As a sports nutritionist, I commonly counsel athletes who have Attention Deficit Hyperactivity Disorder—generally referred to as ADHD (or ADD). ADHD is characterized by hyperactivity, impulsivity, and/or inattention. It affects 4-10% of all American children and an estimated 4.4% of adults (ages 18-44 years). ADHD usually peaks when kids are 7 or 8 years old. Some of the ADHD symptoms diminish with maturation but 65-85% of the kids with AHDH go on to become adults with ADHD.

Ideally, athletes with ADHD have gotten the help they need to learn how to manage their time and impulsiveness. Unfortunately, many youth athletes with ADHD just receive a lot of negative feedback because they have difficulty learning rules and strategies. This frustrates teammates and coaches. Older athletes with ADHD often use exercise to reduce their excess energy, calm their anxiety, and help them focus on the task at hand. This article offers nutrition suggestions that might help coaches, friends, and parents, as well as athletes with ADHD, learn how to calm the annoying ADHD behaviors.  

• To date, no clear scientific evidence indicates ADHD is caused by diet, and no specific dietary regime has been identified that resolves ADHD. High quality ADHD research is hard to do because the added attention given to research subjects with ADHD (as opposed to the special diet) can encourage positive behavior changes. But we do know that when & what a person eats plays a significant role in ADHD management and is an important complimentary treatment in combination with medication.
• ADHD treatment commonly includes medications such as Concerta, Ritalin & Adderall. These medications may enhance sports performance by improving concentration, creating a sense of euphoria, and decreasing pain. These meds are banned by the World Anti-Doping Agency (WADA) and the International Olympic Committee (IOC). Hence, athletes who hope to compete at a high level are discouraged from taking ADHD medications.
• To the detriment of ADHD athletes, their meds quickly blunt the appetite. Hence, they (like all athletes) should eat a good breakfast before taking the medication.
• The medication-induced lack of appetite can thwart the (teen) athlete who wants to gain weight and add muscle. Teens taking ADHD meds should be followed by their pediatricians, to be sure they stay on their expected growth path. If they fall behind, they could meet with a registered dietitian (RD) with knowledge of sports nutritionist (CSSD) to help them reach their weight goals.
• An easy way for “too thin” athletes to boost calories is to swap water for milk (except during exercise). The ADHD athlete who does not feel hungry might find it easier to drink a beverage with calories than eat solid food. Milk (or milk-based protein shake or fruit smoothie) provides fluid the athlete needs for hydration and simultaneously offers protein to help build muscles and stabilize blood glucose.
• A well-balanced diet is important for all athletes, including those with ADHD. Everyone’s brain and body need nutrients to function well. No amount of vitamin pills can compensate for a lousy diet. Minimizing excess sugar, food additives, and artificial food dyes is good for everyone.
• Eating on a regular schedule is very important. All too often, high school athletes with ADHD fall into the trap of eating too little at breakfast and lunch (due to meds), and then try to perform well during afterschool sports. An underfed brain gets restless, inattentive, and is less able to make good decisions. This can really undermine an athlete’s sports career
• Adults with ADHD can also fall into the same pattern of under-fueling by day, “forgetting” to eat lunch, then by late afternoon are hangry and in starvation mode. We all know what happens when any athlete gets too hungry – impulsiveness, sugar cravings, too many treats, and fewer quality calories. This is a bad cycle for anyone and everyone.
• All athletes should eat at least every four hours. The body needs fuel, even if the ADHD meds curb the desire to eat. ADHD athletes can set a timer: breakfast at 7:00, first lunch at 11:00, second lunch at 3:00 (renaming snack as second lunch leads to higher-quality food), dinner at 7.
• For high school athletes with ADHD, the second lunch can be split into fueling up pre-practice and refueling afterwards. This reduces the risk of arriving home starving and looking for (ultra-processed) foods that are crunchy, salty, and/or sweet.
• Athletes with ADHD are often picky eaters and tend to prefer unhealthy snacks. For guidance on how to manage picky eating, click here for adults and here for kids.
• Fiber-rich fruits, vegetables, and whole grains can be low on an ADHD athlete’s food list. Their low fiber diet can lead to constipation. Fiber also feeds the zillions of microbes in their digestive tract that produce chemicals that can positively impact brain function and behavior. Everyone with ADHD should eat more fiber-rich foods like beans (hummus, refried beans in a burrito), seeds (chia, pumpkin, sunflower, sesame), and whole grains (oatmeal, brown rice, popcorn). They offer not only fiber but also magnesium, known to calm nerves.
• With more research, we’ll learn if omega-3 fish oil supplements help manage the symptoms of ADHD. No harm in taking them. At least eat salmon, tuna, and oily fish as often as possible, preferably twice a week, if not more.
• Picky eaters who do not eat red meats, beans, or dark leafy greens can easily become iron deficient. Iron deficiency symptoms include interrupted sleep, fatigue, inattention, and poor learning and can aggravate ADHD. Iron deficiency is common among athletes, especially females, and needs to be corrected with iron supplements.
• While sugar has the reputation of “ramping kids up”, the research is not conclusive about whether sugar itself triggers hyperactivity. The current thinking is the excitement of a party ramps kids up, more so than the sugary frosted cake. Yes, some athletes are sugar-sensitive and know that sugar causes highs and crashes in their bodies. They should choose to limit their sugar intake and at least enjoy protein along with sweets, such as a glass of milk with the cookie, or eggs with a glazed donut. Moderation of sugar intake is likely more sustainable than elimination of all sugar-containing foods.

