Chronic Fatigue Syndrome & Overtraining Syndrome in academy footballers
This article appeared in Functional Sports Nutrition (FSN) magazine, March/April 2021 edition
Introduction
Sam Keen, the American author and modern-day philosopher, once wrote, “Every stranger is a world waiting to be explored.” Meeting a new client in clinic (or video call in 2021!!) I am reminded of this quote. Listening to the client when they tell you their story in the consultation is a privilege. With this listening comes an invitation into the world as the client sees it, an opportunity to share their challenges and to walk with them through ideas and potential solutions.
This is the case with my client, Charlie. At 15 years of age, he is a very talented youth footballer. He has been involved in academy football since the age of 9 and he has dreams of making it as a professional footballer one day. Charlie and his family contacted me as they had seen that I had been working in academy football. Although they lived some way from where I was based, they were happy to conduct the sessions through video call.
Introducing Charlie
Due to the current pandemic, I wasn’t able to watch Charlie play football. Instead, the family sent me some videos of him playing. Charlie’s talent was clear to see. Ian Holloway once famously said that there are two types of footballers; piano players and piano carriers!! Charlie is a piano player. With a ball at his feet, he played like he was conducting an orchestra, it was a joy to watch.
Chronic Fatigue Syndrome & Overtraining Syndrome
Before we started working together, Charlie had been diagnosed with chronic fatigue syndrome (CFS). When he came to see me, he was receiving fantastic care and support from a local NHS chronic fatigue clinic but they had not discussed nutrition with him. CFS is a complex condition without a recognised test to confirm its diagnosis (1). Those with CFS have reported debilitating fatigue lasting at least 6 months, along with other symptoms such as, mental dysfunction, sleep disturbance, pain, microbiome abnormalities, cytokine dysfunction, immune dysregulation with symptoms worsening with any kind of activity (1).
During our initial discussions I couldn’t help but make the connection between CFS and similar symptoms that are seen in overtraining syndrome (OTS). The key characteristics of OTS are fatigue, decreases in performance, psychological and hormonal changes (2). The collection of symptoms are believed to be brought on by an increased load and decreased rest periods (3). Additional life stresses are also thought to be a factor (4). As such, similar to CFS, there are many different components that lead to the progression of the condition. In terms of managing the condition, nutrition, sleep, training load and training periodisation all play a part (5). For the over trained athlete this collection of circumstances ultimately results in failure to induce physical adaptations, and can have serious long term consequences to the career and health of the athlete (6). Charlie and his family were seeking my advice for his sporting performance. I discussed with them the potential of focusing my intervention on his recovery from exercise. They were intrigued by this approach and eager to see if it may help him.
Table 1: Signs and symptoms of CFS and OTS (1,7,8)
During my research prior to our first consultation, I found some promising research highlighting links between diet and a reduction in CFS symptoms. However, at present there is no clear evidence for dietary protocols (9) hence why the NHS teams did not offer any support in this area.
Nutrition intervention
We started by conducting a detailed analysis of Charlie’s lifestyle and eating patterns up to this point. The way I work is to cover the basics first. There is no point heading straight to supplements without making sure we have a firm structure upon which to build health.
The Starting Point
The first aspect that stood out was Charlie’s carbohydrate consumption. The family understood that carbohydrate fuelled energy, therefore they had tried to ensure that Charlie had energy available every time he trained or played. This resulted in excessive consumption of simple carbohydrates.
Table 2: Typical meals pre nutrition intervention
For players at academy level there is a high training requirement, on occasion training twice a day multiple times per week. Therefore, consuming sugar prior to every session, in the understanding that sugar fuels performance, will result in a high sugar consumption. Charlie’s sugar consumption came at the expense of the other macro-nutrients. I felt I needed to explain why constant supply of sugar may not be the most effective approach. When I spoke to the family on one of our Zoom calls, I saw that they had a wood burner in the house and an analogy sprung to mind. I explained that simple carbohydrates might be likened to paper or kindling, they get the fire going but give a short-term solution, quickly burning themselves out if logs or coal are not added to sustain the fire. Prolonged energy needed to be achieved by a balanced diet, with planning for longer term energy taking priority.
What also became clear at this stage of the process was that Charlie really relied on the influx of carbohydrate. This concerned me. I wondered whether his constant need to stimulate was linked to a reduction in an ability to store energy. Interestingly one aspect of OTS is the over stimulation of the adrenal gland which can result in, through a cascade of biochemical process, reduced glycogen resynthesis (7). This means that in the overtrained individual there is an ongoing reduction in quality of recovery possibly resulting in a reliance on exogenous carbohydrate.
Overall energy requirements
The next area that stood out for me was his overall energy intake. Recent research has shown that the calorie requirements for academy footballers is higher than previously thought (10). I conducted energy calculations on Charlie’s dietary intake and estimated that he could be consuming approximately 1,500 kcals per day. With his training load I estimated that his requirements may be closer to 3,500 kcals on a training day. Achieving a higher calorie intake often takes time and planning. If this low intake continued, I felt he was putting himself at risk from conditions associated with low energy availability.
The research around low energy availability demonstrates the metabolic challenges that can be caused by chronically under-consuming food. This condition is called Relative Energy Deficiency syndrome or REDs for short. Although sports other than football have been deemed a higher risk that doesn’t mean that the potential for this to occur in football should be ignored (11). Based on Charlie’s reported eating habits I suspected that he may be chronically under-fuelled.
