Episode 174 of the Institute of Performance Nutrition's "We Do Science" podcast! In this episode, I (Laurent Bannock) discuss "Nutrition Considerations to Optimize Performance in Paralympic Athletes" with Dr Elizabeth Broad (Australia).
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[00:00:00] LB: Hi, and welcome to episode 174 of the Institute of Performance Nutrition's We Do Science podcast. I am Dr. Laurent Bannock.
Now, today I had a great discussion with Dr. Elizabeth Broad. Now, Dr. Broad is well-known to many of us that have been in the sport and exercise nutrition field for some time. And as you'll discover from our conversation today, Liz is just an incredibly experienced, passionate, knowledgeable practitioner in sport and exercise nutrition that's just had a really impressive career over a number of years spanning in a number of different sports. But an area in particular that liz is a noted expert in, and by expert, I mean, published papers, has a textbook. She has authored with an impressive array of co-authors. And most importantly, in my mind, has an immense track record of working with many of the greatest Olympic-level Paralympic athletes around the world. This is going to be a great conversation as I’m sure you will appreciate.
The conversation, well, we got into what actually is a para athlete. We discuss the impairment types. For example, spinal cord injuries, for example, being a common impairment type. But there are many, many, many others, like cerebral palsy, sight impairments just to name a few.
Now, you all have heard me talk about issues, concerns that I and my colleagues, my guests often have about the problems with generalized findings in the research. That is then applied without appropriate sort of context or contextualization, individualization, personalization being factored in. And this is just a really perfect example of why context or individualization is incredibly important when it comes to applying sport and exercise nutrition strategies that are based on evidence into an athlete population such as Paralympic athletes. It's just fascinating subjects, like working out their energy needs, dealing with things like body composition and just practical problems that they have in a world that is primarily focused on able-bodied individuals. There is just such a gap that needs to be bridged.
Anyway, you'll hear us talk about that. And Liz will share her immense knowledge on this with me and with you as the listeners. And you can find out more about that episode in terms of the notes, the book, her own podcast dedicated to Paralympic athletes all at our website at www.theiopn.com. And you can also learn about all the other things that we do, such as our online diploma in performance nutrition. It's an advanced level program for those looking to specialize as sport and exercise nutritionist, particularly as practitioners. That's our program. It's unique. Go check it out. And our software platform called SENPRO, which is specifically designed to support sport and exercise nutritionist working with individual clients and/or in group coaching settings, online, in-person, and of course working in teams. Anyway, come to www, or just one set of ww's, to the iopn.com. And here is my conversation with Dr. Liz Broad, all about sports nutrition for Paralympic athletes. Enjoy.
[00:03:45] LB: Hi, everyone. I am really excited today to be speaking to Dr. Elizabeth Broad. Now, some of you will know Elizabeth well because she is a huge celebrity in the professional sports nutrition field. And I joke, but I don't joke, because – And I mean this in the polite way, of course. But you've been around for quite a long while, haven't you, Liz?
[00:04:08] WS: Yes, I am a bit of an old-timer. I can do my own lunchbox.
[00:04:16] LB: You're a classic, Liz. Let's just leave it at that. Today we're going to have a conversation that I know is central to your heart and your work. You spend a lot of time working in this area. And also, it's an important area for a number of reasons that I think will come out of this discussion that we have today that I think doesn't just apply itself uniquely to Paralympic athletes, which is what we're going to talk about today. And obviously, nutrition, and lifestyle and so on. But primarily, performance nutrition strategies that can impact the health and the performance of a para athlete.
But also, as I was just inferring that, this actually applies with a bit of an adaptation to the thought process to a lot of different people. And the reason why I’m saying that is because I think that this is a particularly good example of why context, or contextualization, or individualization, or personalization matters. When we look at sport and exercise science, particularly sport and exercise nutrition, which of course is done on sort of a pretty generalized basis, which we have talked about many times on this podcast about how the generalization of that information, that evidence isn't necessarily relevant to, for example, elite athletes who tend to be outliers. And of course, when we now discuss para athletes, that's an even more extreme example of just how far away we are from a generalized understanding of nutrition strategies that we should be thinking about to support training adaptations and performance and so on.
Before we just get into that conversation, Liz, why don't you just give us a little bit of an introduction to yourself and who you are, I think that would be a great place to start this conversation.
[00:06:05] WS: Thanks, Laurent. I’ll try and keep it pretty short. Because as you say, I’m a bit of a classic. I graduated as a dietitian in the late 80s in an era where sports nutrition really wasn't a thing. It certainly wasn't taught in dietetic courses. There weren't people who worked you know hand-in-hand with athletes on a regular basis. It just wasn't a topic of discussion and certainly wasn't anywhere near the forefront of my mind. You couldn't do double degrees in exercise science and nutrition that a lot of people can do these days.
I started working as a clinical dietitian and fairly quickly realized that a nine-to-five job was not for me. I’m not geared that way. And over the kind of subsequent four or five years, an opportunity arose to do a fellowship at the AIS, the Australian Institute of Sport in Canberra with Dr. Louise Burke, who's been a guest on your podcast, and is a legend.
And so, I took up that I was able to get that opportunity in 1994. It was a 12-month opportunity where you're basically thrown in the deep end. And if you found that that was something that you enjoyed, then hopefully you were able to progress on from there.
And when I started, it was the first year that the Australian Institute of Sport had a power track and field program. And so, they were one of my responsibilities. And so, that was my first entry point to Paralympic sport. They also had a lot of camps-based programs that came in. And being the little duckling, I was the one that had to deliver all of that information. You start trying to look into the literature and find out a bit more about what do I talk to them about. And there was pretty much nothing. And then Australia got the 2000 games, and eventually they were able to put on a new position under Louise, which I was fortunate enough to get.
Move on, I started a master's in exercise science. And as my master's project, we actually looked at the effects of heat on shooting performance in wheelchair shooters. We had the six Australian Paralympic shooters for the Atlanta games come into a heat chamber. And we did some work with really early stage of the cooling best and trying to cool them down in hot conditions, because they're expecting pretty hot conditions in Atlanta.
And again, you have to do a lit review for a master's project like that. And so, my literature review was like, "Hmm. Okay, there's not a lot out here." And so, it was quite obvious that – And each of the athletes had a different disability, different impairment and had different physiological kind of parameters that they were working within.
And so, I couldn't get it published, it of six number one, and those six very different individuals, and no one would publish that type of work. The data still sits in my master's thesis. And that's about as far as it ever went.