Additional resources:

• Feeding the Child with ADHD—a podcast with Jill Castle RD
• Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) – a national resource center

Nancy Clark MS, RD, CSSD, counsels both fitness exercisers and competitive athletes in the Boston-area (Newton; 617-795-1875). Her best-selling Sports Nutrition Guidebook is a popular resource, as is her online workshop. Visit NancyClarkRD.com for info.

Golf is a sport played by millions of people worldwide. It is unique in the fact that it can be enjoyed by people of all ages and skill levels. And notably, with our recent pandemic, golf provided us a great way to stay active outdoors while still practicing safe social distancing, which has only increased the popularity of the sport.

Unfortunately, some see golfers as not physically fit, but hopefully this is a misconception we can leave in the past. Recent changes at the professional level include increased focus on speed and power, and this emphasis is now seen at all levels of the game. Not only do golfers want to swing faster to increase club head and ball speeds, but they want to be efficient.

There is not one perfect golf swing but rather an infinite number of swing styles based on the most efficient way to hit a golf ball given the golfer’s physical fitness and movement quality. A golf-specific physical screen and swing analysis will help guide the clinician in predicting injury patterns in an individual athlete because golfers often exhibit injury-inducing swing mechanics that are a direct result of a stability or mobility issue.

Golf injuries can be categorized like most into acute and chronic. These are often a result of overuse and related to the repetitive, asymmetric, and rotational nature of the sport. While it is thought that most elite golfers are injured secondary to overuse, the amateur golfer is more likely to be injured due to poor swing mechanics.

Common golf injuries most often involve the low back, elbow, shoulder, wrist and knee. Low back pain is universally found to be the leading cause of issues for golfers of all ages and skill levels. However, while the low back is often the source of pain, it is typically not the cause. It is important to not only focus on this area when evaluating an injured golfer but to also look closely at the mobility of the thoracic spine above and the hips below. When these regions have limited motion, the lumbar spine must rotate more than it is accustomed to, resulting in unwanted stress to the area and eventually to pathologies such as lumbar muscle strain, stress fracture, intervertebral disc disease and herniation, and facet joint arthropathy.

To help prevent injury to the low back, the clinician should emphasize the importance of a dynamic warm-up before each practice session or round of golf. Like athletes in all other sports, golfers will benefit most from starting off with mobile joints, relaxed muscles and increased blood flow to the muscles used to hit the golf ball.

Posture also plays a key role, from the address position to the follow-through. Often, lower crossed syndrome causes the golfer to address the ball with too much thoracic kyphosis, lumbar lordosis and anterior pelvic tilt, which can lead to stress to the low back. To address this problem, gluteus maximus and rectus abdominus weakness and inflexible erector spinae and hip flexors should be identified and corrected. If overlooked, the golfer will frequently find themselves with swing characteristics, such as reverse spine angle or early extension, that will result in lower back pain over time.

For most, time spent playing golf tends to increase as we age, which makes identifying these problems sooner rather than later even more important. All golfers would likely agree, the ultimate goal is to be able to play well and enjoy this exceptional game for a lifetime.

