Bone Injury in Athletes with Inadequate Calcium Intake

A Personal reflection!

As many of my friends and clients know, I have been dealing with a broken finger on my left hand. I have had multiple surgeries, the last being at end of 2017. Not happy with the result. First words from orthopedics mouth were my bones are in a disastrous state. Really, me, fitness model (well almost, right, lol), nutrition expert (we all know what that means, right?) and even “the professor.”   Well, needless to say, pain and bone issues are persistent. My checklist of appropriate solutions has run out. Second opinion – check (still bad bones), hand therapy – check, keeping food logs – check.  Ok, last on the list…  stay tuned!

Well, just to reflect on the nutrition side of what’s going on here. Perfect nutrition – mmm….  wasn’t that one checked off years ago?  So yes, you got me. It was, but it is vital to mention here that one person’s perfect nutrition may be another’s disaster. Nutrition is a very individual concept, and although I know a tremendous amount about the science of metabolism and the value of food as medicine, I am also learning new breakthroughs all the time. I have been teaching clinical nutrition in Life University’s Graduate program for a year or so now. My personal reflection: It turns out, that based on the caloric intake for my individual basal metabolic rate, I am one who at this stage of life and training, a calcium supplement and vitamin D compliment may prove to be essential within my profile. Supplements are not necessary for everyone, and I still work off of the principle that food is one’s most bioavailable source of nutrients and the best medicine for most ailments. Supplements are just that – supplements. And by definition: “to supplement one’s diet in which it lacks.”  Not a replacement of good sources of nutrients through food.

So with that said, this may be the perfect place to write about calcium and bone strength:

The science behind my experience:

Bones have a dual function in the storage and use of calcium. Not only do they serve as a reserve tank to replenish blood calcium, but they act as a storage depot for the calcium collected during the growing years. The downside to this, is that as the tank releases calcium into the blood as needed, the bones weaken. After growth, calcium cannot be put back into the bones, and thus the reserve gets depleted as calcium is needed in the blood for its daily functioning. Calcium balance is therefore determined by the intake of calcium through diet to maintain a high blood calcium level and furthermore, to prevent loss of calcium from bones. It is also important to note though, that an intake of excess calcium, does not result in increased calcium retention.

A stress fracture is defined as a partial or complete bone fracture, resulting from the bone not being able to withstand a certain stressor, such as over pounding over time. An accumulation of bone damage which is not adequately repaired simultaneous to decreased bone strength increases the risk of stress fractures.

So Doc… what are you telling me. I do not eat enough calcium? Do  I over train? My bones are weak? Unfortunately, with a history of disordered eating, genetics and a endurance training regimen, all of the above play a role. Athletes on low calorie intakes, are likely to have low blood calcium levels, and are at a high risk for bone calcium loss and osteoporosis.

Sound familiar to any of you? … especially female athletes that struggle with their relationship to food? Long term consequences of low calorie intakes, amenorrhea (defined as non existent menstrual cycle for more than 6 months) should consult a sports dietitian (as in, me ;-)) or a sports physician for an assessment. Prevent irreversible bone loss before it is too late. An assessment of calcium intake will be performed. Just some inside information here, a minimum of 800mg per day will be recommended. Furthermore, for females that do have amenorrhea, 1500 mg/day may be recommended. Anything over the daily recommended intake of calcium warrants a calcium supplement. Postmenopausal women athletes are also safe to be on a 1500mg/day calcium regimen. During adolescence, or better described in this case as bone density peaking years, it is essential that athletes get an adequate calcium intake to ensure a maximum reservoir of calcium in the bones throughout life. Excessive sodium, protein and caffeine increase calcium loss, these will therefore be assessed and tweaked in your daily diet as well.

In summary, the following lifestyle changes can help maintain an optimal calcium level in both blood for daily functioning, and bones for maximum reserves:

