WHOLE FOODS NUTRITION FORENHANCED INJURY PREVENTIONAND HEALINGby June Kloubec, Ph.D. and Cristen Harris, Ph.D., RDN

Learning ObjectivesTo understand the importance ofwhole foods nutrition in the pre-vention and treatment of injuryand/or healing from surgery. Toguide athletes in meeting energy,macronutrient, and micronutrientneeds with whole food to keepthem ready to play and/or returnto play after injury.

Keywords:RecoveryNutrition, InjuryRecovery, Healing, Inflammation,Whole Foods, Antioxidants

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INTRODUCTION

fter an injury or surgery, one of the primary goals of all athletes is to be ableto heal as quickly as possible and return to play. Trainers and coaches mon- Aitor the athlete’s rehabilitation process and attempt to use themost effectivemodalities and resources available to them. In this process, nutrition oftenis an underutilized component.

Many athletes use dietary supplements on a daily basis and have begun to associate nu-trition with pills and powders instead of real food. One of the roles that health profes-sionals can play is to guide athletes toward a return to whole foods. Whole foods offerthe best nutrition, often at a better price than supplements, and include components thatare not available in pills and powders, because of the synergistic value of whole foods.Postinjury or postsurgery is a critical time to get athletes eating better because this willaid in healing and enhance performance once they return to play.

ENERGY AND MACRONUTRIENT NEEDS FOR INJURY PREVENTION OR HEALING

CaloriesThe fact that nutritional aspects of healing are overlooked is unfortunate, especially whenit is clear that a major injury alters an individual’s nutritional requirements. For example,an athlete’s metabolic rate increases approximately 15% to 20% after injury or minor sur-gery. Major surgery can increase these needs by almost 50% (1). This increase in energyexpenditure is caused by the body’s “gearing up” to repair the injured tissues. Thus, anathlete who might require 2,000 kcal during a typical day with no exercise could see hisor her energy requirements shoot up to 2,400 kcal after minor surgery. A good rule of

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WHOLE FOODS NUTRITION

thumb for athletes to follow is that when they’re injured, theyshould eat less than they did when they were training hard butmore than they would if they were completely sedentary.

ProteinInjury repair requiresmore protein. Atrophy frommuscle disuseafter injury is attributed primarily to a decline in muscle proteinsynthesis rate. Research suggests that focusing on the amount,type, and timing of dietary protein ingestion throughout theday can decrease the loss of muscle mass and strength duringhealing from injury and stimulate muscle protein synthesis(8,11). Injured athletes should aim for 1.5 to 2.0 g/kg bodyweight, which is higher than the usual 1.2 to 1.7 g/kg for athletesand 0.8 to 1.0 g/kg for recreational exercisers. For example, a150-lb (68-kg) athlete would require 102 to 136 g of protein dailyduring healing from an injury.

Many athletes already consume enough protein or even ex-cessive amounts of protein, often through supplementation withpowders. However, many athletes may not be eating protein inan optimal pattern tomaximize muscle protein synthesis. To en-sure optimal healing, athletes should consume protein consistentlyand distribute it evenly throughout the day at 20 to 30 g per mealor snack, rather than back-loading protein at dinner, which iscommon in American culture. A portion with 20 to 30 g of pro-tein equates to one of these: 3 eggs; 1 cup cottage cheese; 1 cupGreek yogurt; 3 to 4 oz of meat, poultry, or fish; two thirds of a14-oz cake of firm tofu; or 1.25 cups of black beans. Vegetariansalso can get quality protein from soy-based food. Almondmilk ispopular, but it is low in protein compared with cow or soy milk.

Branched-chain amino acids (BCAAs) such as leucine, isoleu-cine, and valine are used clinically to boost healing after muscu-loskeletal injury or surgery. Individuals suffering from physicaltrauma need to rapidly manufacture new body tissues while mak-ing sure that cells not affected by the injury remain healthy. Somestudies have shown that BCAAs have a special capacity to boostprotein synthesis and inhibit protein breakdown that none ofthe other amino acids have. Of the BCAAs, leucine may be themost useful (8) and can be found readily in food such as chickenbreast, lean beef, tuna, salmon, turkey breast, eggs, and peanuts.

