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Refeeding syndrome, as a life-threatening condition, is well known among severely malnourished or deeply metabolically stressed patients. This case presents an atypical manifestation of the syndrome to a young bodybuilder, whose extreme diet, including 5 months of insufficient nourishment before the sport competition and 6 days of carbohydrates overload afterwards, has led him to a bilateral lower - limb paralysis and drastic homeostatic disturbances. Severe hypokalemia, hypophosphatemia, hypomagnesemia and hyperglycemia with mildly elevated liver enzymes have occurred. The patient could barely move his legs and arms, and his state has been followed by a hypertensive crisis, which required an immediate intravenous treatment. Although his weight was 112,5 kg with a body mass index of 32,2 kg per square meter, and his blood serum albumin concentration resulted inside the normal range, the overall condition was corresponding to the state of extenuated and malnourished patients. This case reflects to high prevalence of eating disorders or non-adequate nutrition among weight-sensitive sport athletes. The importance of prevention and opportune diagnostics of refeeding syndrome among special vulnerable groups should be considered.
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Consequences of an extreme diet in the professional sport: Refeeding
syndrome to a bodybuilder
e Lapinskien _
, Gabija Mikulevi
cien _
, Gabija Laubner
, Robertas Badaras
Republican Vilnius University Hospital, Centre of Toxicology, Lithuania
Vilnius University, Faculty of Medicine, Centre of Toxicology, Lithuania
article info
Article history:
Received 3 September 2017
Accepted 17 October 2017
Refeeding syndrome, as a life-threatening condition, is well known among severely malnourished or
deeply metabolically stressed patients. This case presents an atypical manifestation of the syndrome to a
young bodybuilder, whose extreme diet, including 5 months of insufcient nourishment before the sport
competition and 6 days of carbohydrates overload afterwards, has led him to a bilateral lower elimb
paralysis and drastic homeostatic disturbances. Severe hypokalemia, hypophosphatemia, hypomagne-
semia and hyperglycemia with mildly elevated liver enzymes have occurred. The patient could barely
move his legs and arms, and his state has been followed by a hypertensive crisis, which required an
immediate intravenous treatment. Although his weight was 112,5 kg with a body mass index of 32,2 kg
per square meter, and his blood serum albumin concentration resulted inside the normal range, the
overall condition was corresponding to the state of extenuated and malnourished patients. This case
reects to high prevalence of eating disorders or non-adequate nutrition among weight-sensitive sport
athletes. The importance of prevention and opportune diagnostics of refeeding syndrome among special
vulnerable groups should be considered.
©2017 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights
Refeeding as a life threatening condition has been known since
the World War II [1].Itisdened as a non-immune syndrome,
caused by metabolic disturbances, such as uid and electrolyte
shifts, to people who happen to be severely malnourished or deeply
metabolically stressed [2,3]. It occurs when nutrition is reintro-
duced into an organism after a period of starvation or fasting [4]
and can be expressed as a mild, moderate or severe stage of
health disturbance [5]. The spectrum of presentation ranges from
nausea and vomiting, to respiratory insufciency, cardiac arrhyth-
mias, delirium, coma and death [6]. The risk of developing the
syndrome is directly linked to the amount of weight, which is lost
during the starvation episode and the rapidity of the weight
restoration process [7]. Other risk factors, which could be also used
to recognise the syndrome, are: low baseline levels of phosphate,
potassium, magnesium, thiamine and little or no nutritional intake
for 5e10 days [8]. Refeeding syndrome is mostly common among
vulnerable groups of people, such as cancer patients (up to 25%)
and hospitalized for anorexia nervosa patients (6% in severe cases
and 22% in mild cases), hospitalized geriatric patients (around 70%)
and extremely preterm infants [9e12]. However, there are some
other special groups, for instance, professional athletes, among
whom strict dietary routine may also become a risk factor [13,14].