Then, still at that point in time, there wasn't a lot of opportunities for people in parasport. I followed my nose. I did a lot of different things. I moved to Scotland after the 2000 game, because my husband had the position as Head Triathlon Coach for Scotland. Did my Ph.D. under Stu Galloway at the University of Stirling, which was a fabulous opportunity that just got presented to me, which I couldn't say no to.
Worked in professional sport. Worked with a lot of Olympic athletes. Went back to the AIS eventually. And 2011, 2010, 2011, the Australian Paralympic Committee wanted to buy out half of my role at the AIS to work with their Paralympic team leading into London. And that's really – You're now looking at a 14-year time gap from the time I first started to the time you really started to get a lot of momentum in that space. And I kind of never turned back after that.
I did another few years. Finished in 2013 and ended up moving to the US for a brand-new position at the US Olympic, and now Paralympic Committee. They changed their name. And working with US Paralympics full-time. I did that for six and a half years. Yeah, was massive opportunities that you just had to wait and be patient for because they were few and far between in the early days.
[00:10:53] LB: Yeah. I mean, look – I mean, yes, that's a podcast in itself. I think if we were to delve into all the different aspects, all the different chapters of your journey. And of course, I guess we're going to summarize aspects of your sort of learnings and knowledge on that. Of course, you've published a great book of which I have the second edition, Sports Nutrition for Paralympic Athletes. And you have authored and/or co-authored a variety of papers so that people like myself who in the past have worked with some para athletes did not have to scratch my head going, "What the hell do I do here." To the level that you had to back it literally in sort of day one and the body of knowledge that we can find on this topic. Not to exclude, of course, you know things like these podcasts. And you've got your own podcast dedicated to this topic, which I will add to the things that I link to in the show notes on our IOPN podcast version of this discussion that we're going to do.
But you made something, you made a comment there about you weren't able to publish your master's thesis. To me, that's criminal for a variety of reasons. And I bang on about this a lot on this podcast because my own obsession is – And my doctoral research was on the gap that exists between science and practice and how we bridge it.
And one area that I looked at, of course, was how we create a body of knowledge evidence. Where do we get that stuff from? Why we should look at things like NF1 case studies, particularly in an elite context as being perhaps more valuable than some people will look at it when you see these hierarchies of evidence that are bandied around. And of course, it is absolutely correct, solid, robust science to try and get as much statistical power and have as many participants and so on. But it does depend on what you're actually trying to learn.
And again, it's not just about numbers and data, or at least statistical type data. There's qualitative data. There are the needs, the preferences, the likes, the socio-economic circumstances of an individual. Practical matters, which is obviously important in this situation, is something that comes up all the time. And, yeah. I mean, maybe we should get your thesis published. I think there's some honor in us attempting to do that, Liz.
But just on that point there, what are your thoughts about the evidence that exists there and the barriers that we have to getting the information that we need so that we can have a much better understanding of how to support Paralympic athletes? And I know you've made plenty of efforts yourself to include your new podcast, of course.
[00:13:42] WS: Yeah. I was listening to a podcast you did recently with Kirsty Elliot-Sale who was – And you asked her the question, "Well, what's the definition of a female athlete?" And she said, "Well, there's multiple definitions."
Well, similarly with para, there's another whole layer of multiple definitions. You've got different impairments. You've got a multitude of different sports, and obviously how you apply that nutrition within that sporting context. Depends on the physiological demands of the sport, the type of environment that it's competed in, the level that they're playing at, all of those things. You've got those layers.
You've got their impairment and the impact that that has on their physical function. But then you also have a layer of medical, clinical and other underlying factors that can come with their impairment or can be separate to their impairment. And so, for example, you could have someone who has a spinal cord injury from a traumatic event, a motor vehicle accident or a motorbike accident, who, in the process, they also had a fairly major injury to their gut. And as a consequence, you have a number of gut related issues that also play a part of the nutrition recommendations and their response to nutrition recommendations, which is a little separate to their actual impairment but they interact with each other.
And I think when I went to write the book, a lot of people said, "Why are you writing a book for sports nutrition for para athletes? Isn't it exactly the same as it is for able-bodied athletes?" I'm like, "Well, the assumption is that it is. But it's how you apply that information and what assumptions you make in knowing that information."
And the biggest deficit, or some of the biggest deficits we have in the Paralympic space, is that a lot of the sports aren't described well from a physiological perspective. You look in the literature, what are the physiological demands of football? There are hundreds of papers that go through the physiological demands of women's football, men's football. How much distance they cover? Yadi-yadi-yada.
You look for that in a Paralympic space, what are the physiological demands of goalball? Most people will look at you and go, "Never heard of the sport." Let alone, these are their average heart rates. This is the amount of work that they do. This is the type of training. You can't apply your nutrition knowledge without having an understanding of what the physiological demands are, because that drives a lot of the nutrition in terms of the performance nutrition space.
And so, that's really where the kind of the book tries to sort of drill down a little bit more in terms of what are some of the things you have to think about in trying to transfer that information that we have in able-bodied athletes? Into different aspects of a Paralympic athlete perspective.
Most of the time, it's an N of one problem-solving exercise, where you just have to think logically, but also be willing to be – To think really flexibly and holistically about all the different parameters you may be coming across.
[00:16:58] LB: Yeah. I mean, look, it's great, because we've moved so far forwards from where we were as a discipline. And by discipline, sport and excise nutrition, that 10 years ago had picked up a fair amount of momentum, I guess, in the last 10 years. But you go back 15 years or so, as like you say, it didn't even exist. And we're still, year-on-year, the explosion of research. Numerous guests in the past have talked about this, but I think particularly when Graham Close was on, who's been on many times of course, where we talked about his group's paper to podium paper, which was particularly important, I feel, in terms of a practitioner looking at the evidence and differentiating not just the quality of it, but the relevance of it, which is my new word you see, Liz.
For years, I’ve been obsessed with the word context. But actually, I think relevance is the new one I’m giong to have tattooed to my forehead. Is it relevant, though? It might be great. It might be fantastic high-quality sports science research. But how is this relevant to my para athlete?
And I think when reading – Well, based on a conversation we had before this podcast, and when I’m reading some of your papers, some of which I’ve read again recently, it just really hits home to me the importance of individualization, the N of one thing that you've just mentioned. And yet, the gap between that and all of the research that exists out there is pretty interesting. But that is why it is so important for us as practitioners to be able to not only source the right evidence, but learn how to translate that into the applied context, which of course is why the likes of you and me having these sorts of conversations try and add to that process.