CarbohydratesIncomplete recovery from consecutive bouts of high-intensity train-ing or competition can result in subsequent underperformance andinjury (5). Research has shown that carbohydrate ingestion beforeand during prolonged periods of exercise helpsmaintain blood glu-cose during exercise, reduce stress hormones (12), and reduce therisk of injury (5). Carbohydrate ingestion shortly after prolongedand/or exhaustive exercise helps replenish muscle glycogen stores,thus providing energy to refuel muscles for the next exercise boutand to repair those same muscles.

Athletes should aim for daily carbohydrate intakes of 5 to12 g/kg body weight, favoring the lower end during times ofmore limited energy needs to help prevent unwanted weight gain.Carbohydrate intakes of up to 60 g per hour during heavy

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training can help diminish immune inflammatory responses(12). Within the first 30 minutes after exercise, when musclesare most efficient at replacing muscle glycogen, goal carbohy-drate intake is 1 to 1.2 g/kg body weight. Best sources of carbohy-drates include fruits, starchy vegetables (like corn, peas, potatoes,yams), whole grains (such as brown rice or quinoa), and foodmade with whole grains like bread, cereal, rice, and pasta.

Several studies have shown that the combination of carbohy-drate and protein consumed during and after exercise may in-clude such benefits as decreased fatigue, delayed-onset musclesoreness (DOMS), reduced muscle breakdown, and optimizedmuscle damage repair (6,9). The suggested ratio is 3 to 4 g of car-bohydrate to 1 g of protein, with as little as 6 to 20 total grams ofprotein (9). This mixture can be found naturally, as in many dairyproducts (e.g., chocolate milk), or you can create your own.

Dietary FatFat intake may be an important factor in the prevention of inju-ries. Low intake of dietary fat has been associated with increasedinjury risk in female runners, including stress fractures. Further-more, a low intake of omega-3 fatty acids may contribute to anenhanced inflammatory response and may increase the severityof injury (3). Dietary fat has gotten a bad rap during the pastyears, but athletes should be reminded that not all fats are cre-ated equal and should be encouraged to include healthy fats intheir diet fromwhole foods such as avocados and nuts (especiallywalnuts, cashews, almonds, and nut butters made from thesenuts), extra virgin olive oil, canola oil, and sunflower and saffloweroils. Athletes should be advised to regulate their intake of satu-rated fat, including fatty red meats (like ribs) and deli meats (likesalami), and products made with coconut and palm kernel oil.Athletes also should be advised to avoid or limit the use of transfats found in margarine, vegetable shortening, and all productsmade with partially hydrogenated oils, which include many com-mercially prepared desserts, chips, and crackers.

FiberIt may sound odd to mention fiber with healing food, but painmedications commonly prescribed after injury or surgery can

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cause constipation. Prunes or prune juice (along with drinkingplenty of water) have a natural laxative effect that can alleviateconstipation while on pain medications. Other good sources offiber include bran cereals, oatmeal, whole-grain bread (wholewheat or rye), brown rice, popcorn, lentils, and legumes (likeblack beans, kidney beans, chickpeas, pinto beans, white beans,etc.). Be sure to drink enough water when increasing fiber intakebecause fiber absorbs fluid in the gut.

IronDietary intake and total body stores of iron, a key mineral, mayhave some effect on an athlete’s risk of injury. In research car-ried out at the Center for Sports Medicine in San Francisco,101 female high school runners were monitored during thecourse of a cross-country season. During the cross-country season,there were 71 injuries severe enough to cause lost training time.Those runners who were injured had average ferritin levels (anindication of iron stores) that were about 40% lower than thosefound in noninjured runners, suggesting that iron status is an im-portant factor in injury prevention (4).

Additional studies have not been able to identify a clearmechanism for increased injury rate when iron stores are low,although it may be related to the activity of the inflammatory-driven iron-regulatory hormone hepcidin. The inflammatory-mediated increases in hepcidin ultimately result in an accumulationof plasma iron in macrophages and hepatocytes, reduced in-testinal absorption of iron by enterocytes, and a decreasedplasma level. Inevitably, these processes can lead to anemia(10). Because long-duration or high-intensity exercise com-monly results in inflammation, it is possible that hepcidinmight be a mechanism or contributing factor behind the highincidence of iron deficiency and, perhaps concomitantly, injuryamong athletes (7).

Preventing iron deficiency can be accomplished by includingiron-rich food sources in the daily diet such as lean red meats,lean pork, poultry (especially dark meat), beans and legumes,dark green leafy vegetables (like spinach), dried fruits (such asraisins and apricots), and iron-fortified cereals, bread, andpastas. Consuming iron-rich food with a good source of vita-min C such as oranges, tomatoes, or potatoes can enhance theabsorption of iron.