Case presentation
We report a case of a 28-year-old man, who was admitted to the
Emergency Department on the 20th of June 2016, due to a sudden
bilateral lower limb paralysis (Medical Research Council (MRC)
Scale for Muscle Strength eGrade 2). He had no history of injury or
trauma, as well as other previous illness or disability, remained
fully conscious (Glasgow Coma Score (GCS) 15) during the exami-
nation and had no other complaints except muscle weakness. Ac-
cording to the anamnesis and visibly pronounced general muscle
hypertrophy, the patient was a professional bodybuilder, attending
an annual international tness competition. Two days after the
*Corresponding author. Republican Vilnius University Hospital, Siltnamiu 29, LT
04130 Vilnius, Lithuania.
E-mail address: (G. Mikulevi
cien _
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Clinical Nutrition ESPEN xxx (2017) e1ee3
Please cite this article in press as: Lapinskien_
e I, et al., Consequences of an extreme diet in the professional sport: Refeeding syndrome to a
bodybuilder, Clinical Nutrition ESPEN (2017),
event (where he became a vice echampion) he started to feel
annoying muscle cramps and palpitations, and after one more day a
bilateral leg paralysis and whole body weakness occurred. While
preparing for the competition, he admitted being on a special diet,
which included a suppressed nutrient income regime for one
month and then a massive consumption of carbohydrates just a few
days after the event. Although his usual diet routine consisted of
1000 g of different types of grains, plus 500 g of lean meat per day,
while preparing for the competition all carbohydrates step-by-step
were eliminated from the regime within a four-month period and
for the last month before the event patient was using no carbo-
hydrates at all. Energy requirements had to be compensated by
other nutrients eproteins and fats ealone. Fast-acting carbohy-
drates (such as chocolate bars) were used only on the competition
day and after the event e800 g of various carbohydrates eevery
day for 5 more days. The patient strongly denied using any medi-
cine or other chemical substances, only some legal dietary sup-
plements, including protein shakes and multivitamins. During the
preparations stage he lost 19 kg of body mass and on admission to
the hospital day his weight was 112,5 kg and his height e1,87 m.
Vital parameters were: arterial blood pressure (BP) 190/100 mmHg,
heart rate (HR) 86 beats per minute, peripheral oxygen saturation
96%, body temperature 37,2
C. According to the anamnesis and
clinical symptoms, refeeding syndrome was suspected as a primary
diagnosis. A broad spectrum analysis of his blood tests was chosen.
His venous blood showed severe hypokalemia (1,50 mmol/L),
hypophosphatemia (0,20 mmol/L), relatively low magnesium con-
centration (0,77 mmol/L), hyperglycemia (13,20 mmol/L or
237,60 mg/dL), elevated creatine kinase (2600 U/L) and liver func-
tion parameters (aspartate aminotransferase 92 U/L, alanine
aminotransferase 112 U/L), serum lactate 2,3 mmol/L. Other mea-
surements (pH, sodium, chloride, calcium, c-reactive protein, tro-
ponine I, serum creatinine) varied at normal ranges, serum albumin
was 47,32 g/L. According to bioimpedance analysis, an approach for
body composition, his body mass index (BMI) was 32,2 kg/m
, lean
tissue index (LTI) 22,5 kg/m
, fat tissue index (FTI) 10,1 kg/m
26 kg (23,1%) of total body fat. Electrocardiography showed U-
waves, conrming the hypokalemic state. The patient felt a whole
body weakness. He could barely move his legs (MRC muscle
strength grade 2) and the grip strength of his right (R) and left (L)
hands was correspondingly: R 40 N and L 10 N according to
dynamometric measurement, while comparing to an average grip
strength of a 24-29 year-old male: 538 N (R) and 494 N (L) [15]. The
patient was admitted to the Intensive care unit (ICU), where he was
immediately given an intravenous potassium infusion (180,5 g
totally, during the stay in ICU), as well as other electrolyte (phos-
phorus, magnesium) and uid supplementation. Hyperglycemia
was corrected with intravenous insulin infusion (66,5 Units totally
within 34 h) and hypertensive crisis was controlled by using
nitroglycerine intravenously. A special consideration was
approached to the patient's nutrition plan. He was given a balanced
diet, composed by a clinical dietician, as well as an oral micro-
nutrient supplementation, together with injectable vitamins and
other vital microelements. Hyperglycemia and aggressive arterial
hypertension were corrected during the rst 48 h hospital stay.
Fatigue and muscle strength recovered gradually (Fig. 1) in 3 days
time. After being 2 days in ICU, the patient was moved to an in-
patient department where he stayed for 2 more days and after-
wards was discharged from the hospital without any residual
outcomes. He underwent a health screening program on April 2017.