[00:18:42] WS: Yeah. Because I think a lot of practitioners don't have the bells and whistles to – The simplest question I get asked is, "How do I work out the energy requirements of my athlete?" And if you're in a research setting, you go, "Oh, maybe we could do some – Do a resting metabolic rate. Maybe we could do an DEXA scan extra scan. Maybe we could do this. Maybe we could do that." But a practitioner, particularly a private practitioner, doesn't have access to all of that stuff.
And so, you have to make decisions that are logical in using parameters that are the best thing that you have. And I think that's the other part, is to make it to kind of bring things down to a point where a practitioner with very little bells and whistles can still make good decisions and have that athlete's best interest looked after.
And I think the one thing that you learn with para athletes is you ask them a lot of questions. And I don't know that you do that a lot with – There's assumptions that are built into working with able-bodied athletes. You kind of assume that they all operate in a similar sort of framework. Their body works normally. Whatever normal is. In a power athlete, you can't make assumptions.
And so, you learn to ask a lot of questions. And what you realize is that those athletes actually know a lot about their bodies. And they're often part of the problem solving. Because you say, "This is what I’m trying to do. This is where I’m trying to get to. Where do you think we need to make a change? Or how do you think we can get there?"
And so, I think that's one of the things that I’ve learned the most in working with para athletes, is that engaging them in the conversation and being able to explain to them the reason why you're trying to achieve whatever the thing you're trying to achieve is, and bring them along in that journey and as part of that conversation. And it means that you end up with a better outcome, because you're not telling them to do something. You're working with them to find a better solution.
[00:20:54] LB: Absolutely. I talk a lot about the practitioners’ toolbox. We have, literally, I guess, the well-understood version of the term tool, which in our world might be DEXA, skin fold calipers, that sort of thing. But I also mean that to include knowledge, critical thinking, skills, coaching skills, communication skills, all these sorts of things.
And the bells and whistles that we look at and we see in research laboratories or what have you still doesn't compare to the ultimate bells and whistles that we have that is our brain, and our eyes, and our mouth and so on. And yet, all of these, things of course, like any tool, you need to know the strengths and limitations of those tools. And that is that is perhaps a weakness in itself, is where people don't necessarily realize where they fit in that spectrum of competence, or mastery, or whatever.
But look, let's just dial this back to something. You mentioned the podcast I did with Kirsty and Jose on nutrition for female athletes. And what I do with most of my podcast is we try and define what we mean about something and then sort of unpack the evidence in that context.
You've already given us just a little bit of a hint there. But when you're talking about a para athlete, or when somebody's looking at your books or papers, what does that term actually mean?
[00:22:25] WS: Yeah, great question. I think a para athlete, for me, it's an athlete with an impairment. And I choose my words fairly carefully. If you look at the International Paralympic Committee, they actually have recommendations on terminology to use. But rather than using athlete with a disability, they prefer the term athlete with an impairment.
And so, we use – But the term para athlete can be used as an all-encompassing term for an athlete with an impairment. Now, that impairment can be a physical impairment. It could be an amputation, a missing limb. It could be a spinal cord injury. It could be cerebral palsy. Anything that produces – Even club foot is considered to be an eligible impairment. And you can go to the International Paralympic Committee website if you really want to get technical about what an eligible impairment is. But it's anything that creates a physical, I guess, situation that needs to be overcome that creates a challenge that may be different to a what fully able-bodied individual.
There's also vision impairments and intellectual impairments. Some sports that are played at the Paralympic games include individuals with an intellectual impairment. And there's a very – I guess, there's a specific term or way of classifying those athletes. It's to do with their IQ before the age of 18 for an intellectual impairment.
But it can also be impairments like a traumatic brain injury. It may not be obvious to the non-discerning eye that there's something else going on. But there's a really interesting dynamic in terms of the interaction between the neurology, the nervous system, and then the muscle. The nerve may be saying do this and the muscle's not responding in the same way that it should be. Yeah, to cut a long story short, a para athlete is an athlete with an impairment, whether that'd be physical, intellectual or vision.
[00:24:30] LB: That's fascinating. Recently, of course, we've been talking about the differences that potentially exist between males and females. And of course, it depends on what context we're talking about that we've covered in a number of podcasts. We've also talked about differences in terms of needs, particularly like protein, for example, and/or how to bring about optimal training adaptations particularly as it relates to muscle hypertrophy in older populations, for example. We've covered that.
We've looked at vegan vegetarian plant-based athletes. But this area is I think interesting. Because although you're discussing the various descriptors of impairments that ticks a box for an official competition, as you walk down any high-street and you look at people, you can imagine that many of these people are ticking various impairment boxes, whether it's stress, anxiety, depression, long-COVID, suffering from an injury from falling off a bike. It may be a temporary impairment. Recent surgery, hip replacement, you name it. And yes, they may not be elite athletes, but they still might have ambitious plans to be physically fit and active for whatever reason.
Of course, that's why I think this conversation lends itself to a slightly broader range of clients than just that para Olympic title. Nonetheless, this is where the interest lies. Now, you've talked about impairment types. You've described some of those impairment types. And that I find particularly fascinating. And we could spend hours talking about these different things.
But in one of your papers, which is the key nutritional strategies to optimize performance in para athletes, you've got a very useful table in there, which is on factors affecting nutrition status and performance. And you also talk about we're looking at the pretty well-defined nutrition strategies that exist to support training adaptations and performance. And of course, we've talked about issues of generalization and so on. But the particular factors that may have a negative impact, or at least an impact that you need to consider, as it relates to specific causes is what I found particularly interesting as I was going through this paper of yours.
And what I thought would be quite useful at this point in the podcast would be for us to address some of those key factors. And you could help us understand what some of those potential causes could be. What potential impact that might have on performance and maybe some potential solutions, or strategies, or perspectives. Of course, the big one, the big one, which you've already referred to, is how on earth do we deal with a reduced metabolic rate and energy expenditure in these particular impairment types?
[00:27:20] WS: It's a real challenge. And even if you take someone with a spinal cord injury. We'll just focus on that as an example of the spectrum that you have. The spinal cord injury can be anywhere along the spinal cord. Some individuals will have their spinal cord injury at the lower part of the spinal cord and may actually ambulate perhaps with the help of some crutches or some braces on their legs. They may actually walk. Not everyone with a spinal cord injury is wheelchair-requiring. At least not for the mainstay of their day-to-day activities.
And then you have someone with a spinal cord injury at the cervical level, where their primary function is above. They can sometimes even have trouble moving their hands, and let alone their arms. And their lungs and their ability to breathe on their own can sometimes – Certainly, if they're very high, you generally don't find these people as athletes though. They have difficulty breathing on their own.