Vitamins and MineralsThe changes in nutrient requirements in response to an injuryare not simply a matter of increased energy needs. Various partsof the body have unique nutritional needs to heal a particular in-jury. For example, many athletes already take vitamin supple-ments regularly. They know that they need vitamins but donot understand that vitamins are only one piece of the nutri-tional picture. In addition, because many processed foods thatathletes eat are already fortified and enriched with vitamins,they may actually be ingesting more of certain vitamins thanthey realize. Advice should focus on purchasing and eating

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whole food, such as fruits, vegetables, and whole grains, to pro-mote the most balanced and optimal nutrition. Nature haspacked the perfect synergy of nutrients into whole foods. Somenutrients that have taken center stage in the research on healinginclude vitamin C, flavonoids, vitamin A, protein, and zinc.These will be discussed in the sections below.

NUTRITION TO COMBAT INFLAMMATIONInflammation plays a critical role in the recovery and healingprocess. One of the primary goals in rehabilitation is to reduceinflammation and oxidative stress. Nutrition can serve as a pow-erful adjunct in this process. A direct result of inflammation is anincrease in the production of free radicals. Free radicals arehighly reactive oxidized molecules that cause damage to cells.One major by-product of muscle contraction is free radicals.The more training an athlete performs, the more free radicalsare generated, and these levels build up. Antioxidants are nutri-ents that neutralize these damaging effects and help repair thecellular damage they cause. Important antioxidants in the bodyare vitamin C, vitamin E, beta-carotene, vitamin A, selenium, andzinc. The body produces some antioxidants naturally, whereasothers need to be obtained from the diet. A general suggestion isto include a variety of fruits, vegetables, whole grains, legumes, leanmeats, poultry, fatty fish, and nuts and seeds in the daily diet to helpensure adequate intake of these important nutrients.

During acute phases of injury, we do not want to suppress theinflammatory response completely; we just want to keep it undercontrol. Flavonoids found in cocoa, tea, red wine, fruits, vegeta-bles, and legumes can help manage inflammation through theirantioxidant actions. It is probably good to eat more flavonoid-rich food in general and more so during acute injuries. The pro-tective role of flavonoids during inflammation may be associatedwith their ability to sequester iron and the regulatory effect theyexert on immune components involved in inflammatory pro-cesses (10). A variety of whole food, herbs, and spices can assistin this process. Garlic, turmeric (found in curry powder), greentea, blueberries, apples, citrus fruits, and pineapples also contain

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TABLE 1: Case Scenario — Estimated Energy andMacronutrient Needs for Injury Recovery

Case: TK is a 20-year old, 5'10'' tall, 150-lb (68 kg) male runnerrecovering from knee surgery

Resting energy expenditure: ~1,700 kcal/day (based onMifflin–St. Jeor equation)

Total daily estimated energy: ~2,550 kcal/day using a currently“light” activity factor of 1.3 and a 20% increase aboveresting metabolism for surgery recovery

Protein: 1.5 to 2.0 g/kg body weight ~102 to 136 g/day (16%to 21% of kilocalories)

Carbohydrate: 5.0 g/kg body weight ~340 g/day (53%of kilocalories)

Fat: 73 to 88 g/day body weight (26% to 31% of kilocalories)

WHOLE FOODS NUTRITION

nutrients helpful for combatting the inflammation that occurswith training each day.

Tip: Eat more flavonoid-rich food such as blueberries, strawberries, car-

rots, broccoli, and pineapple in general and more so during acute injuries.

In addition to antioxidants, there are other nutrients knownto decrease inflammation. A class of essential fatty acids bestknown for controlling general inflammation is omega-3 fattyacids, which come in different types: alpha-linolenic acid(ALA), docosahexaenoic acid (DHA), and eicosapentaenoic acid(EPA). Our bodies can convert ALA into DHA and EPA, butnot very efficiently. Although omega 3s can be obtained in pillform, whole foods sources of DHA and EPA include algae andfatty fish such as salmon, halibut, herring, oysters, sardines,trout, and fresh tuna. Plant-based ALA sources include flaxseeds, chia seeds, hemp seeds, walnuts, and sunflower, safflower,and seed oils. Foods that are fortified with omega 3smay includeeggs, milk, soy milk, yogurt, and buttery spreads. For a reduc-tion of inflammation, animal sources of omega-3, because oftheir higher DHA and EPA content, are better absorbed andused by the body.