Blood serology tests (without variances from normal range) and
MRC muscle strength (grade 5) with the measured grip strength of
his right (420 N) and left (420 N) hands showed a recovery after the
This is an atypical case and manifestation of refeeding syn-
drome. Bodybuilders are a specic group of people, usually having a
strict dietetic routine [16e18] . According to literature, three phases
have been described. The rst phase involves few months of
hypercaloric nutrition rich in proteins, for the build-up of muscle
mass. The second phase is a period of restricted caloric intake to
reduce subcutaneous fat. The third phase, during the last week of
preparations, includes simultaneous extreme carbohydrate intake
to load muscle glycogen, sodium, and water restriction to produce
subcutaneous volume decit and better denition of muscle con-
tours [19]. Our patient, while preparing for the competition, by
eliminating all carbohydrates from his diet before the event and
restoring their income (in sizeable amounts) right after it, has
modied the last two phases in his own way. However, the
mechanism of the process remains the same. The second phase,
especially if it lasts more than a few days, leads to a starvation ef-
fect. During starvation blood glucose level begins to fall within
24e72 h [20]. As glucose is essential to the body, organism tries to
maintain its concentration by glycogenolysis and gluconeogenesis.
Glycogen stores usually last up to 72 h [21]. and for further main-
tenance of homeostasis other substances, such as fatty acids and
8 p.m 11 p.m. 8 a.m 11 a.m 6 p.m 9 p.m 8 a.m 11 a.m 6 p.m 9 p.m 8 a.m 11 a.m
Fig. 1. Grip strength (Newtons) of the right (R) and left (L) hands during the 1st e4th days of hospitalisation (measured using an isometric hand grip dynamometer).
I. Lapinskien_
e et al. / Clinical Nutrition ESPEN xxx (2017) e1ee3e2
Please cite this article in press as: Lapinskien_
e I, et al., Consequences of an extreme diet in the professional sport: Refeeding syndrome to a
bodybuilder, Clinical Nutrition ESPEN (2017),
amino acids, are being used (Krebs and Cori cycles) [22]. During this
metabolic adaptation a resultant loss of body fat and protein, as
well as depletion of elements, especially, phosphate, potassium and
magnesium, occurs [23]. Insulin stimulates the absorption of po-
tassium into the cells through the sodium-potassium ATPase pump,
which also transports glucose into the cells. Magnessium is also
taken into the cells. Stimulation of glycolysis increases formation of
phosphorylated carbohydrate compounds in liver and skeletal
muscle, which source is inorganic phosphate in the extracellular
uid [24]. A decrease in serum levels of these elements occurs. Our
psatient, within his second phase of preparations, lost 19 kg. During
the third phase situation became even worse when a huge intake of
glucose provoked hyperinsulinemia. Insulin, by transporting
glucose into cells, has as well activated potassium transport. As
extracellular storages of potassium and other nutrients have
already been depleted during the second phase, a shift of extra-
cellular electrolytes has increased the decit and initiated muscle
spasms and weakness, which led to the condition we have
mentioned before. Although multivitamins and other dietary sup-
plements have been used orally during the preparation stage, they
could not manage to cover the extracellular decit because of a
disturbed homeostasis and relatively low bioavailability. In this
case manifestation of refeeding syndrome was difcult to predict as
even after a starvation period the patient's BMI and total weight
could not show the threat. One of the markers of this condition
could be a low serum albumin concentration. It usually goes along
with hypophosphatemia [25]. However, as the bodybuilder had a
well-expressed musculature and his BMI and LTI were high
(32,2 kg/m
and 22.5 kg/m
correspondingly), albumin concentra-
tion varied in normal range (47,32 g/L). This situation supports the
idea that serum albumin not always correlates with nutritional
status and has a limited value as a nutritional marker [26]. Current
studies suggest a new variable ethe importance of energy avail-
ability (EA), which describes how much energy is available for the
basic metabolic functions of a human body, such as reproduction,
immunity and skeletal homeostasis. A low EA, the state when EA
reaches <30 kcal/kg of a fat free mass and when the lower limits of
body fat (~4e5% in males) are approached, the consequences result
in muscle loss, hormonal imbalance, psychological problems,
negatively affected cardiovascular system [27]. EA could become
one of the markers that show the risk of refeeding. According to our
case, despite fasting patient's body fat was 23,1%. He did not reach
the critical limit and that, as a result, ended in a relatively milder
physiological distress, as well as a faster recovery from the syn-
drome. Treatment of refeeding syndrome depends on the imme-
diate correction of the electrolyte and uid imbalance, as well as
other nutrients supplementation. According to the current guide-
lines, articial nutritional support is recommended to start
together with a correction of homeostatic abnormalities [28]. Our
patient has succeeded in a quick and complete recovery after the
syndrome due to an adequate treatment, balanced diet, his physi-
ological abilities and young age. However, not all such cases are
managed to be solved without any harmful consequences.
