International Journal of Sport Nutrition and Exercise Metabolism, 2011, 21, 417 -425
© 2011 Human Kinetics, Inc.
Risk of Nutrient Inadequacies
in Elite Canadian Athletes With Spinal Cord Injury
Jennifer L. Krempien and Susan I. Barr
Energy intakes of adults with spinal cord injury (SCI) have been reported to be relatively low, with many
micronutrients below recommended amounts, but little is known about the diets of athletes with SCI. The
purpose of this cross-sectional, observational study was to assess energy intakes and estimate the prevalence
of dietary inadequacy in a sample of elite Canadian athletes with SCI (n = 32). Three-day self-reported food
diaries completed at home and training camp were analyzed for energy (kcal), macronutrients, vitamins, and
minerals and compared with the dietary reference intakes (DRIs). The prevalence of nutrient inadequacy was
estimated by the proportion of athletes with mean intakes below the estimated average requirement (EAR).
Energy intakes were 2,156 ± 431 kcal for men and 1,991 ± 510 kcal for women. Macronutrient intakes were
within the acceptable macronutrient distribution ranges. While at training camp, >25% of men had intakes
below the EAR for calcium, magnesium, zinc, riboflavin, folate, vitamin B12, and vitamin D. Thiamin, riboflavin, calcium, and vitamin D intakes were higher at home than training camp. Over 25% of women had intakes
below the EAR for calcium, magnesium, folate, and vitamin D, with no significant differences in mean intakes
between home and training camp. Vitamin/mineral supplement use significantly increased men’s intakes of
most nutrients but did not affect prevalence of inadequacy. Women’s intakes did not change significantly
with vitamin/mineral supplementation. These results demonstrate that athletes with SCI are at risk for several
nutrient inadequacies relative to the DRIs.
Keywords: wheelchair athletes, Paralympic sport, dietary reference intakes, vitamin and mineral intake, energy,
macronutrients
Canadian athletes with spinal cord injury (SCI) are
training at relative intensities, durations, and frequencies that rival those of their Olympic counterparts. The
competitive nature of the Paralympic Games demands
that athletes optimize training and performance strategies
(including nutrition) to attain competition goals. Those with
SCI are a unique population with physiological and physical
differences that dramatically affect cardiovascular control
(Teasell, Arnold, Krassioukov, & Delaney, 2000), body
composition (Spungen et al., 2003), and energy requirements
(Buchholz, McGillivray, & Pencharz, 2003; Monroe et al.,
1998). Although considerable research has been done to
serve as a basis for nutrition recommendations for ablebodied athletes (Rodriguez et al., 2009; American College
of Sports Medicine et al., 2007), these standards may not
be appropriate for athletes with SCI, and comparable
standards are not available. Moreover, very little is known
about the dietary choices these athletes are making or the
nutrient adequacy of those choices.
There have been several small studies of dietary
intake of athletes with disabilities (Goosey-Tolfrey &
Crosland, 2010; Potvin, Nadon, Royer, & Farrar, 1996;
Ribeiro, Da Silva, De Castro, & Tirapegui, 2005; Wang,
The authors are with Food, Nutrition and Health, University of
British Columbia, Vancouver, BC, Canada.
Goebert, Hartung, & Quigley, 1992). In general, those
studies reported energy intakes and macronutrient
percentages similar to those reported for nonathletes
with SCI (Groah et al., 2009; Tomey, Chen, Wang, &
Braunschweig, 2005; Walters, Buchholz, & Martin Ginis,
2009). Energy intakes range from approximately 1,500
to 2,200 kcal/day, with 46–53% of energy from carbohydrate (3.4–4.1 g/kg), 15–20% from protein (1.0–1.4
g/kg), and 28–37% from fat. Intakes of several vitamins
and minerals including calcium, vitamin D, folate, zinc,
and iron fell below recommendations (Goosey-Tolfrey &
Crosland, 2010; Groah et al., 2009; Tomey et al., 2005).