Tip: Did you know that turmeric is a flowering plant in the ginger family

and that turmeric has long been used as an anti-inflammatory agent and in

wound healing? Current research shows that the active ingredient, curcumin,

is responsible for some of the benefits of turmeric.

NUTRITION FOR REGENERATION ANDANABOLIC SUPPORTOnce inflammation begins to subside, the injured part of thebody begins to make scar tissue and remake connective tissue,which will have to be regenerated for complete healing. This isespecially true after surgery, when the proinflammatory re-sponse causes muscle dysfunction that can lead to muscle atro-phy. Research suggests that antioxidants, like vitamins C andE, can help modulate the activity of these proinflammatory mol-ecules (cytokines) (12). Vitamin C– and flavonoid-containing cit-rus fruits (like oranges and grapefruit), bell peppers, and berries,as well as wheat germ and whole grains that contain vitamin E,might be useful at this stage of rehabilitation. Vitamin E also canbe found in foods such as nuts and oils.

Connective tissue, which includes tendons, ligaments, joints,cartilage, and muscle fascia, has a very unique structure that isdifferent from most tissues in the body because it is not com-posed of cells but rather a matrix of proteins, fibers, and cross-purpose molecules (part carbohydrate and part protein in manycases) all embedded in a fluid environment. Evidence supports afocus on several major nutrients when connective tissue healingis required: vitamin C, vitamin A, vitamin E, the B-complexvitamins, and zinc (12).

Tip: One small stalk of broccoli can provide the recommended daily

allowance of vitamin C, a nutrient known to enhance healing.

Vitamin C is needed to make collagen and also is needed forrepairing tendons and ligaments and healing surgical wounds.

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Citrus fruits are high in vitamin C; however, do not overlookother sources of vitamin C, such as strawberries, kiwi fruit,baked potatoes, broccoli, and bell peppers. Vitamin A alsomay enhance the development of collagen. Beta-carotene is aprecursor to vitamin A and can be found in whole foods suchas sweet potatoes, carrots, kale, squash, romaine lettuce, prunes,dried apricots, cantaloupe melons, sweet red peppers, andmangos. Emphasizing green leafy vegetables could allow theathlete to cover all of his or her bases well in combatting inflam-mation and oxidative stress. For example, kale is considered anexcellent source of vitamins A (as in beta-carotene) and C, agood source of vitamin E, and also contains a variety ofB-complex vitamins, including B1, B2, B3, B6, and folate. Zincis a mineral also involved in wound healing and is found mostlyin animal foods: meat, fish, poultry, and dairy foods. It also ispresent in whole-grain breads and cereals, dried beans and peas(legumes), and nuts.

NUTRITION FOR BONE HEALINGAthletes should be sure to consume adequate amounts of calciumand vitamin D, which help to strengthen bones. This is an impor-tant consideration for athletes prone to stress fractures or whilehealing from broken bones. The best sources of these nutrientsare low-fat dairy products. Nonfat milk has slightly more calciumthan full-fat or low-fat milk and is fortified with vitamin D to helpabsorb calcium. Yogurt, also a good source of calcium, is not al-ways fortified with vitamin D, so check the nutrition label of yourfavorite yogurt to make sure you are getting vitamin D. Nondairysources of calcium and vitamin D include fortified soy, rice, andalmond milks, as well as fortified orange juice.

APPLICATION TO PRACTICETable 1 shows the estimated energy and macronutrient needsfor injury recovery for a case scenario featuring a 20-year-oldmale runner, “TK,”who is healing from knee surgery. The sam-ple meal plan described in Table 2 meets TK’s estimated

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TABLE 2: Sample 1-Day Meal Plan for Injury Recovery

Breakfast Morning Snack Lunch Afternoon Snack Dinner Evening Snack

2 sliceswhole-wheat bread

1 large apple Chicken wrap withwhole-wheat tortillaand cheese

6 oz low-fat vanillayogurt

1 cup cooked brownrice

8 large strawberriesdrizzled with 1 Tbspchocolate syrup

1 banana ¼ cup almonds 1 fresh pear ¼ cup cranberries 6 oz grilled salmon

2 Tbsp peanutbutter

16 oz water ½ cup carrot sticks ¼ cup low-fatgranola

1 cup broccolisautéed in 1 tspolive oil

16 oz water 16 oz water 16 oz water 16 oz water

12 oz low-fatchocolate milkafter workout

nutritional needs exceptionally well. At 2,585 calories, 115 gprotein, 340 g carbohydrate, 85 g total fat, and 45 g dietary fiber(2), this delectable menu also is rich in vitamins and minerals.Equipped with a well-planned whole foods diet that can be furtherdeveloped in consultation with a sports dietitian/nutritionist,TK is well on his way to returning to play!