  • Under circumstances where dietary calcium requirements cannot be met, a calcium supplement is warranted. Be aware that supplemental calcium is not as bioavailable as calcium from food.  Calcium supplements are particularly warranted for people who are lactose intolerant, dislike or are allergic to dairy products, or cannot meet calcium requirements through dietary means in general.
  • People whose daily diet is too high in protein, sodium and/or caffeine may also benefit from calcium supplementation, although reducing these calcium inhibitors may be a more healthy and appropriate solution.
  • Taking calcium at bedtime and without food (between meals) may increase the bioavailability because the interference of calcium inhibitors in natural food are hereby prevented (eg. Phytic acid and vitamin C).
  • Maintaining a recommended vitamin D intake is also essential for bone health. Not only does vitamin D  increases the absorption of calcium but it also is an essential nutrient that makes up bone structure and bone density.  The most bioavailable source of Vitamin D is sunlight. People with minimum exposure to the sun warrant a Vitamin D supplement. Vitamin D supplements are also recommended when Calcium supplements are prescribed, since both these nutrients increase the absorption of the other.
  • Regular weight bearing exercises has a positive role in maintaining bone density. Lifting weights is thus vital as a cross training regimen to ensure optimal bone density while endurance training. Other ideas for cross training could include ground reaction forces, such as running, tennis, aerobics and any court sports (stop-start motions) since the ground reaction has a greater effect on bone density than non-ground reactive sports such as swimming and cycling.
  • Some research has found that calcium supplements are best absorbed in doses of 500 mg or less, thus splitting high supplemental doses into 2 or 3 intakes a day is recommended.


  1. Clinical Sports Nutrition. Louise Burke and Vicki Deaken. 3rd Edition. McGraw and Hill publishers.
  2. Heaney RP et al. Variability of calcium absorption. Am J Clin Nutr, 47:262-4.
  3. Bennell et al. Risk factors for stress fractures in female athletes. Clin J of Sports Med. 5:229-3

Go with your Gut   –   GI Distress from a different perspective

Ilana Katz MS, RD, CSSD

Since a big part of my work with athletes involves reducing the risk of Gastrointestinal (GI) distress I thought a different perspective of the GI environment and how to nurture it would be rather informative.  The organisms and their metabolic processes themselves, the majority of which live in the colon, are referred to as microbiome and they dramatically effect human health in general, not just for athletism. The microbiome is made up of trillions of microorganisms ranging between bacteria, fungi, viruses, and others., all of which impact the immune system.

The microbiome multitasks between maintenance of immunity, digestion, hormonal and nutrient balance by:

  • maintaining optimal gut flora (by fighting pathogens and embracing working microorganisms)
  • activates anti-inflammatory responses1
  • uptake of hormones2
  • detoxifies environmental negatives (such as drugs, chemicals, unnatural “food” items eg. artificial sweetener, sugar alcohols, etc.)1
  • synthesizes essential nutrients (particular to the gut are biotin, folate and vitamin K)1.

Inflammation and digestion, and most other functions mentioned above, differs greatly between individuals, and is mostly influenced by stress, age, past infections (antibodies), gender (and within gender experience of natural birth, breast feeding, etc.), medications, lifestyle habits (smoking, alcohol, etc.). and most importantly, diet3.

It is thus safe to say that almost every chronic (and probably acute too) inflammatory response is affected by changes in the microorganism composition of the gut. There is no blueprint for an ideal breakdown of gut microbiome but the diversity of the microorganisms has shown an increase in symbiosis – the mutually beneficial relationship between them.

Lower level symbiosis results from higher than necessary caloric intake, highly processed foods, saturated fat, refined sugar, and soda (chemicals) whereas microbial diversity and therefore increased likelihood of positive symbiosis result from dietary intakes such as coffee, tea, red wine, fruits and vegetables, nuts and buttermilk.4   Stress would be the biggest contributor to low diversity and reduced symbiosis as well as high triglycerides, irritable bowel symptoms (diarrhea) and intestinal inflammation.5

In research on dietary effects of microbiome, the summary states that eating plant-based foods and nuts are related to reduced bowel inflammation and aid in healthy cholesterol management5.  The typical American diet of low earth based nutrients, high saturated fats, high refined sugars and high in processed animal proteins negatively reduces gut microbial diversity, symbiosis and overall gut health.

So what is it about the earthy foods that assist in a positive microbiome? Simply, the content of fiber. Why? Because although fiber is the undigestible carbohydrate for humans it provides the gut microorganisms with essential “food” for them to produce enzymes. These enzymes in turn, breakdown these undigested carbohydrates in process of fermentation.6 Fermentations’ end-product is butyrate, the preferred food-source for cells in the large intestines. The healthier cells are then able to maintain the intestinal wall health, reducing risk of other major chronic disease states such as colon cancer, colitis and Chron’s disease.

Why then are people with a diagnosis of inflammatory bowel diseases (IBD) like Chron’s and colitis advised to keep their diet lower in fiber?  It may be a case of which came first, their dysbiotic colons, or the fact that fibrous foods can cause abdominal pain, bloating, cramping, diarrhea, and obstructions.7   Symptoms of IBD could then be reduced by limiting fiber however the vicious circle of health impacted colon and dysbios will ensue. It is therefore in the best interest of a person struggling with GI distress to seek professional help within the dietetic realm to work on tolerance of fiber. Because GI distress should not mean a low fibrous diet, dietitians will often teach such patients to increase fiber progressively, maintain excellent hydration processes and learn new techniques such as juicing, blending, other cooking methods to pre-breakdown tough fibrous skins of earthy produce, and removing completely undigestible seeds.