The physiological alterations and adaptations associated with SCI (Bhambhani, 2002) in combination with
the physical demands of training and competition create
a unique set of nutritional challenges for athletes with
SCI. Compared with able-bodied athletes, the energy
expenditure of physical activity in athletes with SCI is
likely lower because smaller amounts of muscle mass are
used during activity (Mojtahedi, Valentine, Arngrimsson,
Wilund, & Evans, 2008; Price & Campbell, 1997) and
resting energy expenditure is lower (Buchholz et al.,
2003). Accordingly, the overall quality of the diet would
need to be high to meet vitamin and mineral requirements.
The release of the dietary reference intakes (DRIs)
has provided an opportunity for more meaningful
417
418 Krempien and Barr
assessment of dietary intakes (Institute of Medicine,
2000). In the past, intakes were frequently compared
with recommendations such as the recommended dietary
allowance (RDA). However, because the RDA is set at
an intake level exceeding the requirements of almost all
individuals, an intake below the RDA cannot be assessed as
inadequate. Moreover, if the mean intake of a group is at or
above the RDA, the group cannot be assumed to have a low
prevalence of inadequate intakes. Instead, for most nutrients
the group prevalence of inadequate intakes can be estimated
as the proportion of the group with usual intakes below the
estimated average requirement (EAR; Institute of Medicine,
2000). In this context, the prevalence of inadequacy would
approximate the proportion of the group expected to fall
below the biological criterion used to establish the EAR.
It should be noted that with this framework, conclusions
are made about the group prevalence of inadequate
intakes; individual intakes cannot be assessed as adequate
or inadequate because the individual requirements are not
known (Institute of Medicine, 2000).
The purpose of this study was to use the DRI framework to assess the adequacy of dietary intakes of elite
athletes with SCI. Specifically, we compared athletes’
intakes in home and training camp environments and
also assessed dietary adequacy both with and without
additional vitamin/mineral supplement use.
Methods
Participants
Elite athletes with SCI resulting in tetraplegia (a reduction or loss of function in all four limbs) or paraplegia
(reduction or loss of function in the lower limbs) were
recruited for the study. Eligibility criteria included age
≥19 years, training ≥12 hr/week, and ability to understand
written and spoken English. At the time of the study, it was
estimated that 75–80 athletes in Canada met the inclusion
criteria. National head coaches of 11 eligible Paralympic
sports were contacted, with 10 of those sports having athletes
who met the inclusion criteria. Some coaches indicated that
their athletes would not be available to participate because
they were training outside the country or a national team
training event was not planned. Of the 41 national-team
athletes approached in person, 34 consented to participate
and 32 completed all aspects of the study. The study
protocol was approved by the behavioral research ethics
board at the University of British Columbia, and all participants provided informed written consent.
Anthropometry
Weight was measured to the nearest 0.1 kg, with athletes
wearing light indoor clothing and no shoes, using a portable digital scale with remote display (Universal Weight
Enterprise Company Ltd., Model AMP-150, Taipei,
Taiwan). The scale was modified with a larger seating
platform and participants sat directly on the scale for
measurement. Length was measured with participants in
a supine position on a firm surface with the soles of their
feet against a wall. Each subject’s length was marked on
the surface and then measured. The measured length was
verbally reported to the subject. If the measurement was
more than 2 cm different from what the subject believed
his or her height to be, the measurement procedure was
repeated. Body-mass index (BMI) was calculated (kg/
m2). Sum of skinfolds was used as a rough measure of
body adiposity. All skinfold measurements were taken
on the right side of the body according to standardized
procedures (Lohman, Roche, & Martorell, 1991) using
Harpenden skin calipers. Triplicate measurements were
taken in rotation to the nearest 1 mm at the triceps, biceps,
subscapular, and iliac crest sites, with the mean at each
site used to calculate the sum of skinfolds.
Self-Reported Food and Activity Records
Nutrient intake data were collected using a self-reported
food diary, with records kept for 3 consecutive days
during the training camp and during a 3-day follow-up
period (2 weekdays and 1 weekend day) once the athlete
had returned to his or her home environment. The food
diary completed at home reflected the athlete’s typical
dietary choices and intakes in a less artificial environment.