1. Bledsoe J. The sports injury doctor. Nutritional sports injury therapies— what youeat can play a significant part in preventing or healing a sports injury; [cited 2015Mar 3]. Available from: http://www.sportsinjurybulletin.com/archive/nutritional-therapies.html#.

2. CalorieKing Food Database. CalorieKing Wellness Solutions, Inc., La Mesa, CA;[cited 2015 Mar 3]. Available from: www.calorieking.com/foods/search

3. Gerlach KE, Burton HW, Dorn JM, Leddy JJ, Horvath PJ. Fat intake and injury infemale runners. J Int Soc Sports Nutr. 2008;5:1.

4. Loosli AR, Requa RK, Garrick JG. Serum ferritin and injuries in female high schoolcross country runners. Med Sci Sports Exerc. 1993;25(5) Suppl:S2.

5. Nédélec M, McCall A, Carling C, Legall F, Berthoin S, Dupont G. Recovery insoccer: part I — post-match fatigue and time course of recovery. Sports Med.2012;42(12):997–1015.

6. Nédélec M, McCall A, Carling C, Legall F, Berthoin S, Dupont G. Recovery insoccer: part II— recovery strategies. Sports Med. 2013;43(1):9–22.

7. Peeling P, Dawson B, Goodman C, Landers G, Trinder D. Athletic induced irondeficiency: new insights into the role of inflammation, cytokines and hormones.Eur J Appl Physiol. 2008;103(4):381–91.

8. Phillips SM. A brief review of critical processes in exercise-induced muscularhypertrophy. Sports Med. 2014;44(Suppl 1):S71–S77.

9. Saunders MJ. Coingestion of carbohydrate-protein during endurance exercise:influence on performance and recovery. Int J Sport Nutr Exerc Metab. 2007;17(Suppl):S87–S103.

10. Skarpanska-Stejnborn A, Basta P, Sadowska J, Pilaczynska-Szczesniak L. Effectof supplementation with chokeberry juice on the inflammatory status andmarkers of iron metabolism in rowers. J Int Soc Sports Nutr. 2014;11(1):48.

11. Wall BT, Morton JP, van Loon LJ. Strategies to maintain skeletal muscle mass inthe injured athlete: nutritional considerations and exercise mimetics. Eur J SportSci. 2015;15(1):53–62.

12. Walsh NP, Gleeson M, Pyne DB, et al. Position statement. Part two: maintainingimmune health. Exerc Immunol Rev. 2011;17:64–103.

Disclosure: The authors declare no conflicts of interest and did not receivefinancial support or inducements for the preparation of this article.

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June Kloubec, Ph.D., is a full professor at

Bastyr University in Kenmore, WA. She has been

involved in several multisite national studies on car-

diovascular disease, obesity, and diabetes, as well as

studies about physical activity and the elderly. She has

been a certified personal trainer since 1985 and is cer-

tified in yoga and Pilates. She also has been a collegiate

track and cross-country coach.

Cristen Harris, Ph.D., RDN, is an associateprofessor at Bastyr University in Kenmore, WA. As

an educator, researcher, and practitioner, her special

areas of interest include sports nutrition, eating

disorders, women’s health, cardiovascular dis-ease, family nutrition and child feeding issues,

intuitive eating, and weight-neutral approaches

to health and fitness. She has been a certified clin-

ical exercise physiologist since 1998 and a certified

specialist in sports dietetics since 2010.

BRIDGING THE GAPNutrition should have a starring role in keeping athletesready to play and in hastening their return to competitionafter an injury. Whole foods offer synergistic andmedicinal value in combatting inflammation, supportingregeneration and anabolism of injured tissues, andpromoting healing and recovery. Helping athletes gainaccess to a wide variety of whole foods that meet energy,macronutrient, and micronutrient needs and assistingthem in making sound nutritional choices can helpmaximize athletic performance and return to play.

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