So far, I have focused mostly on the digestion of fibrous carbohydrates. But when talking about microbial flora it is important to consider that some undigested animal protein lands up in the colon too. Unlike plant based proteins, the fermentation of animal protein does not result in butyrate and the formation of healthy enzymes, instead they are fermented by colonic bacteria and produce potential toxins such as ammonia, and hydrogen sulfide.8    These toxins inhibit butyrate formation that would otherwise protect the colon lining from harmful entry of microbial invasion. The toxic gases thus increase inflammation responses further risk GI distress and chronic bowel diseases.  Not only do they inhibit the growth of anti-inflammatory bacteria, but they also support the growth of pro-inflammatory bacteria3.  Furthermore, hydrogen sulfate results in foul smelling gas, a common side effect of high protein, low fibrous diets. From a dietetic standpoint, if the diet is high in meat, by simply adding a variety of colorful, and fibrous vegetables could reduce the protein fermentation.

In summary, whether you are an athlete looking to reduce the risk of gastrointestinal distress while training/racing, or an individual wanting to reduce irritable bowel syndrome, or just an individual trying to keep the gut healthy, diet is the major factor determining microbiome make-up. The best diet for a healthy flora in the colon is simply a whole food diet with a variety of non-processed macronutrients (fibrous carbohydrates, lean protein and unsaturated fat), favoring plant-based more than animal proteins, non-excessive alcohol (favoring red wine) and the elimination of refined and processed sugars, artificial sweeteners and sodas.


  1. Gut Microbiome for health.
  2. Camilleri MD., Serotonin in the Gastrointestinal Tract. Curr Opin Endocrinol Diabetes Obes. 2009 Feb; 16(1):53-59.
  3. Brown K, et al. Diet-induced dysbiosis of the intestinal microbiome and effects on disease. Nutrients. 2012;4:1095-1119.
  4. Conlon MA, Bird AR. The impact of diet and lifestyle on gut microbiota and human health. 2015;7:17-44.
  5. Zhernakova A, et al. Population-based metagenomics analysis reveals markers for microbiome composition. Science. 2016;565-569.
  6. Rose DJ, et al. Influence of dietary fiber on inflammatory bowel disease and colon cancer: importance of of fermentation patterns. Nutr Rev. 2007:65:51-62.
  7. Limdi et al. Dietary practices and beliefs in patients with IBD. Inflamm Bowel Dis. 2016:22:164-172.
  8. Yao CK., etal. Insights into colonic protein fermentation and its health implications. Ailment Pharmoco ther. 2016;43:181-196.

New York City Marathon – thank you!

Hi Ilana,

I had a great race on Sunday.  No cramping and felt strong at the finish!  I can’t thank you enough for all your help through this process!
Thank you!!!


tg start



Over 200 years ago President Abraham Lincoln
declared the fourth Thursday in November the national day to celebrate
Thanksgiving. In 1941 it became a national holiday.

In 1621 the Pilgrim’s had their first successful
corn harvest, and a celebratory feast was organized. They invited the Native
American allies and had the first celebrated thanksgiving.

Every year families gather on Thanksgiving day  to celebrate family, giving to others and what they are most thankful for.
But it is also that time of year, when most of us tug a little harder at our belt buckles – a feat especially
difficult on this post-Thanksgiving Friday.

So, the turkey day leftovers will soon be
overflowing, and the holiday sweets have already started to jam your workplace
and mailbox. The next month will be filled with family gatherings, cocktail
parties, cookie exchanges and elaborate feasts. Simply put, those trying to
battle the bulge will struggle mightily.

If you are concerned about nutrition during this
time, let the tips and recipes in the up and coming newsletters help you stay
realistic about healthy nutrition, yet enjoy the season!!  Food is part of our culture, relax,
celebrate, but stay focused on your health and nutrition goals.


tg charlie



Quote for the month

“Physical activity is the currency with which you pay for food.”

gerry class



Did You Know??