And so, if you look at, "Well, how do I work out their energy requirements?" Some of those – And the spinal cord injury may be complete. It's a complete severing. So there's no sensation, no movement, whatsoever. Or it may be incomplete.
And so, the higher the level of the lesion, the more muscle atrophy there is. And by virtue of that, theoretically, the lower their resting metabolic rate will be. Seeing the resting model metabolic rate is primarily driven by the amount of muscle mass that we have.
However, it doesn't always – There's no logical kind of, "Oh, I applied a 20% reduction for someone with a T-level – a T6-level spinal cord injury. I apply a 30% reduction in energy requirements." There's no set proportion of expected resting metabolic rate that you can put into play there.
And the other thing is that with someone with a – I’ve had, for example, a wheelchair tennis player, one tennis player. High-level spinal cord injury, [inaudible 00:29:30] level, quadriplegic. But at rest, his leg would – I’m trying to work out a way of saying it, fidget. It would jiggle up and down. This is someone who has no sensory level at their leg. No voluntary movement of their leg. And yet, their leg would sit and have muscle contraction where it moved up and down.
And so, that's obviously expending energy. But how do I calculate that? That's just one example of – It's really hard to measure proportionality of muscle atrophy. And then apply that in an equation to automatically change the resting metabolic rate for something like Harris-Benedict.
Now, you can use something like Scofield if you can get a DEXA scan. Get an accurate measure of lean body mass. And that's probably the best that you can do. But that requires you to have the ability to get that DEXA scan done. And so, that's just one example from one subgroup of para populations.
But if you look at any of other subgroups, there's a [inaudible 00:30:47] energy required – Amputees, particularly lower limb amputees, you can say, "Okay. Well, they're missing some of their legs. So there's less muscle." If they're below the knee, you maybe take off 5% for their energy requirements." Or if they're above the knee, single leg, maybe you take off 10%. I’m just plucking numbers out of the air.
But then when they walk, they walk with an unsteady gait with their prosthesis. And that increases energy demand. Whilst there may be a reduction in resting metabolic rate, the activities of daily living requirements may actually be higher due to the instability of their gait.
[00:31:33] LB: Yeah. I mean, of course, as I’m thinking about this, the challenge to the answer to that question. If we look at it as a one-off, like it's sort of approached from I need to solve this problem. And it's a bit of a lottery situation. I either get it right or I don't. And this is seconds before their competition. But the reality is, hopefully, you're working with your athlete for a period of time, where you're working out the best possible starting point. And then you have a process of not just an initial, but a continuing process of assessments. Sort of prescribing advice, recommendations, you monitor, you support, and that cycle goes on and on and on. And you tweak. I love that word, tweak. You tweak in the right direction. And obviously, hopefully, your athlete stays with you as a practitioner throughout that process and so on. But again, that's an issue. I think when we look at textbooks or papers, it's very static. But the reality is that ongoing relationship. I hate the word trial and error. But it is effectively is –
[00:32:36] WS: It is. Yeah, I mean, it is a lot with para athletes. And I do a lot of reverse engineering, which is instead of saying, "This is what I think your energy requirements are." I go, "What are you eating? And are you weight stable?" That gives me a bit of a ballpark to work with. And then you kind of work backwards from there. That's if you trust them telling you what they eat accurately. You kind of have to – But again, that comes into the skill as a nutritionist or as a dietitian in being able to develop a rapport where you develop that confidence fairly quickly and develop that ability to really tease out the truth. And the longer you can have that relationship, the better it becomes, because that trust in that knowledge transfer becomes – It really enhances that ability to work with them and particularly at the pointy end, the real performance enhances. And you can do a lot more with that over time.
[00:33:39] LB: Absolutely. You've sort of briefly inferred the issue of reduced muscle mass. And I find this area particularly interesting mainly because, in my mind's eye, I’m thinking back to a para athlete I once worked with many years ago now, who was a canoeist, a sprint canoeist. I mean, this guy was a physical beast from the waist up. Immensely powerful. And it just looked like he could really handle himself in the water or otherwise. But from the waist down, because of the nature of his impairment, had practically no muscle in his lower limbs, particularly in one of the legs where the main impairment was.
And that, for me, at the time didn't feel like it was a massive problem because he was a canoeist. He wasn't using his legs. but of course, I now realize that there are other implications that a reduced muscle mass might have on the overall performance in people who aren't necessarily a sprint canoeist. What are your thoughts on that? And what are the sort of varying causes of reduced muscle mass? And how might that impact performance, Liz?
[00:34:44] WS: Most of the reduction in muscle mass is related to the neural drive and the ability to contract that muscle. And so, that can be interrupted through, as we've talked about already, a spinal cord injury, cerebral palsy or any form of brain related injury. Cerebral palsy is a damage to the brain at birth or just prior to birth. But you can also equate that to an acquired brain injury, where someone has had a traumatic brain injury of some sort. And as a result, they have a lack of neural drive to particular muscle groups. And because of that lack of drive and also the lack of return feedback from that muscle, it atrophies, because it simply can't be used in the same way.
There's a lot of things that can cause that atrophy. Favoring a leg is also – If you look at amputees, if you're an above the knee amputee, you actually have a lot of muscle atrophy on that side. And you also have an impact on bone density on the side of that, because you get less load-bearing capability and less capability to contract whole muscle groups. They're all factors. And that influences energy expenditure. But it can also influence a lot in terms of trainability and fatigue.
If you look at them in their home environment and, for example, doing cooking sessions. I’ve done some cooking sessions. Particularly in the early days, I’d do cooking sessions. And I might have a bunch of amputees. And they're all wearing their prosthetic. But they get tired. And if you've got them standing to do work a lot of the time, then they simply get more fatigued. Because having to keep themselves stable in an upright position with that imbalance of muscle capability, it actually is quite neurologically fatiguing. That's one area where you have to kind of think about, "Okay. Well, how does this impact them in their home life?" Just as much as how does that potentially impact them in their sport?
And I did a podcast episode with a very well-renowned track and field coach, para track and field coach, Iryna Dvoskina. She was originally Ukrainian. And she said, "If I have a single leg amputee or someone with a fairly major impairment on their left side, I won't get them to run a 400-meter event. Because of the curve that they have to run on that side, that is the weaker side, it creates too many stresses in their hips and the other parts of their body." That she actually is concerned about their ability to be mobile in an older age group. And so, she's like, "They run the 100 and the 200." I don't let them run the 400." I think that's the really interesting perspective of looking after their health and welfare in later years, as well as looking at them in their competitive years.