One of the researchers (a registered dietitian) provided
detailed explanations of how to accurately record food
intake. She was present at the training camps to help
record food diaries and was able to discreetly observe
food intake. Any recorded information that was unclear
was clarified directly with the athlete. Participants were
also instructed to record the brand name and amount
consumed for all vitamin/mineral supplements. Any
nutritional supplement that contributed energy or macronutrients, such as protein/energy bars and sports drinks,
was treated as food and averaged into the daily intake. The
composition of reported vitamin/mineral supplements
was then added to the daily means and a second analysis
was completed. Athletes recorded the number of minutes
they participated in physical activity and their rating of
perceived exertion (Borg, 1998) for the same days they
recorded food intake during training camp and at home.
Dietary Analysis
Food-record data were entered into Food Processor for
Windows, version 9.0.0 (database version December 2007,
ESHA Research, Salem, OR), which includes both Canadian
(Nutrition Research Division [NRD] & Biostatistics and
Computer Application Division [BCAD], Health Protection
Branch [HPB], 2007) and American (U.S. Department of
Agriculture, Agricultural Research Service, 2010) nutrient
databases. The Canadian Nutrient File (NRD & BCAD,
HPB, 2007) database was the primary nutrient reference
database used. Food volumes were recorded by the athletes as either household measures or grams. The same
measure was then entered into Food Processor to calculate
nutrient composition. If food values were not available, the
nutritional content for equivalent items from the USDA
Nutrient Intakes of Canadian Athletes With SCI 419
Standard Reference database or values provided by the
manufacturer were used. Because of a technical software
issue, nutrient values for vitamin D were calculated manually and vitamin A values were omitted.
Statistical Analysis
All statistical analyses were completed using SPSS version 17.0. Descriptive statistics are presented as means
and standard deviations. A p value of <.05 was considered
statistically significant. Dietary micronutrient intakes
were compared with the DRIs to assess adequacy. Specifically, for most nutrients with an EAR, the prevalence
of inadequate intakes was estimated as the proportion of
individuals with mean intakes below the EAR (Institute
of Medicine, 2000, 2006). However, because the distribution of iron requirements in reproductive-age women
is skewed, the probability approach was used (the probability of inadequacy was calculated for each individual’s
intake, and the average of the individual probabilities
was used to reflect the estimated prevalence in the group;
Institute of Medicine, 2001). The prevalence of nutrient inadequacy was compared between the home and
training camp environments using McNemar’s test. For
nutrients with an adequate intake, if the median intake
for the sample was at or above the adequate intake, it was
assumed that the group’s usual intake was adequate, with
a relatively low prevalence of inadequacy. If the median
intake fell below the adequate intake, no assessment of
adequacy for that nutrient was determined (Institute of
Medicine, 2000). In addition, mean intakes from food
alone versus intakes from the combination of food and
vitamin/mineral supplements were compared by paired t
test using 6-day averages. The effect of vitamin/mineral
supplementation on the prevalence of nutrient inadequacy
was assessed using McNemar’s test.
Results
Participant Characteristics
Most of the participants were on the wheelchair rugby
team (n = 20; 19 men, 1 woman), with the remainder
competing in wheelchair basketball (n = 7; 3 men, 4
women), para-Alpine skiing (n = 3; 2 men, 1 woman),
and wheelchair athletics (n = 2 women). Background
characteristics including reported total training time are
presented in Table 1. As expected, the men were taller,
Table 1 Participant Characteristics, M ± SD or n (%)
Participants
All (N = 32)
Men (n = 24)
Women (n = 8)
30.6 ± 6.2
30.5 ± 6.7
30.6 ± 4.7
Length (cm)
177.2 ± 8.9
179.2 ± 9.0a
171.1 ± 5.8b
Weight (kg)
67.0 ± 13.7
70.9 ± 13.3a
55.4 ± 6.0b
Body-mass index (kg/m2)
21.3 ± 3.4
22.1 ± 3.5a
18.9 ± 1.9b
Sum of skinfolds (mm)
51.1 ± 20.6
50.9 ± 22.8
51.5 ± 13.4
13.4 ± 6.5
13.8 ± 6.8
12.5 ± 5.9
Characteristic
Age (Years)
Anthropometrics
Spinal Cord Injury
Years since injury
Paraplegic
12 (38%)
7 (29%)
5 (63%)
Tetraplegic
20 (63%)
17 (71%)
3 (38%)
492 ± 266a
488 ± 290
507 ± 193
Sum of Training Minutes (3-Day Period)
Training camp
very hard (RPE 18–20)
65 ± 106
71 ± 114
47 ± 81
hard (RPE 15–17)
221 ± 181
204 ± 170
271 ± 214
moderate (RPE 11–14)
120 ± 98
128 ± 109
98 ± 56
light (RPE 6–10)
87 ± 78
85 ± 86
93 ± 53
386 ± 176
306 ± 155
60 ± 60
64 ± 65
45 ± 42
hard (RPE 15–17)
127 ± 115
140 ± 124
86 ± 73
moderate (RPE 11–14)
130 ± 128
130 ± 139
129 ± 96
50 ± 54
51 ± 57
46 ± 48
Home
very hard (RPE 18–20)
light (RPE 6–10)
366 ±
Note. RPE = rating of perceived exertion (Borg, 1998).
