organization, 86(8), 650–652. PubMed doi:10.2471/BLT.08.050955
Yanci, J., Granados, C., Otero, M., Badiola, A., Olasagasti, J., Bidaurrazaga-Letona, I., . . .
Gil, S. (2015). Sprint, agility, strength and endurance capacity in wheelchair basketball
players. Biology of Sport, 32(1), 71–78. PubMed doi:10.5604/20831862.1127285