[00:38:07] LB: And of course, as performance nutritionists, we're obsessed with anything that can either increase or optimize this functional body mass. The strategies that we have to support training adaptations to bring about hypertrophy, strength, power, etc., is something we know quite a bit about. And of course, as I mentioned, we've delved in previous episodes on the various strategies that can ameliorate muscle loss. Whether it's from time off training through injury, and aging and all these other things that are fascinating in themselves.
But in this particular context, because nutrition is obviously the thing that we're particularly interested in here, when we're dealing with reduced muscle mass, there are a number of implications there, I would imagine, as it relates to the sort of protein, and carbohydrate and particularly the glycogen storage and re-synthesis factors. What are the areas there that we should be mindful of as nutritionists with that client?
[00:39:07] WS: Well, I think the thing that you've got to go back to is where is that data come from. How do we know what protein requirements are? How do we know what carbohydrate requirements are? Basically, they've done – Studies are done predominantly on runners and cyclists with a big quad muscle, because it's a great to stick a needle into and get a bit of muscle out of. And so, you're dealing with a pretty big muscle group.
And if you look at research that's done on upper body muscles, no one will do a muscle biopsy. There's one study back in the 80s that did a muscle biopsy of an upper body muscle. Because there's a lot more proximity to big blood vessels and nerve fibers. A lot of people just don't want to do biopsies of that muscle. But do we know that those muscles work in a similar way to a big quad muscle? Do we know that it uses protein in the same way? Do we know that it stores carbohydrate in the same way?
And if you look at the literature in terms of muscle, they talk about glycogen and storage capacity per kilogram of weight muscle. It's proportional to the volume of muscle that's there.
And so, if you look at someone who's using predominantly upper body muscles, can you make the same assumption that they can store the same amount of glycogen? Or an endurance event. Take a wheelchair marathon, for example. Now, bearing in mind that a wheelchair marathon is completed in a faster rate than a foot-based marathon, depending on the distance. I mean, not the distance. Obviously, this is – But the wind and the terrain. You're looking at maybe sort of 90 minutes, give or take, for the higher-level races. Up to two hours for the perhaps more physically-challenged races.
If you look at the marathon, they say, "Theoretically, for endurance, if you've got a well-stocked muscle, it should last you two hours, give or take, of high-intensity continuous endurance exercise." If it's a smaller muscle group, then surely it can only store less total amount of glycogen. And would that mean that they run out faster?
Does their muscle glycogen last them the same length of time in a small muscle group? And if you talk to the athletes, they say, "Yeah, I run out at about 90 minutes." Could they benefit from carbo-loading? Quite possibly. Could they benefit from consuming carbohydrate during that event? Quite possibly. How are they going to do that is then the next question?
I haven't really answered your question. But you've got to go back to where does that research come from? And how do we then transfer that in terms of how we relate that to enable to a Paralympic athlete? And I’ve asked Stu Phillips. I’ve asked Kevin. I’ve asked Luke van Loon, "If you had someone with a spinal cord injury, would you recommend the same amount of protein?" And they're like, "Per kilo active muscle mass? Possibly."
Then it comes – Because our recommendations are per kilo body mass. Not per kilo active muscle mass. And see, that's where if you've got someone with a spinal cord injury and you look at their percent lean body mass and their percent body fat, because of the muscle atrophy, they're always going to have a higher percentage body fat. They'll probably have 40-50 percentage body fat, which means that the active amount of muscles that they have is proportional to their total body mass is lower. Do you still apply the same formula? And we just don't know. We don't know the answers to those questions.
[00:43:16] LB: Yeah. Well, obviously, I mean, the whole concept of body composition becomes interesting particularly with the more bells and whistles approaches of things like DEXA, MRI or even good old water-displacement plethosmography. I actually said that right. Wow! As I said, plethosmograph. How did I do that? And of course, good old skinfolds, some are skinfolds, that sort of thing. But we'll come back to that in a minute.
But we're talking about this concept of a well-stocked muscle. And I would expand that to a well-supplied human being in terms of their overall nutritional requirements. We can be overly obsessed with – In sports nutritional performance, talk about carbohydrates. Fueling, glycogen re-synthesis, power, strength, endurance. But what about their needs as a human being particularly when they might have additional complications because of their varying impairments? It's a pretty broad area. But in terms of the challenges that are going to sit in front of us when considering how to feed and support and keep healthy this human being, what are the main challenges that you can think of and have experienced as it relates to feeding our human being clients here?
[00:44:35] WS: Well, it goes back to energy needs. A lot of it. And so, some of these athletes have what we call a small energy budget. Their energy metabolic rate is lower. So they don't need as many calories. And again, that goes back to, well, if you're prescribing six grams per kilobody mass of carbs, and that just blows their energy budget, then you've defeated the purpose as it is. Everything always has to kind of get framed around what are the basic energy needs? And how do I make sure that we're meeting all of our requirements?
And one of the biggest challenges in a lot of instances, and particularly with our female para athletes, is often their iron levels. If you think about how do you get a recommendation, 20 plus milligrams of iron per day, or a female athlete, for example. How do you get that in 2000 calories? And then how do you get that if their energy budget is 1600 calories? You've got less food to be able to get that same nutrient requirement out of.
And similarly, with vitamin D, with pretty much any of those micronutrients, when you've got a smaller energy budget, that you're still trying to give them good balance, it just becomes challenging at times to meet their micronutrient needs. And without them just thinking that they have to think about food 24/7 and they can't live a normal life. Like, they want to be human beings and and live a normal life as well.
And so, I think iron is probably the one that is often the most challenging. Vitamin D is probably – Most people can't get their vitamin D needs from their diet alone anyway. So it becomes more a sunlight exposure issue. From a nutritional intake issue, I would say, generally, iron is the big one. Calcium is probably the other big one, especially if you have someone who has any form of intolerance to dairy product.
[00:46:55] LB: Look. I mean, obviously, when you start working with a para athlete, you meet them. As I said, those tools that we have called eyes, and a brain, and ears to listen to people, you're going to learn a lot about the individual needs and challenges as long as you're actually going to have a proper conversation and get the trust, the buy-in. The relationship there is clearly a skill set that we need as practitioners. And in the process of performing your needs analysis, your understanding of your athlete, another thing that you're going to presumably be confronted with more often than not, I’m guessing, is the very nature of their disability, if you like, their impairment, their problem, whatever happened to them is going to be associated with medications, drugs, that sort of thing.