a,bIndicates pair with a statistically significant difference, p < .05.
172b
420 Krempien and Barr
weighed more, and had a higher BMI than the women,
although the sum of skinfolds did not differ. There were
no differences between men and women pertaining to
age or years since SCI. During training camp, the group
reported a greater total training time than while at home.
Dietary Analysis From Food Sources Only
Average energy intakes and grams of carbohydrate,
protein, and fat (including per kilogram body weight)
for each of the 3-day periods and an average for all 6
days are shown in Table 2. Comparison of the energy
intakes between the home and training environments for
the group showed an increased energy intake during the
training camp. Macronutrient intakes as a percentage of
energy were within the acceptable macronutrient distribution ranges (54.2% carbohydrate, 17.6% protein, 28.7%
fat), with no significant differences based on gender, sport,
or training environment. Acceptable macronutrient distribution ranges were established for able-bodied adults who are
not elite athletes, and they are not specific to athletes with
SCI. Carbohydrate intake averaged 285 ± 57 g/day (4.4 g/
kg), and all participants’ intakes were well above the EAR
of 100 g. EAR for carbohydrate reflects brain glucose
utilization rates and not glycogen replenishment rates.
Relative to body weight, men had a slightly greater carbohydrate intake at training camp. Protein intakes averaged
1.4 ± 0.4 g/kg, more than double the EAR of 0.66 g/kg.
Results for nutrients with an adequate intake as the
reference value are presented in Table 3. All participants
Table 2 Reported Energy and Macronutrient Intakes of Elite Athletes
With Spinal Cord Injury, M ± SD
Participants
All (N = 32)
Men (n = 24)
Women (n = 8)
2,227 ± 523a
2,285 ± 540
2,056 ± 458
Training Camp (3-Day Mean)
Energy, kcal/day
34 ± 8
33 ± 8
37 ± 8
Carbohydrate, g/day
kcal/kg
296 ± 69
305 ± 69
269 ± 64
g/kg
4.5 ± 1.2
4.4 ± 1.2a
4.9 ±1.1
Protein, g/day
97 ± 24
98 ± 25
95 ± 21
g/kg
1.5 ± 0.4
1.4 ± 0.4
1.7 ± 0.3
Fat, g/day
73 ± 25
75 ± 24
68 ± 29
g/kg
1.1 ± 0.4
1.1 ± 0.3
1.2 ± 0.5
2,003 ± 517b
2,028 ± 528
1,927 ± 510
Home (3-Day Mean)
Energy, kcal/day
kcal/kg
31 ± 10
30 ± 10
35 ± 9
Carbohydrate, g/day
275 ± 76
275 ± 78
272 ± 77
g/kg
4.3 ±1.5
4.1 ± 1.5b
4.9 ± 1.4
Protein, g/day
88 ± 26
88 ± 22
90 ± 35
g/kg
1.4 ± 0.5
1.3 ± 0.4
1.6 ± 0.6
Fat, g/day
63 ± 21
64 ± 23
58 ± 18
g/kg
1.0 ± 0.3
0.9 ± 0.3
1.0 ± 0.3
2,115 ± 420
2,156 ± 431
1,991 ± 383
33 ± 8
31 ± 8
36 ± 7
Carbohydrate, g/day
285 ± 57
290 ± 57
271 ± 58
g/kg
4.4 ± 1.1
4.2 ± 1.2
4.9 ± 1.0
Intake (6-Day Mean)
Energy, kcal/day
kcal/kg
Protein, g/day
93 ± 22
93 ± 21
92 ± 24
g/kg
1.4 ± 0.4
1.4 ± 0.4
1.7 ± 0.4
Fat, g/day
68 ± 19
69 ± 19
63 ± 19
g/kg
1.0 ± 0.3
1.0 ± 0.3
1.1 ± 0.3
Note. No differences were detected between men and women.