Commonly described high prevalence of eating disorders among
athletes [29e31], especially in weight-sensitive sports, shows the
problem of underdiagnosed refeeding cases in this population. The
importance of adequate diagnostic and prevention of the syndrome
despite normal or higher BMI should be reconsidered [32] and new
possibilities to a quicker and easier screening, which could be used
on a daily basis, introduced.
Conict of interest
The authors declare that there is no conict of interest regarding
this publication.
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e et al. / Clinical Nutrition ESPEN xxx (2017) e1ee3 e3
Please cite this article in press as: Lapinskien_
e I, et al., Consequences of an extreme diet in the professional sport: Refeeding syndrome to a
bodybuilder, Clinical Nutrition ESPEN (2017),
... Можливий розвиток РС у пацієнтів з ожирінням з явною та швидкою втратою ваги [3]. Також описуються окремі випадки розвитку РС серед спортсменів та військовослужбовців [1,2,5]. Наприклад, один із випадків прояву РС у молодого боди-білдера, який, готуючись до змагань, протягом п'яти місяців отримував недостатнє харчування (для зменшення відсотка жирового компонента тіла). ...
... Після цього протягом шести днів він перевантажувався вуглеводами, що призвело до двостороннього паралічу нижніх кінцівок і різких гомеостатичних порушень. Виникали тяжка гіпокаліємія, гіпофосфатемія, гіпомагніємія та гіперглікемія з помірним підвищенням рівня печінкових ферментів [5]. ...
... 4. Спортсмени у видах спорту, що потребують жорсткого контролю маси та складу тіла, мають підвищений ризик розладу харчової поведінки, а в деяких випадках, рефідинг-синдрому. 5. Обізнаність виявлення та менеджменту рефідинг-синдрому у спортсменів та осіб з групи ризику дозволяє запобігти розвитку загрозливих станів. ...
Full-text available
Резюме. Рефідинг-синдром (РС) визначається як зниження рівня фосфору, калію та/або магнію або прояв дефіциту тіаміну, що розвивається від кількох годин до кількох днів після початку надання калорій особі, яка зазнала тривалого періоду недоїдання. Мета. Дослідити сучасні дані про патогенез РС, настанови щодо його діагностики, профілактики та лікування, підвищити обізнаність спеціалістів про виявлення та менеджмент РС. Методи. Огляд сучасних настанов ASPEN щодо діагностики, профілактики та лікування РС. Результати. Визначено, що починати годування осіб, які зазнали тривалого періоду недоїдання, потрібно після визначення рівнів електролітів та ризику розвитку РС. За необхідності має проводитися корекція електролітних змін та обмеження надходження калорій. Спортсмени мають підвищений ризик розладу харчової поведінки, а в деяких випадках, рефідинг-синдром, що обумовлює необхідність в обізнаності виявлення і менеджменту РС. Ключові слова: рефідинг-синдром, мальнутриція, гіпофосфатемія, розлади харчової поведінки.
... The dangers of this are demonstrated by a case report of life-threatening hypokalemia and rhabdomyolysis in a 28-year-old bodybuilder who gained 10 kg in a 4-day eating binge shortly after a competition [116]. Another example has been reported for a different 28-year-old bodybuilder, who developed similar health issues after losing 19 kg prior to a bodybuilding contest and then consuming 800 g of carbohydrates daily for 5 days [117]. This "refeeding syndrome" might account for some of the deaths which happen within a week after a bodybuilding competition (of which there is one reported in Table 1, O.G.). ...