Now, when you're working with able-bodied athletes, we're all about, "Oh, let's make sure that supplements are tested. We don't want any doping violations. We don't want any problems with that." And of course, that is a completely different situation here. That athlete absolutely has to take those medications. What sort of medications do – Obviously, it's very individualized. But what sort of things might we come across? And what are the implications particularly from a nutrition and a performance perspective should we bear in mind?
[00:48:17] WS: Oh, man, they could open up a whole different can of worms.
[00:48:23] LB: Well, I’ll give you a little can opener here. We won't spend too long on it.
[00:48:27] WS: A lot of things that you'll find, anti-spasmodics are a common one. That's to try and control that degree of muscle spasm. And on the whole, there's probably very few interactions and issues that you get with that. But you do need to know someone is on an anti-spasmodic. And when they're taking it. Are they taking it mostly at night so that they can get to sleep? And fair enough. But that means that during the day they're getting more spasm, and you need to factor that in in terms of their energy needs, for example.
Understanding their medications can certainly give you a lot of insight into some of the varying parameters that they're they're working with. Other ones, I guess, obviously, they're not allowed to use diuretics even if they get some degree of edema, which some of them do. Then they may be using other methods like compression socks and things like that. But there can be a lot of pain relief is probably the big one. Pain, neuropathic pain, lots of reasons, phantom limb pain. There's lots of reasons why para athletes may be taking some form of pain medication.
And some of them have certainly looked at cannabinoids and CBD, which is an interesting sort of avenue that we're keeping a close eye on. But it's the pain relief. And that can certainly have impact on mood state. It can have impacts on appetite. It can have impacts on a lot of areas that is really worth kind of understanding what level of pain they experience on a day-to-day basis. Because pain is something that a lot of these athletes will just – They just deal with it. It's a constant part of their day. And understanding what makes their pain worse. And if there's any sort of strategy that can actually alleviate that pain. Fatigue often makes pain worse. If you can alleviate as much of the fatigue component, then that can be a really useful thing to do.
[00:50:50] LB: And in terms of drug nutrient interactions, are there any particular nutrients that are the most likely risk factors on this you think?
[00:50:59] WS: Not that I’ve – I haven't come across a really consistent sort of framework of, "Oh, if they're on this medication, then you're more than likely going to have this issue." It's probably the interaction between all the medications. And so, some athletes will be on number of medications. And it's just understanding whether there's an interaction effect on all of those medications together. Yeah. On an individual basis, there's not too many that you'd be concerned about. But I think when they're are multiple medications, it's worth looking in.
[00:51:33] LB: Yeah. And of course, I think it's just about being as aware as possible. But also recognizing the limits of not just your scope of practice, but your scope of understanding. And ideally, they do have other well-trained, well-educated professionals supporting them who you can reach out to, like their doctor or whatever.
[00:51:53] WS: Yes. Yeah, yeah, yeah, absolutely. And if they do, having a good conversation with that medical individual is I think a really useful thing to understand. They can give you a slightly different perspective and maybe something that the athlete hasn't necessarily sort of spoken to you about that can actually give you insight to other areas of how they're dealing with their day-to-day life. And I think that can be – Any anything that you can do in a team environment with getting other professionals involved is really valuable.
[00:52:29] LB: Absolutely. Well, I’m thinking right off the bat is trying to understand the the physical needs for their training and their performance, and ultimately their competition needs. You want to be talking to their coaches and so on.
[00:52:44] WS: And observing.
[00:52:45] WS: Like just getting down – It's hard really hard for a practitioner, like in private practice. But if you're in an environment where you can actually go down and watch them, and observe what they do in training, and observe what they do in competition, that gives you so much information and so much context.
If you look at quad tennis and how quad tennis is played as opposed to an able-bodied tennis game, the games themselves are much, much shorter. There are only usually two or three balls over the net for each game. Those long rallies that you see in some of the big tournaments, you just don't see that in quad tennis. The breaks between play tend to be a little bit longer. And the game duration is a bit shorter.
And so, actually, if you look at it, there's a lot of really high intensity work, but also a lot of downtime in between. And so, if you didn't understand that, you would probably give them a lot more calories than what they actually need, because you're not really fully understanding what their sport is about. I think observing and understanding what that looks like is really important.
[00:54:03] LB: Absolutely. And look, that goes to able-bodied athletes in many different sports, doesn't it? You think I work with a lot of football players. You think, "Oh, it's a game of football." That means completely different things if it's a Saturday night five-a-side game, or a well-meaning game of pretty decent players, League 3 or whatever, all the way up to Premier League or tournament football in particular. It's a very different setup. Being there and watching, I completely agree. It gives you a really great idea.
In terms of being there, we're working with people who will have worked out a lot of things for themselves in their home environment. And I think that is obviously an area you still want to have a look at. Help them optimize and improve that. But particularly when we think about athletes, they go somewhere to compete. And a lot of those facilities are set up for decades to suit able-bodied people.
But what are the implications of an incorrectly set up environment for these athletes? And how can we play a role in improving that environment to minimize any potential negative impact?
[00:55:16] WS: Advocacy is always a wonderful thing. Yeah, I mean, I think a good example that we can give is sit skiers, or even skiers, full stop. Alpine skiers. And this happens with able-bodied skiers. If you've ever been skiing, there's not a lot of bathrooms out there. Great for the guys. They can find a tree usually. But for the women, they either have to ski down to the bottom of the hill and then get off their skis and go and find a bathroom. And then they can jump over on a chair lift.
Now, if you've got someone who's a sit skier. Someone who has either a double leg amputee, or a spinal cord injury, or some major impairment that they can't physically stand on their skis, they'll be in a bucket. They call it a bucket. It's the best way of describing it, on a single ski. They're strapped in. They have no access to their wheelchair, or their crutches, or their normal mode of ambulation, unless they go down to the bottom of the hill. Let alone, finding an accessible bathroom to be able to wheel into.
And so, one of the big issues that we have is hydration on hill in training. That they will deliberately dehydrate because they can't get access to a bathroom. And we know that they're at altitude. They're in a very dry environment around snow. Their fluid needs are often high because of the environmental conditions. They may not have great sweat rates. So they may not sweat a lot. But the environmental conditions may create a situation where they're dehydrated.
The practical side of your brain then has to think about, "Well, how much do I push this fluid? If, in reality, the outcome is that they then have an embarrassing accident because they've got no way of passing the extra fluid that you're trying to give them. And so, a strategy that you may need to use is, "Okay, do I give them small amounts of fluid with high electrolytes to kind of try and retain that fluid in their body?" Do we work more on a post-training rehydration solution so they're not carrying that dehydration through for the whole day? That's where you have to think about, "Well, what is the best strategy for that individual?" And understand that that limitation of access is something that they have no control over. But you've got to look after them and their dignity at the same time.