a,bIndicates pair with a statistically significant difference between intakes at training camp and home, p < .05.
Nutrient Intakes of Canadian Athletes With SCI 421
had dietary fiber intakes well below the recommended
amount, with no differences observed based on gender
or training environment. Men consumed less potassium
and more sodium while at training camp than when at
home. Mean sodium intake in all cases was above both
the adequate intake of 1,500 mg and the tolerable upper
intake level of 2,300 mg. With the exception of 1 woman,
no athletes had mean intakes above the adequate intake
of 4,700 mg for potassium.
Table 4 shows mean nutrient intakes from food in
the home and training camp environments for nutrients
with an EAR. Among men, intakes of thiamin, riboflavin,
Table 3 Mean Intakes From Food Sources Compared With Adequate Intake (AI) for Fiber,
Potassium, and Sodium, M ± SD
Men (n = 24)
Fiber (g)
Potassium (mg)
Sodium (mg)
a,bIndicates
Women (n = 8)
AI
Home
Training camp
AI
Home
Training camp
38
20.6 ± 6.0
19.1 ± 4.0
4,700
1,500
3,201 ±
3,582 ±
741a
1,016a
25
19.1 ± 4.0
18.8 ± 4.7
648b
4,700
3,478 ± 1,272
3,014 ± 849
1,302b
1,500
3,353 ± 1,145
3,383 ± 1,024
2,872 ±
4,702 ±
pair with a statistically significant difference, p < .05.
Table 4 Mean Nutrient Intakes From Food and Estimated Prevalence of Inadequate Intakes While
at Home and Training Camp
Men (n = 24)
Nutrient
Thiamin (mg), M ± SD
(% inadequate)
Riboflavin (mg), M ± SD
(% inadequate)
Niacin (mg), M ± SD
(% inadequate)
Vitamin B6 (mg), M ± SD
(% inadequate)
Folate (μg), M ± SD
(% inadequate)
Vitamin B12 (μg), M ± SD
(% inadequate)
Vitamin C (mg), M ± SD
(% inadequate)
Vitamin D (IU), M ± SD
(% inadequate)
Calcium (mg), M ± SD
(% inadequate)
Iron (mg), M ± SD
(% inadequate)
Magnesium (mg), M ± SD
(% inadequate)
Phosphorus (mg), M ± SD
(% inadequate)
Zinc (mg), M ± SD
(% inadequate)
Women (n = 8)
Home
Training Camp
Home
Training Camp
1.7 ± 0.6
4
1.8 ± 0.6
12
20.1 ± 7.7
12
1.9 ± 0.7
12
339 ± 119
50
3.8 ± 1.9
17
165 ± 73
4
135 ± 93
100
856 ± 330
54
14.5 ± 4.2
4
336 ± 84
42
1,373 ± 416
0
10.3 ± 3.6
38
1.4 ± 0.4**
21
1.4 ± 0.5***
29
18.8 ± 7.5
17
1.7 ± 0.7
12
341 ± 94
38
3.4 ± 2.5
29
174 ± 80
4
39 ± 78***
100
693 ± 204*
62
15.1 ± 4.3
0
323 ± 78
58
1,278 ± 363
0
9.5 ± 2.9
46
1.7 ± 0.8
12
1.9 ± 0.5
0
14.5 ± 3.9
12
1.8 ± 0.7
12
390 ± 92
25
5.0 ± 1.3
0
195 ± 95
12
180 ± 197
75
1,077 ± 481
38
15.2 ± 7.1
16
372 ± 174
12
1,563 ± 687
0
9.5 ± 4.2
25
1.8 ± 0.9
0
2.1 ± 0.7
12
16.6 ± 6.3
25
2.8 ± 2.3
12
332 ± 113
38
3.8 ± 1.7
0
151 ± 44
0
151 ± 131
100
1,102 ± 433
25
17.0 ± 5.7
7
328 ± 114
38
1,500 ± 502
0
11.1 ± 3.5
12
Note. Prevalence of inadequacy estimated as proportion of the population with intake less than the estimated average requirement, except that the
probability approach was used to estimate prevalence of iron inadequacy in women. The prevalence of inadequate intakes did not differ between
home and training camp.