Full-text available
Premature deaths in bodybuilders regularly make headlines and are cited as evidence that bodybuilding is a dangerous activity. A wealth of research has revealed elite athletes typically enjoy lower mortality rates than non-athletes, but research on bodybuilder lifespan is surprisingly limited. Anabolic androgenic steroid (AAS) use is commonly cited as a key contributor to morbidity and premature mortality in bodybuilders, but this area of research is highly nuanced and influenced by numerous confounders unique to bodybuilding. It is quite possible that bodybuilders are at elevated risk and that AAS use is the primary reason for this, but there remains much unknown in this realm. As global participation in bodybuilding increases, and healthcare providers play a more active role in monitoring bodybuilder health, there is a need to identify how numerous factors associated with bodybuilding ultimately influence short- and long-term health and mortality rate. In this Current Opinion, we discuss what is currently known about the bodybuilder lifespan, identify the nuances of the literature regarding bodybuilder health and AAS use, and provide recommendations for future research on this topic.
... 19 Likewise, Lapinskienė et al described the case of a young body builder, who developed refeeding syndrome after starving himself for a competition and who presented with similar symptoms to our patient. 20 These cases, like the present one, illustrate that in the well-nourished western world, unsupervised prolonged hypocaloric diets or fasting, followed by rapidly reintroducing food, can lead to this life-threatening condition. Patients may reveal lifestyle-modifying interventions, such as the hCG diet, only after repeated inquiry. ...
We present the case of a young male patient who presented with paralysing muscle weakness due to severe hypokalaemia and hypophosphataemia. The initial patient history evaluations could not establish the aetiology. Only after we reviewed the patient’s history did he reveal that he had been following a severe calorie-restricted regime, the human chorionic gonadotropin diet, which had ended 2 days prior to developing symptoms. This information then allowed us to diagnose severe refeeding syndrome. As a further complication, the patient developed rhabdomyolysis. After correction of serum electrolytes, symptoms resolved completely. This case emphasises the potential harm of severely calorie-restricted diets, often recommended by online ‘experts’. Furthermore, we underline the importance of thorough history taking.
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Introduction: In the spring of 2017, the American Society for Parenteral and Enteral Nutrition (ASPEN) Parenteral Nutrition Safety Committee and the Clinical Practice Committee convened an interprofessional task force to develop consensus recommendations for identifying patients with or at risk for refeeding syndrome (RS) and for avoiding and managing the condition. This report provides narrative review and consensus recommendations in hospitalized adult and pediatric populations. Methods: Because of the variation in definitions and methods reported in the literature, a consensus process was developed. Subgroups of authors investigated specific issues through literature review. Summaries were presented to the entire group for discussion via email and teleconferences. Each section was then compiled into a master document, several revisions of which were reviewed by the committee. Findings/recommendations: This group proposes a new clinical definition, and criteria for stratifying risk with treatment and screening strategies. The authors propose that RS diagnostic criteria be stratified as follows: a decrease in any 1, 2, or 3 of serum phosphorus, potassium, and/or magnesium levels by 10%-20% (mild), 20%-30% (moderate), or >30% and/or organ dysfunction resulting from a decrease in any of these and/or due to thiamin deficiency (severe), occurring within 5 days of reintroduction of calories. Conclusions: These consensus recommendations are intended to provide guidance regarding recognizing risk and identifying, stratifying, avoiding and managing RS. This consensus definition is additionally intended to be used as a basis for further research into the incidence, consequences, pathophysiology, avoidance, and treatment of RS.
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The purpose of this study was to report and analyze the practices adopted by bodybuilders in light of scientific evidence and to propose evidence-based alternatives. Six (four male and two female) bodybuilders and their coaches were directly interviewed. According to the reports, the quantity of anabolic steroids used by the men was 500–750 mg/week during the bulking phase and 720–1160 mg during the cutting phase. The values for women were 400 and 740 mg, respectively. The participants also used ephedrine and hydrochlorothiazide during the cutting phase. Resistance training was designed to train each muscle once per week and all participants performed aerobic exercise in the fasted state in order to reduce body fat. During the bulking phase, bodybuilders ingested ~2.5 g of protein/kg of body weight. During the cutting phase, protein ingestion increased to ~3 g/kg and carbohydrate ingestion decreased by 10–20%. During all phases, fat ingestion corresponded to ~15% of the calories ingested. The supplements used were whey protein, chromium picolinate, omega 3 fatty acids, branched chain amino acids, poly-vitamins, glutamine and caffeine. The men also used creatine in the bulking phase. In general, the participants gained large amounts of fat-free mass during the bulking phase; however, much of that fat-free mass was lost during the cutting phase along with fat mass. Based on our analysis, we recommend an evidence-based approach by people involved in bodybuilding, with the adoption of a more balanced and less artificial diet. One important alert should be given for the combined use of anabolic steroids and stimulants, since both are independently associated with serious cardiovascular events. A special focus should be given to revisiting resistance training and avoiding fasted cardio in order to decrease the reliance on drugs and thus preserve bodybuilders' health and integrity.