Now, there's also the risk of increasing the risk of urinary tract infections through that chronic dehydration. There's a health component. There's lots of components that need to be considered. And so, the more you can kind of work with them on trying to get a little happy medium in there and them understanding how that fluid, how their ingestion frequency, and volume and all of those things can influence how they can utilize that fluid. They're all the things and conversations that you can have with them. That's just one sort of fairly simple example of how you may need to think through the practicality of what you're trying to get them to achieve.
[00:58:36] LB: You touched on something there that is clearly going to be a really important area, and that is thermoregulation. And obviously, we have our hydration strategies for able-bodied athletes and so on. But the very nature of some of the impairments and some of the equipment devices, I’m thinking supporting their day-to-day needs as well as the specific needs to compete in a specific sport, like a wheelchair or whatever, it involves more kit, more equipment. Things that will impact their ability to thermo-regulate appropriately.
I mean, do you have any particular sort of examples, case studies or whatever in your head through your own experience or those of your colleagues that would be sort of interesting to discuss at this point as it relates to thermoregulation?
[00:59:27] WS: Yeah. I mean, thermoregulation is a massive challenge in a number of athletes, and not just spinal cord injuries. And often, people think of spinal cord injuries, because, generally, your sweat capability below the level of the spinal cord lesion is non-existent in most individuals. And if you can't sweat, your body just heats up if under exercising conditions. But it also is a problem with amputees, with MS, multiple sclerosis. There's a lot of traumatic brain injuries. There's a lot of people who have – A lot of athletes who have issues with it.
But I think a one good example would be if you do sweat rate testing. Weigh them in. Weigh them out. Have a look at what their sweat rates are. We've done that in wheelchair rugby. And so, wheelchair rugby is predominantly high spinal cord injuries, but mostly quadriplegic.
And if you look at athletes with quadriplegia and you try and do a sweat rate test on them, it wouldn't be uncommon to have a zero result. They don't sweat. They may sweat a little bit on their eyebrow. Maybe a little bit on their hands and their face. But otherwise, they're not sweating. Do you give them fluid? If someone's not sweating, what's the point of giving them fluid? They feel hot and they want to drink, because that's the automatic response.
And so, some of the advice we've had to give is actually to reduce their fluid intake and find other ways to cool themselves down. To control that feeling of, "I’m feeling so hot." Because the risk of drinking too much – And we're talking about, "Okay, maybe they'll drink 300 mils an hour when they've got a sweat rate of 40 mils an hour. Okay, over a two-hour training period, maybe that's 500 mils of extra fluid that they've got in their system."
Well, where's that fluid going? Is it going to their bladder? And how do they then release that? These are individuals who can't urinate voluntarily. They'd have to go to a bathroom and catheterize themselves to release that pressure on their bladder. That also means transferring out of their competition chair into their day chair, because their competition chair is most likely not going to get through a bathroom door. And also, take all the taping off their hands that they've put on, yadi-yadi-yada. You can imagine, this is not something that happens in a two-second turnover. It's something that takes 15 minutes for them to do.
The other thing that can happen is they can develop quite a potentially dangerous scenario of autonomic dysreflexia. If that bladder is distended, it's a noxious stimulus to the body. And what happens is that sends their blood pressure up really, really high to dangerous levels. And again, you don't want that.
And so, that's where you do need to manage their fluid intake for their safety and also for the practicality of it and not assume that, "Oh, everyone needs fluid." And if they get dehydrated, they just need more fluid. Well, these coasters don't – They don't dehydrate from that reason. They may dehydrate for other reasons. They don't dehydrate for that reason. Find other methods that work in terms of keeping them cool. Keeping their body temperature down. Whether that's a fan, where they spray you know water on their face with a fan in front of them to help cool, whether that's ice towels, whether that's perhaps a slushy in a very small volume. But you have to be careful with the volume. Whatever it is, you cool them down, rather than automatically thinking, "Oh, they've just got to get more fluid so they can sweat more."
[01:03:17] LB: I mean, it's sort of mind-blowing, isn't it? I mean, I hope that aspiring performance nutritionist, or sport scientists or whatever, looking to support para athletes aren't like, "Oh, actually, I think I’m going to go work somewhere else." I mean, the challenge is a particularly amazing opportunity for well-trained performance nutritionists. It's just clear. There's so much that you can do to help your athlete.
But one area that we, as performance nutritionists, sport scientists and so on, strength conditioning coaches, etc., we are always interested in things like body composition. It's a useful tool to baseline your athlete. You're able to differentiate quality from – Well, functional from dysfunctional body mass. And the impact of your nutrition strategies and training strategies on that functional muscle mass. And if you're overeating, you're getting body fat and all this sort of thing.
However, obviously, there's challenges here when it comes to assessing body composition and how you use body composition to inform your practice, your advice. And in my head, there's several challenges right off the bat. Obviously, there's the bells and whistles, testing methodologies that we almost certainly won't have access to. And even then, that's just for normal able-bodied people. Thinking DEXA and so on. But we do have access to tools, particularly things like skinfold testing.
But even then, if you're looking at ISAK protocols, that has a very specific full-body approach in terms of skin folds girths and so on.
[01:04:55] WS: That doesn't have to.
[01:04:57] LB: No. Exactly. ANd that's what I was asking you to think about now. What are your thoughts on that? And how should we apply that?
[01:05:04] WS: Well, I’m a Level 3 ISAK trained anthropometrist. I can teach ISAK methods to people. And I use my skinfold calipers on a regular basis. I don't necessarily do all the sites. You have to work out why do you want to measure and what do you want to measure? And what's the most relevant tool to do that?
One thing with skinfolds is converting it to percent body fat is meaningless, and particularly meaningless in most of this population. I mean, yeah, you could do that with someone who's minimal level of impairment with cerebral palsy, or their vision impaired, or their intellectually impaired. Their physical body is more like a normal able-bodied individual. But we still wouldn't do it, because what you want to do is track over time. What can I accurately and consistently track over time that is meaningful to this athlete?
If we go back to your kayaker, would you do lower body skin folds on them where there's substantial muscle atrophy? Is it going to give you any relevant information where is the change most likely going to happen? It's most likely going to happen in their upper body where they're more functional. And so, I would select a set of skin folds and girths that is relevant that I can measure consistently, that I can landmark accurately and repeatably.