*p < .05, **p < .01, ***p < .001, intakes at home and training camp differed significantly.
422 Krempien and Barr
vitamin D, and calcium were significantly higher at home
than at training camp, whereas women’s intakes did
not differ significantly between home and training camp.
Table 4 also shows the estimated prevalence of inadequate
nutrient intakes at home and training camp. It can be seen
that vitamin D intakes were inadequate in almost all participants. High prevalences of inadequacy were also observed
for folate, calcium, magnesium, and zinc, particularly
among men. Although differences were not significant,
the prevalence of inadequacy of most nutrients tended to
be higher at training camp than at home for men, whereas
differences were not consistent for women.
Dietary Analysis Incorporating
Supplemental Vitamin and Minerals
While at home, 44% of participants (n = 14; 9 men, 5
women) reported consuming a vitamin/mineral supplement, with consumption decreasing to 34% at training
camp. Mean intakes from all 6 days of reported food
intake were compared with mean intakes from all 6 days
of reported food intakes with the additional micronutrients from reported vitamin/mineral supplements incorporated, as shown in Table 5. Supplementation significantly
increased men’s mean intakes of all micronutrients except
calcium (which approached significance) and vitamin
B12. However, as shown in Figure 1, the vitamin/mineral
supplements did not decrease the proportion of men or
women with intakes below the EAR. Women’s mean
nutrient intakes did not differ significantly with the vitamin/mineral supplements.
Discussion
This study is the first to report on usual dietary intakes
of athletes with SCI while assessing the prevalence of
inadequate nutrient intakes according to the established
standards of the DRIs (Institute of Medicine, 2000). The
average reported energy intake of 33 kcal · kg–1 · day–1
for the men in this study is similar to intakes of 31 kcal ·
kg–1 · day–1 reported in tennis and wheelchair basketball
athletes (Goosey-Tolfrey & Crosland, 2010) and 35 kcal
· kg–1 · day–1 for marathoners (Potvin et al., 1996). The
women in this study reported energy intakes of 37 kcal
· kg–1 · day–1, which is greater than the reported energy
intakes of 23 kcal · kg–1 · day–1 in a group of female
wheelchair basketball athletes (Goosey-Tolfrey &
Crosland, 2010). Intakes of athletes with SCI in our
study were similar to those of nonathletes with SCI,
who had considerably higher body weights but presumably lower levels of physical activity (Groah et
al., 2009; Tomey et al., 2005; Walters et al., 2009).