  • Almost  20% of all cranberries consumed in the United States per year are  eaten on Thanksgiving.
  • Over  85% of Americans consume turkey on Thanksgiving.
  • About  $3 billion dollars worth of turkeys are sold for Thanksgiving
  • Benjamin  Franklin wanted the national bird to be a turkey.
  • Turkeys  can drown if they look up when it is raining.
  • A  typical Thanksgiving dinner of turkey, stuffing, mashed potatoes, gravy,
    sweet potatoes, cranberries, bread, pumpkin pie and one glass of wine has
    3,550 calories.




Sure to be the staple of many holiday meals, turkey is a  great addition to your diet. It’s low in fat and high in protein, and a good
source of iron, zinc, phosphorus, potassium and B vitamins. Here are some tips  for turkey safety:

A frozen turkey can be bought months in advance and stored
in the freezer. Allow ~24 hours of defrost time for every 5 lbs of turkey. A
20-pound turkey takes 4-5 days to thaw! Never thaw turkey at room temperature.

Stuff your turkey just before you place the bird in the
oven. Allow ½  to ¾  cup stuffing per lb of turkey. The stuffing
must be cooked to a minimum temperature of 165 degrees to be safe.

To roast the perfect turkey, place the bird in a shallow
pan. Insert a meat thermometer into the inner thigh of the bird and roast it in
a pre-heated oven set at 325 degrees. Your turkey is cooked when the
thermometer in the inner thigh reads 180 degrees, and the juices run clear. Be
sure the thermometer is not touching any bones.

On that note….  Overeating  on Thanksgiving…

Remember, it takes 3,500 calories to gain a pound. Most
people almost or actually do gain 1 pound from just one meal. Sounds crazy, huh?

Thanksgiving food tends to be exceptionally high in fat, and
body works differently with excess fat than it does with excess carbohydrate and protein.

When we overeat carbs and protein, the body’s initial  response is to use the majority of the extra food for energy, storage, and
building of tissues. Smaller amounts are stored as fat. Excess dietary fat is preferentially stored as body fat.

Also, fat consumption does not cause as great an increase in metabolism as carbs and protein as these calories are more easily stored.

But keep in mind that consistently overeating carbs and protein will also lead to weight gain.


Don’t go to the Thanksgiving dinner hungry: we often eat faster and more when we are
hungry – therefore eat a wholesome breakfast and lunch on the day to avoid overeating at dinner time.

Thanksgiving dinner is not an all-you-can-eat buffet: Fill your plate half with vegetables,
one quarter with a lean meat and the rest with a starch of your choice. Eat slowly and stop when you are full.

Turkey- go skinless: choose your 4-oz  turkey portion skinless to slash away some fat and cholesterol.

Save your appetite for the side dishes and desserts.

Make a conscious choice to limit high fat items: For instance, mashed potatoes are
usually made with butter and milk; green bean casseroles are often prepared
with cream of mushroom soup, cheese and milk and topped with fried onions;
candied yams  means cream, sugar and  marshmallows. Limit yourself to a smaller
helping size. Moderation is the key to these challenges.

Drink plenty of water: alcohol and coffee can dehydrate your body. Drink calorie-free
water to help fill up your stomach and keep you hydrated.

One of the best tips – avoid having too many leftovers as  this would mean extraordinary calories multiplied:

SOOOOOO…..  Help the Hungry:

Although the US is the wealthiest nation, 13% of the population live in poverty and hunger.

The easiest way to help, is to donate extra food to national nutrition  programs, such as food banks. It may not
solve the problem, but it will definitely help.

tg thanks



High fat food items are typically traditional for the
holiday celebrations. For instance, mashed potatoes are usually made with
butter; green bean casseroles are often prepared with cream of mushroom soup,
cheese and milk and topped with fried onions; candied yams are loaded with
cream, sugar and marshmallows.

Recipe calls for:                                                            Substitute:

1 whole egg                                                    2 egg whites

Sour cream                                                     fat free sour
cream or plain light yogurt

Milk                                                                   skim
or 1% milk

Ice cream                                                         low
fat frozen yogurt

Heavy Cream                                                  1:1 ratio of
flour to or 1% skim milk

Whipping cream                                          chilled evaporated
milk, or coolwhip

Cheese, butter or cream of mushroom             All these come in lighter versions


If you cannot control the ingredients that go in to a dish, simply limit yourself to a smaller helping size. 

Again moderation is the key.