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Electrolyte balances have not been sufficiently evaluated in extremely preterm infants after early parenteral nutrition. We investigated the risk of early hypophosphatemia and hypokalemia in extremely preterm infants born small for gestational age (SGA) who received nutrition as currently recommended. This prospective, observational cohort study included all consecutive extremely preterm infants born at 24 to 27 weeks who received high amino acids and lipid perfusion from birth. We evaluated the electrolyte levels of SGA infants and infants born appropriate for gestational age (AGA) during the first five days of life. The 12 SGA infants had lower plasma potassium levels from day one compared to the 36 AGA infants and were more likely to have hypokalemia (58% versus 17%, p = 0.001) and hypophosphatemia (40% versus 9%, p < 0.01) during the five-day observation period. After adjusting for perinatal factors, SGA remained significantly associated with hypophosphatemia (odds ratio 1.39, confidence intervals 1.07-1.81, p = 0.01). Extremely preterm infants born SGA who were managed with currently recommended early parenteral nutrition had a high risk of early hypokalemia and hypophosphatemia Potassium and phosphorus intakes should be set at sufficient levels from birth onwards, especially in SGA infants. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
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Competitive bodybuilders are well known for extreme physique traits and extremes in diet and training manipulation to optimize lean mass and achieve a low body fat. Although many of the dietary dogmas in bodybuilding lack scientific scrutiny, a number, including timing and dosing of high biological value proteins across the day, have more recently been confirmed as effective by empirical research studies. A more comprehensive understanding of the dietary intakes of bodybuilders has the potential to uncover other dietary approaches, deserving of scientific investigation, with application to the wider sporting, and potential health contexts, where manipulation of physique traits is desired. Our objective was to conduct a systematic review of dietary intake practices of competitive bodybuilders, evaluate the quality and currency of the existing literature, and identify research gaps to inform future studies. A systematic search of electronic databases was conducted from the earliest record until March 2014. The search combined permutations of the terms 'bodybuilding', 'dietary intake', and 'dietary supplement'. Included studies needed to report quantitative data (energy and macronutrients at a minimum) on habitual dietary intake of competitive bodybuilders. The 18 manuscripts meeting eligibility criteria reported on 385 participants (n = 62 women). Most studies were published in the 1980-1990s, with three published in the past 5 years. Study methodological quality was evaluated as poor. Energy intake ranged from 10 to 24 MJ/day for men and from 4 to 14 MJ/day for women. Protein intake ranged from 1.9 to 4.3 g/kg for men and from 0.8 to 2.8 g/kg for women. Intake of carbohydrate and fat was <6 g/kg/day and below 30 % of energy, respectively. Carbohydrate intakes were below, and protein (in men) intakes were higher than, the current recommendations for strength athletes, with no consideration for exploration of macronutrient quality or distribution over the day. Energy intakes varied over different phases of preparation, typically being highest in the non-competition (>6 months from competition) or immediate post-competition period and lowest during competition preparation (≤6 months from competition) or competition week. The most commonly reported dietary supplements were protein powders/liquids and amino acids. The studies failed to provide details on rationale for different dietary intakes. The contribution of diet supplements was also often not reported. When supplements were reported, intakes of some micronutrients were excessive (~1000 % of US Recommended Dietary Allowance) and above the tolerable upper limit. This review demonstrates that literature describing the dietary intake practices of competitive bodybuilders is dated and often of poor quality. Intake reporting required better specificity and details of the rationale underpinning the use. The review suggests that high-quality contemporary research is needed in this area, with the potential to uncover dietary strategies worthy of scientific exploration.