Table 3: Potential Performance Consequences of Relative Energy Deficiency in Sports (11)
Protein requirements
With Charlie’s diet predominantly being made up of carbohydrates, consumption of the remaining macronutrients seemed to be low. Protein is our repair and rebuild nutrient, it plays a significant role in recovery from exercise. During exercise the muscles are broken down and need protein to help them rebuild. The timing of protein in certain situations can be important also, helping the athlete come back stronger (12).
Possibly more interestingly in Charlie’s case, research has shown that certain proteins have a role in mental performance following exercise. More accurately the lack of protein post exercise can impact upon feelings of fatigue and concentration levels both of which are compromised in OTS (13). I discussed this with Charlie and his parents and we agreed to prepare some post training snacks alongside eating a meal when he returned home. The priority was to achieve the best possible recovery post exercise and to avoid Charlie wanting to stop at the services on the way home from training where junk foods are more likely to be consumed.
Table 4: Post-exercise protein snacks
Integrative thinking
My thoughts throughout our work together had been the idea that conditions exist on a spectrum. When Charlie had been first diagnosed with CFS he was at his lowest point, struggling to get out of bed (very often not getting out of bed at all), experiencing heightened muscle soreness, and low mood bordering on depression. But it wasn’t always like this. When I looked at the data on distance covered in training and matches, I found something surprising. In the times when Charlie felt well, he would actually often cover more ground than his teammates. What plagued him however, was the thought that someday seemingly out of nowhere the fatigue would return. I felt that in my work with him and his family I needed to explain how this condition may come back and that, if it does, it perhaps isn’t out of the blue but in fact is part of a cycle.
Where the initial intervention felt like we were covering familiar sports nutrition ground, it was important to get the structure and basics of Charlie’s health in order. As our work together progressed and trust and confidence were built, I was able to look at other aspects of the interaction between fatigue conditions and nutrition. I wanted him to improve his digestion and take time when eating food, giving him the best chance of breaking down and absorbing the nutrients he ate. As my research continued I came across some studies investigating CFS and exercise, which had found a tendency for reduced oxygen transport capacity, reduction in muscle mitochondria, and a reduction in fitness in CFS (14). This would be a good place to start the next phase of our work together.
Oxygen transport capacity
In exercise oxygen transport is fundamental to facilitate ATP production. Charlie’s diet was relatively low in dietary nitrates which are found in foods such as celery, cress, lettuce, beetroot, spinach and rocket. While dietary nitrates carry out many roles within the body, one is to promote blood flow. We added these foods to Charlie’s diet. We also started to supplement with the amino acid, arginine, again for its links to nitric oxide production helping to support blood flow.
Charlie had completed blood tests through the NHS clinic which had identified that he had low iron levels for which he was now supplementing. But his dietary consumption of iron was also low. The research tells us that the iron levels of athletes can be affected by multiple different actions including training load and gastrointestinal disturbances, therefore providing adequate iron is fundamentally important to athletes. We set about trying to introduce iron-containing foods. Like many aspects of nutrition vitamins and minerals work in synergy with each other so introducing one nutrient may not be as beneficial as introducing groups of nutrients. To this end I also worked on introducing foods with B-vitamins, folic acid and adding more antioxidants, all of which help towards the production of red blood cells.
Mitochondrial function
The mitochondria are much more than just the powerhouses of the cells, however energy production is an important component of their actions. The number of mitochondria in the muscle is seen to increase with training, this is thought to be one of the reasons for improved training capacity in athletes (15). However, in CFS there are fewer muscle mitochondria. With this in mind I wanted to focus on nutritional strategies to enhance mitochondrial biogenesis. Here we turned to antioxidants as I felt that if we could improve Charlie’s nutrient status this would help improve mitochondrial function. It was important not to just focus on high dose single nutrients so I tried to avoid supplementation at this stage. Antioxidants work on reducing Reactive Oxygen Species (ROS), however in certain situations ROS actually stimulate physiological processes that help with adaptation. It seems that it is this balancing act and, although some research actually recommends supplementation over food, this would require testing to ensure that it was done effectively (16). Hopefully this is an aspect that we can explore moving forwards.
Table 5: Foods high in antioxidants
There are other nutrients that are known to play a role in mitochondrial health, such as L-carnitine, B-vitamins, vitamin C, magnesium, sodium, zinc, L-tryptophan, coenzymes Q10 and essential fatty acids but at this point in our work together we haven’t focused directly on these nutrients apart from a recommendation to soak in a magnesium flakes bath before bed to help with sleep.
Although we had started to experiment with nutritional recommendations for CFS, he was still under the care of the NHS for that condition. However, by linking CFS and OTS I was able to offer a fresh perspective about his health and I think he has benefited from this. The discussions that we had about health and links to overtraining were so relevant in this case. It was this that ended up being the penny dropping moment for Charlie and his family. Instead of thinking of CFS as some mystery illness out of his control if he applied the idea of ‘give and take’ to his health then he could start to develop an awareness of rest and recovery being a vital part of the process.
I would love to be able to report a fairy tale ending to the story with the nutritional intervention being the hero but unfortunately the pandemic has seen to that. However, we continue to stay in touch and I hope to be able to develop my ideas with Charlie as we come out of lockdown in 2021. One thing I would say is that Sam Keen was right. I have thoroughly enjoyed being part of Charlie’s world for the time that we have worked together and I believe that our explorations around health and exercise have developed us both; him as a player and me as a practitioner.
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