Moreover, despite their high activity level, intakes were
lower than (for men) or similar to (for women) estimated energy requirements of sedentary able-bodied
individuals of similar size (Institute of Medicine,
2006). It is difficult to assess the adequacy of energy
intakes of athletes with SCI because there are not yet
validated predictive equations for energy requirements
(Buchholz & Pencharz, 2004; Price, 2010), and the
actual measurement of energy expenditure or analysis
of body composition with dual-energy X-ray absorptiometry is often not possible. Therefore, we can only
Table 5 Comparison of 6-Day Mean Intakes of Selected Nutrients From Food Sources and Food
Sources Combined With Vitamin/Mineral Supplements, M ± SD
Men (n = 24)
Women (n = 8)
Food only
Food and
supplements
Food only
Food and
supplements
Thiamin (mg)
1.5 ± 0.5
2.1 ± 1.5*
1.8 ± 0.8
2.0 ± 1.2
Riboflavin (mg)
1.6 ± 0.5
2.6 ± 1.7*
2.0 ± 0.4
2.4 ± 1.0
Niacin (mg)
19.5 ± 6.7
22.1 ± 7.5***
15.6 ± 3.1
17.4 ± 5.0
Vitamin B6 (mg)
1.8 ± 0.6
3.6 ± 2.6***
2.3 ± 1.2
3.6 ± 3.5
Folate (μg)
340 ± 84
454 ± 178***
361 ± 69
480 ± 192
Vitamin B12 (μg)
3.6 ± 2.1
34.4 ± 124.0
9.0 ± 13.3
12.1 ± 13.4
Vitamin C (mg)
169 ± 54
262 ± 174*
173 ± 39
204 ± 80
Vitamin D (IU)
87 ± 66
177 ± 200*
166 ± 130
216 ± 173
Calcium (mg)
775 ± 206
853 ± 283
1,089 ± 419
1,118 ± 428
Iron (mg)
14.8 ± 3.4
16.3 ± 4.3**
16.1 ± 6.1
21.6 ± 12.4
Magnesium (mg)
330 ± 66
352 ± 78**
350 ± 121
363 ± 132
Zinc (mg)
9.9 ± 2.5
13.0 ± 5.3**
10.3 ±2.9
12.2 ± 5.6
*p < .05, **p < .01, ***p < .001, intake food sources compared with food sources with additional nutrients from vitamin/mineral supplements
differed significantly.
Nutrient Intakes of Canadian Athletes With SCI 423
Figure 1 — Estimated prevalence of inadequate nutrient intakes from food alone and from the combination of food plus supplements in male and female elite athletes with spinal cord injury. WF = Women, intake from food alone; WFS = women, intake from
food plus supplements; MF = men, intake from food alone; MFS = men, intake from food plus supplements.
make inferences about the adequacy of energy intakes
based on BMI within the anticipated range and moderate
values for skinfold measurements. Based on these indirect
parameters, however, energy intakes of the athletes we
studied appeared to meet their needs.
Intakes of both carbohydrate and protein were
more than adequate as assessed against the DRIs, and
protein intakes fell within the range recommended for
athletes (Rodriguez et al., 2009). Carbohydrate intake,
at 4.4 g/kg, was below the recommended intake of
6–10 g/kg for able-bodied athletes (Rodriguez et al.,
2009); however, it is probable that this standard is not
appropriate for athletes with SCI. For example, given
the mean 70-kg body weight of the male athletes we
studied and their mean energy intake of 2,156 kcal/
day, meeting even the minimum carbohydrate recommendation of 6 g/kg would represent 78% of energy
intake and would leave only about 2% for energy intake
from fat. This clearly illustrates the need for research to
develop appropriate recommendations for this group of
athletes.
Another example of the difficulty of applying recommendations for able-bodied athletes to athletes with SCI
is provided by sodium. The sodium content of sweat in
able-bodied athletes averages about 1 g/L; thus, some
endurance athletes with daily sweat losses in excess of 2
L may have requirements that exceed the tolerable upper
intake level (Institute of Medicine, 2006, Rodriguez et al.,
2009). However, sweat losses of athletes with SCI, par-
ticularly those with tetraplegia, are generally not as high
because of the decreased ability to sweat below the level
of the spinal-cord lesion. Thus, it cannot be assumed that
additional sodium intakes are appropriate or necessary for
athletes with SCI. Again, additional research is required
to determine the sodium and electrolyte requirements of
athletes with SCI.
Dietary micronutrient inadequacy was observed
both at home and at training camp. It was not improved
by higher energy intakes at training camp or by use of
vitamin/mineral supplements. Although vitamin/mineral
supplement use increased men’s mean intakes of most
nutrients, it had little impact on inadequacy (i.e., the
proportion of men with intakes below the EAR) and
made little difference to the intakes of women. Fewer
than half the athletes used vitamin/mineral supplements,
and the failure of supplementation to improve adequacy
suggests that the athletes with the poorest diets were
less likely to use supplements. With observed energy
intakes lower than what would be observed in ablebodied athletes (van Erp-Baart, Saris, Binkhorst, Vos,
& Elvers, 1989), it becomes even more important for
athletes to have access to nutrient-dense food choices
along with the knowledge and skills to make sound nutritional choices regardless of their environment. Although
appropriate vitamin/mineral supplement use has the
potential to improve nutrient adequacy, improving food
choices to increase nutrient density should be the first
approach to enhancing intakes.