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Following DIY (do it yourself) diets as well as consuming supplements exceeding by far the recommended daily intake levels, is common among athletes; these dietary habits often lead to an overconsumption of some macro and/or micronutrients, exposing athletes to potential health risks. The aim of this study is to document the development of possible adverse effects in a 33 year-old amateur bodybuilder who consumed for 16 years a DIY high protein diet associated to nutrient supplementation. Body composition, biochemical measures and anamnestic findings were evaluated. We present this case to put on alert about the possible risks of such behavior repeated over time, focusing on the adverse gastrointestinal effects. We discuss the energy and nutrient composition of his DIY diet as well as the use of supplements. This study provides preliminary data of the potential risks of a long-term DIY dietary supplementation and a high protein diet. In this case, permanent abdominal discomfort was evidenced in an amateur body builder with an intake exceeding tolerable upper limit for vitamin A, selenium and zinc, according to our national and updated recommendations. As many amateur athletes usually adopt self-made diets and supplementation, it would be advisable for them to be supervised in order to prevent health risks due to a long-term DIY diet and over-supplementation.
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We report a case of life-threatening hypokalemia in a 28-year-old bodybuilder who presented with sudden onset bilateral lower limbs paralysis few days after his bodybuilding competition. His electrocardiogram (ECG) showed typical u-waves due to severe hypokalemia (serum potassium 1.6 mmol/L, reference range (RR) 3.5-5.0 mmol/L). He was admitted to the intensive care unit (ICU) and was treated with potassium replacement. The patient later admitted that he had exposed himself to weight loss agents of unknown nature, purchased online, and large carbohydrate loads in preparation for the competition. He made a full recovery after a few days and discharged himself from the hospital against medical advice. The severe hypokalemia was thought to be caused by several mechanisms to be discussed in this report. With the ever rising number of new fitness centers recently, the ease of online purchasing of almost any drug, and the increasing numbers of youngsters getting into the bodybuilding arena, clinicians should be able to recognize the possible causes of sudden severe hypokalemia in these patients in order to revert the pathophysiology.
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Abstract The prevalence of disordered eating and eating disorders vary from 0-19% in male athletes and 6-45% in female athletes. The objective of this paper is to present an overview of eating disorders in adolescent and adult athletes including: (1) prevalence data; (2) suggested sport- and gender-specific risk factors and (3) importance of early detection, management and prevention of eating disorders. Additionally, this paper presents suggestions for future research which includes: (1) the need for knowledge regarding possible gender-specific risk factors and sport- and gender-specific prevention programmes for eating disorders in sports; (2) suggestions for long-term follow-up for female and male athletes with eating disorders and (3) exploration of a possible male athlete triad.
Background and aims Despite the high prevalence of malnutrition among older hospitalized persons, it is unknown how many of these malnourished patients are at risk of developing the refeeding syndrome (RFS). In this study, we sought to compare the prevalence and severity of malnutrition among older hospitalized patients with prevalence of known risk factors of RFS. Methods This cross-sectional multicenter-study investigated older participants who were consecutively admitted to the geriatric acute care ward. Malnutrition screening was conducted using Nutritional Risk Screening (NRS-2002), Malnutrition Universal Screening Tool (MUST) and Mini Nutritional Assessment-Short Form (MNA-SF). The National Institute for Health and Clinical Excellence (NICE) criteria were applied for assessing patients at risk of RFS. Weight and height were measured. Degree of weight loss (WL) was obtained by interview. Serum phosphate, magnesium, potassium, sodium, calcium, creatinine and urea were analyzed according to standard procedures. Results The study group comprised 342 participants (222 females) with a mean age of 83.1± 6.8 and BMI range of 14.7–43.6 kg/m². More participants were assessed at risk of malnutrition using NRS-2002 (n=253, 74.0%) compared to MUST (n=170, 49.7%) and MNA-SF (n=191, 55.8%). Of total participants, 239 (69.9%; 157 females) were considered to be at risk of RFS. Based on NRS-2002, 75.9% (n=192) of patients at risk of malnutrition are at risk of RFS whereas according to MUST and MNA-SF, 85.9 % (n=146) and 69.1% (n=132) of patients at risk of malnutrition are exposed to high risk of RFS, respectively. In addition, the prevalence of risk of RFS is significantly increased with higher score of NRS-2002 and MUST and lower score of MNA-SF. In a stepwise multiple regression analysis, disease severity (38.2%), WL in 3 months (20.3%) and BMI (33.3%) mainly explained variance in NRS-2002, MUST and MNA-SF scores, respectively, in patients with risk of RFS. Conclusion Nearly three-quarters of geriatric hospitalized patients with risk of malnutrition demonstrated significant risk of RFS. Therefore, additional screening for risk of RFS in patients screened for malnutrition appears to be abdicable among this population.