And so, you modify it. And then you just make sure you keep a note of what the modifications are. If their cerebral palsy affects their right side and they're getting – They've got less function on that side, swap over to the left side. If they're a spinal cord-injured athlete, I don't get them out of their chair to landmark. And if I was out landmarking correctly for all landmarks, you'd have to. You'd have to get them lying on the floor to do that. I don't. I just do a upper body force skin folds, tricep, bicep, subscap, abdominal, because I can landmark them appropriately. I can measure them. And then flexed arm girth, a waist girth and maybe a chest girth.
It depends on what you're trying to measure and what change over time you're likely to see. And where is the most relevant area that you're going to see that in? If you're using other methods, you just really need to understand what the assumptions built into that method are and when that's going to be violated in an individual.
For example, with DEXA, DEXA is great for bone density. But if you've got a metal rod in your spine, there goes your bone density. It's going to pick up the metal rod and say, "You've got fabulous density in that bony area." But it's not bone that it's measuring.
I think the other thing that DEXA assumes is a normal proportionality of structure. And a lot of para athletes don't have that proportionality. Even individuals with short stature, for example, their proportionality may be similar, but it's shrunk down. And so, it's not what the DEXA is expecting to see. Is it going to read the same and interpret it in the same way?
I think they're the things you've got to think about before you actually then go, "Okay, we're going to do this bells and whistle sort of thing." It's really through understanding what are the assumptions. Are they going to be appropriate for this individual? And can I track something over time in a better way? And I think there's some simple things that you can do to track change over time.
[01:08:56] WS: Yeah, absolutely. I mean, look, we all love body composition in many different ways. It's a great hands-on method, particularly if it's something like ISAK, which in itself is an opportunity for you to interact with your athlete and have a good chat. I always find that even in team sports where I work. Sometimes the information that comes out of that is I can look at them. I know he's in great shape, for example. But it's a good opportunity to have a quality conversation with that individual.
But this whole issue of body composition, I’ve done my best to cover that in various podcasts going back a few years with Shawn Arent, Professor Shawn Arent. We talked about test, don't guess. The title sort of gives that away. Dr. Julia Bone was on a few years ago where we talked about this idea of DEXA being the gold standard. Maybe not just gold plated, which is a great conversation for people to listen to. And more recently, this past year, with Graham Close, Professor Graham Close. We talked about his group's paper on comeback skin folds. All is forgiven. I love these titles that these people come up with. But it is a brilliant tool to inform practice.
In terms of tools to inform practice when it comes to para athletes, apart from anthropometry equipment, what other tools spring to mind that you might typically use in the field, Liz?
[01:10:15] WS: Your brain. Your brain and your ears. Your ears, I think, are the most – Just listening. Be willing to listen. To ask questions. Having an inquiring mind. And truly understand where they're coming from and without assumptions. A lot of para athletes, some of them are born with their impairment. And so, they've lived with it their entire life. And they've probably done some sport as a youngster. And so, they have a little bit of sporting history. But you also have athletes who come in having acquired an impairment. Maybe never done sport in their life. And they've got no idea what you're talking about when you start talking high-performance sport lingo. Really understanding their background, where they've come from.
And in terms of tools, there's lots of tools. But you've got to find the one thing that's going to make a difference to that individual at that point in time, rather than throwing your entire toolbox at them. Just because it's there and it's available, it may not be relevant.
And you say, that relevance and the context is so important with a para athlete, as it is with every athlete. But take your time and find the one thing that is bothering them the most, or that you feel you can have an impact on, and pull that tool out. And that could be something that's related to their practical side of things, their ability to prepare a meal. Their ability to go shopping. It could be a supplement, but it's probably not likely to be for a while. You've probably got a lot of food related things that you can work with. It may be just the consistency and the timing of their eating around their training. There's lots of tools that you have. Find what their biggest issue is and use the most appropriate tool to address that. And then you'll gain and have a great relationship with them.
[01:12:18] LB: Liz, you've summed up, I think, the key points very well there without – I'm not even asking you to make key points. It's like they say, I guess you've got two eyes and two ears for a reason, isn't it? You've only got one mouth, because you need to get the order of that perspective right.
But look, in terms of ears people have been able to listen to the podcast. And I think that we've had a great conversation selfishly, Liz. I’ve just loved the conversation. I got a lot out of it. And I know the listeners will. In terms of eyes, we will provide links to the various papers. And your great book has really useful tools in the information toolbox that people can have.
And once again, back to ears, your own podcast, let's just quickly discuss your podcast. I don't want to selfishly have people only listen to my podcast. I think people just listening to you will want to hear a lot more from you. Tell us about your podcast.
[01:13:17] WS: The podcast is called Para Sports Nutrition. If you look that up on pretty much any podcast platform, you should be able to find it. And really, I’m trying to hit a lot of targets. I’m interviewing athletes. I’m interviewing coaches, practitioners, experts in the field. I want to try and showcase parasports. We go through with the coaches. What is that sports? Like, goalball? What is the sport of goalball? What are the eligible impairments? What are the physical demands? What does training look like? What does competition look like? We're trying to kind of give a little bit of an explanation of what each sport is. And we're working through that.
We talk to the athletes about their experience, their background, some of their challenges. How they work their nutrition in with their sport? And then we also draw on the practitioners and the experts in terms of, for example, what is on? I had a really good interview about what is iron and iron deficiency. And then why might that be an issue for a para athlete? And how can they approach a management plan for that? We always bring it back to a para perspective. But the conversation isn't always around specific sports nutrition or the para completely kind of being the overriding perspective.
[01:14:39] LB: Brilliant. Well, look, I mean, I think it speaks for itself, your knowledge, and expertise, and your passion and your interest in it. Thank you very much for sharing that with all of us. If people want to find out more about you, Liz, I know you're a little bit on social media. But you have a healthy relationship with social media by not being on it very much. You've got a website and so on. How can people find you if they want to access more information about you and your various output?
[01:15:07] WS: They can probably find me on LinkedIn, just under the name Liz Broad, or on the Para Sports Nutrition podcast website. They're probably the two key areas that they can get in contact.
[01:15:18] LB: That's great. I will link to those. And of course, for our listeners here at the Institute Performance Nutrition's We Do Science podcast, you can learn – You can find this particular episode at our website at www.theiopn.com. Just click on podcasts and you'll find this episode there. Of course, you'll find us on Apple iTunes, and Spotify and all the many different places you can find these podcasts. I am the host, of course, Dr. Laurent Bannock. And it's been a real pleasure to have this conversation for everyone's benefit. Thank you so much, Liz. Take care.
[01:15:53] WS: Thanks, Laurent. Bye.