424 Krempien and Barr
Strengths and Limitations
The strengths of this study include the repeated measurements of activity and food records in two different environments and the incorporation of nutrients from vitamin/
mineral supplements. Comparison of dietary intakes with
the standards established by the Institute of Medicine
allowed for a more comprehensive analysis of dietary
adequacy than has been conducted previously. Most other
studies have compared mean intakes with recommended
values. However, this can be misleading because even
when mean intakes exceed the recommended allowance,
the prevalence of inadequacy can be considerable. One of
the major limitations with this study was the reliance on
self-reporting of dietary intake and the risk of under- or
overreporting, for which there is potential in any study
of free-living individuals (Livingstone & Black, 2003).
Many steps were taken to minimize these risks, including providing a detailed explanation of how to accurately
record food intake, having a researcher with the athletes
for the initial 3-day period to assist with recording food
diaries, clarification if any of the recorded information
was unclear, and discreet observation of athletes’ food
choices. Furthermore, it is our impression that the athletes were motivated to record their data as accurately
as possible, based on the level of detail in the reporting
of food intake in most food diaries and the high return
rate for the second set of food diaries (94% return). A
number of methods to assess energy and dietary intakes
are available, including doubly labeled water, weighed
food records, or self-reported food records. A review of
over 100 studies indicated that 3- to 4-day self-reported
dietary intake was the method chosen most often to
estimate usual intake (Burke, Cox, Culmmings, & Desbrow, 2001). Future work using doubly labeled water to
measure energy expenditure, dual-energy X-ray absorptiometry to measure body composition, and biochemical
assessment of micronutrient status is required to confirm
dietary assessments.
Conclusions and Applications
This study provides preliminary evidence of dietary
intakes and inadequacies in elite Canadian athletes with
SCI. It demonstrates that the energy intakes of elite male
and female athletes with SCI are relatively low. Although
the macronutrient distribution was within the recommended ranges, there was a relatively high prevalence
of inadequate intakes of several vitamins and minerals.
Within the limited energy intakes, it is even more important for these athletes to optimize their dietary choices
to ensure that they are consuming adequate amounts of
micronutrients, ideally from nutrient-dense foods, to
reduce the risk of suboptimal nutrient intakes. It may be
necessary for many athletes with SCI, especially those
with energy intakes below 1,800 kcal/day, to have their
diets assessed by a registered dietitian who may provide
them with specific food suggestions and recommend
supplemental vitamins and minerals as appropriate.
Dietary micronutrient inadequacies appeared to
be more pronounced at training camp, highlighting an
opportunity for coaches, administrators, sport scientists,
and registered dietitians working with these athletes to
improve their access to better food choices and educate
them in making more balanced food choices. Because
the nutrient density of food choices needs to be optimal
for these athletes to meet their recommended vitamin
and mineral intakes, a closer evaluation of the dietary
choices available to athletes at national-team events is
warranted. Restaurant meals may not be appropriate to
provide the complement of vitamins and minerals in a
reduced energy intake, and customized lower fat meals
emphasizing whole grains, vegetables and fruits, and
low-fat milk and milk products should be considered to
provide the most appropriate food choices for athletes.
Although the prevalence of dietary inadequacies was
typically less when the athletes were at home, several
improvements could still be made to optimize their daily
training diet. Ongoing nutrition education and dietary
assessment provided by registered dietitians with expertise in the area of sport nutrition would be a valuable asset
to the integrated support team for all athletes with SCI.
Acknowledgments
The authors would like to extend a tremendous thank you to
all the athletes who participated in this study. Your willing
participation, with thoughtful and complete responses, greatly
enhanced the results of this study.
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