Energy availability (EA) is a scientific concept describing how much energy is available for basic metabolic functions such as reproduction, immunity and skeletal homeostasis. Carefully controlled studies on women have shown pathological effects of EA<30kcal/kg fat free mass (FFM) and this state has been labeled low EA (LEA). Bodybuilding is a sport in which athletes compete to show muscular definition, symmetry and low body fat. The process of contest preparation in bodybuilding includes months of underfeeding, thus increasing the risk of LEA and its negative health consequences. Since no well-controlled studies have been conducted in natural male bodybuilders on effects of LEA, the aim of this review was to summarize what can be extrapolated from previous relevant research findings in which EA can be calculated. The reviewed literature indicates that a prolonged EA<25kcal/kgFFM results in muscle loss, hormonal imbalances, psychological problems, and negatively affects the cardiovascular system when approaching the lower limits of body fat (~4-5%) among males. Case-studies on natural male bodybuilders who prepare for contest show muscle loss (>40% of total weight loss) with EA<20kcal/kgFFM, and in the study with the lowest observed body fat (~4kg) major mood disturbance and hormonal imbalances co-occurred. Studies also underline the problem of body fat overshoot during refeeding after extremes of LEA among males. A more tempered approach (EA>25kcal/kgFFM) might result in less muscle loss among natural male bodybuilders who prepare for contest, but more research is needed.
Background: Equipoise exists regarding the benefits of restricting caloric intake during electrolyte replacement for refeeding syndrome, with half of intensive care specialists choosing to continue normal caloric intake. We aimed to assess whether energy restriction affects the duration of critical illness, and other measures of morbidity, compared with standard care. Methods: We did a randomised, multicentre, single-blind clinical trial in 13 hospital intensive care units (ICUs) in Australia (11 sites) and New Zealand (two sites). Adult critically ill patients who developed refeeding syndrome within 72 h of commencing nutritional support in the ICU were enrolled and allocated to receive continued standard nutritional support or protocolised caloric restriction. 1:1 computer-based randomisation was done in blocks of variable size, stratified by enrolment serum phosphate concentration (>0·32 mmol/L vs ≤0·32 mmol/L) and body-mass index (BMI; >18 kg/m(2)vs ≤18 kg/m(2)). The primary outcome was the number of days alive after ICU discharge, with 60 day follow-up, in a modified intention-to-treat population of all randomly allocated patients except those mistakenly enrolled. Days alive after ICU discharge was a composite outcome based on ICU length of stay, overall survival time, and mortality. The Refeeding Syndrome Trial was registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR number 12609001043224). Findings: Between Dec 3, 2010, and Aug 13, 2014, we enrolled 339 adult critically ill patients: 170 were randomly allocated to continued standard nutritional support and 169 to protocolised caloric restriction. During the 60 day follow-up, the mean number of days alive after ICU discharge in 165 assessable patients in the standard care group was 39·9 (95% CI 36·4-43·7) compared with 44·8 (95% CI 40·9-49·1) in 166 assessable patients in the caloric restriction group (difference 4·9 days, 95% CI -2·3 to 13·6, p=0·19). Nevertheless, protocolised caloric restriction improved key individual components of the primary outcome: more patients were alive at day 60 (128 [78%] of 163 vs 149 [91%] of 164, p=0·002) and overall survival time was increased (48·9 [SD 1·46] days vs 53·65 [0·97] days, log-rank p=0·002). Interpretation: Protocolised caloric restriction is a suitable therapeutic option for critically ill adults who develop refeeding syndrome. We did not identify any safety concerns associated with the use of protocolised caloric restriction. Funding: National Health and Medical Research Council of Australia.
After the passage of Title IX in 1972, female sports participation skyrocketed. In 1992, the female athlete triad was first defined; diagnosis required the presence of an eating disorder, amenorrhea, and osteoporosis. However, many athletes remained undiagnosed because they did not meet all three of these criteria. In 2007, the definition was modified to a spectrum disorder involving low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density. With the new definition, all three components need not be present for a diagnosis of female athlete triad. Studies using the 1992 definition of the disorder demonstrated a prevalence of 1% to 4% in athletes. However, in certain sports, many female athletes may meet at least one of these criteria. The actual prevalence of athletes who fall under the "umbrella" diagnosis of the female athlete triad remains unknown. Copyright 2015 by the American Academy of Orthopaedic Surgeons.