Recipe of the Month:

Maple Roasted Sweet Potatoes


2 1/2 pounds sweet potatoes, peeled and cut into 1 1/2-inch
pieces (about 8 cups)

1/3 cup pure maple syrup

2 tablespoons butter, melted

1 tablespoon lemon juice

1/2 teaspoon salt

Freshly ground pepper, to taste


Preheat oven to 400°F. Arrange sweet potatoes in an even
layer in a 9-by-13-inch glass baking dish. Combine maple syrup, butter, lemon
juice, salt and pepper in small bowl. Pour the mixture over the sweet potatoes;
toss to coat. Cover and bake the sweet potatoes for 15 minutes. Uncover, stir
and cook, stirring every 15 minutes, until tender and starting to brown, 45 to
50 minutes more.

Makes 12 servings, ½ cup servings each.

Nutritional Content Per Serving:

96 Calories, 2 grams of Fat, 5 milligrams of Cholesterol,
118 milligrams of Sodium, and high amounts of Vitamin A and Vitamin C.




(serves 6)

1 can, 16 oz., pumpkin

1/2 cup prunes, pitted and finely chopped

1/4 cup frozen apple juice concentrate, thawed

1/4 cup frozen orange juice concentrate, thawed

2 tsp. margarine, reduced calorie

1 cup evaporated skim milk

1/2 cup fat-free egg substitute

1 Tbsp. grated orange peel

2 tsp. pumpkin-pie spice

8 mini (3 1/2 inches in diameter) pumpkins (called Jack-be-little pumpkins)

In a med pan, stir together the pumpkin, prunes, apple, orange juice and margarine. Simmer for 15 mins,
stirring frequently. Transfer to a food processor and add milk, egg subs, orange peel and spice. Process until smooth.

Cut off the tops of each pumpkin about 1 inch down. Scoop out the seeds. Place
the shells in a 13″ X 9″ baking dish. Bake at 3500 F for
about 30 mins or until the flesh is tender but the shells are not in danger of
collapsing. Spoon the custard mixture into the shells. Bake at 350 degrees for
about 30 minutes or until a knife inserted near the center of custard comes out clean.

Nutritional information per serving:

Calories: 106                Fat: 1g

Cholesterol: 1 mg        Sodium: 74mg

Fiber 2g                      Carbohydrate: 18g


tg end

Triathlete Nutrition Plan: For Your Skin?

As triathletes we are constantly abusing our skin with hours in chlorine filled pools and hours of sweating in the hot sun.  We KNOW you are diligent with the sunscreen but what else can you do to protect and improve your skin?

While sunscreen, beauty creams, microdermabrasions and other high priced spa treatments for skincare are all good, they are not the only way to keep your skin vibrant and constantly younger looking. Similar to your heart, your skin is another organ in the body that requires good nutrition for its upkeep. In fact, it’s the largest organ and although it’s an external one, its care comes from the inside.

The top skin care nutrients include:

  • WATER:

Hydration is essential for maintaining strong and vibrant skin, improving its main function as a protective barrier to the rest of the body. Water alone can give you  a more younger, radiant and blemish free look.


UV rays penetrate skin, even through the best sunscreens available, causing cellular and tissue damage, increasing premature aging and the risk of skin cancer. Scientifically based evidence exists to show that the antioxidants in lycopene (found in tomatoes) protect the skin’s inner layers from harmful UV exposure.


Omega 3 fatty acids are required by every cell in the body, including every cell in the skin, for flexibility and function. It is important to ensure omega 3’s are a part of  your diet, because the body cannot make them. Essential fats are found in flaxseed meal, chai seeds, hemp seeds, kiwi fruit and black raspberry and many fish sources such as salmon, tuna, mahi mahi, etc.


Not only does vitamin A have antioxidant capabilities but it also has specific functioning in the skin’s repairing and inflammation processes. Good sources of vitamin A include carrots, sweet potato, pumpkin, melons, spinach and organ meats, such as liver.


While many vitamins offer antioxidants and other benefits to the skin, like Vitamin A, vitamin B has specific functionality in the skin for repair and healing. Good sources of vitamin B are red meat, potatoes, bananas, lentils, chile peppers, tempeh, beans, nutritional yeast, brewer’s yeast, and molasses.

The worst substance for your skin:


It causes the skin’s blood vessels to narrow and thus impairs blood flow to the skin, resulting in decreased oxygen and vital nutrients,  thus accelerating the aging process. Nicotine further damages collagen and elastin, reducing the elasticity and skin strength.

Don’t forget to include regular exercise to compliment these results. Regular exercise can reduce weight fluctuations which reduce the skin’s elasticity. Exercise also increases circulation enhancing delivery of vital nutrient to the skin and removal of damaging toxins. Furthermore, exercise is known to reduce stress and reduced stress means less hormonal flair ups often evident in the skin.

Increasing the best and reducing the worst nutrients and substances for your skin can improve luster and vitality.