Additional resources: 
Blog | How to Modify Programs for Clients and Athletes With Injuries
Video | Using Sport Injury Surveillance Data to Study Injury Outcomes
Call to Action | Increasing the Availability of Automated External Defibrillators at Sporting Events

Drew Duerson, M.D., RMSK, is a Sports Medicine physician at Nationwide Children’s Hospital in the Division of Sports Medicine.  He is the medical director of the Nationwide Children’s Hospital Golf Medicine Program.  He is also a clinical associate professor of Pediatrics at the Ohio State University. He received a bachelor’s degree from Bellarmine University where he was an academic all-american in golf. He received his medical degree from the University of Louisville School of Medicine. He completed his Pediatric residency followed by a Sports Medicine fellowship at Nationwide Children’s Hospital. Drew is a board-certified Pediatrician with a certificate of added qualification in Sports Medicine. He is Titleist Performance Institute Medical 2 Certified and the only TPI certified physician in central Ohio.

He is a member of the Sports Medicine fellowship faculty at Nationwide Children's and the team physician for Canal Winchester high school. He is a fellow of the American Academy of Pediatrics and an active member of the American College of Sports Medicine, American Medical Society of Sports Medicine and American Institute of Ultrasound in Medicine. His clinical areas of interest include musculoskeletal ultrasound and the diagnosis, treatment, and prevention of golf injuries in the young athlete.

Patients with sport-related concussion have traditionally been advised to employ strict physical and cognitive rest until all of their symptoms resolve, i.e., until they become asymptomatic. This “cocoon therapy” was based largely upon animal research showing that early uncontrolled physical activity delayed recovery from simulated concussion. Emerging evidence over the past decade, however, demonstrates that there is no empirical human evidence that “cocooning” is therapeutic and that most persons do not live their normal lives in an asymptomatic state.

Since 2001, the international Concussion in Sport Group (CISG) has issued statements on the evidence for concussion assessment and management. The statement from the 2016 meeting recommends an initial period of relative (as opposed to strict) rest during the first 24-48 hours followed by gradual return to school and social activities (prior to contact sport). The statement also says that sub-symptom threshold aerobic exercise may be effective for concussion recovery. Since its publication, several randomized controlled trials have confirmed that early sub-symptom threshold aerobic exercise treatment safely speeds recovery from sport-related concussion. What remains unknown is (a) whether there is there a direct relationship between adherence to a personalized exercise prescription and recovery, and (b) does initial concussion symptom burden determine adherence to the prescription?

Our study, published in the September issue of Medicine & Science in Sports & Exercise_®, is a secondary analysis from our recent randomized controlled trial in adolescents. It showed aerobic exercise initiated within 10 days of sport-related concussion was more effective than placebo-like stretching for recovery. Importantly, early aerobic exercise treatment significantly reduced incidence of delayed (>1 month) recovery. Exercise prescription was based on 90% of the heart rate threshold at the point of symptom exacerbation on the Buffalo Concussion Treadmill Test. Adherence was determined objectively by heart rate monitor data during exercise sessions at home. We found that adherent participants were more symptomatic and were more exercise intolerant at their initial visit (i.e., they had more severe concussion), yet they recovered faster than those who were not adherent.

The key takeaway from this study is that symptomatic adolescents who best adhered to the exercise prescription within the first week after initial evaluation recovered significantly faster from sport-related concussion than those who did not adhere. Unexpectedly, adolescents with more clinically severe concussions were the most adherent, suggesting they had a stronger motivation to engage in a potentially effective intervention.

Our study provides evidence regarding the timing and amount of aerobic exercise required to elicit a meaningful clinical effect. One interesting finding was that participants who exercised considerably more than their prescription dictated recovered rapidly without adverse effect. The effectiveness of any prescription depends upon the benefit of the prescription itself as well as the degree to which the patient adheres to it. Adolescent athletes who better adhered to this proven effective treatment for sport-related concussion, even those with more severe concussion signs and symptoms, recovered faster than those who did not adhere as well. Clinicians caring for concussed adolescents after sport-related concussion should avoid recommending strict rest. They should not only permit, but consider prescribing, early sub-threshold physical activity to treat sport-related concussion and to help reduce the risk for delayed recovery. A greater understanding of factors that influence adherence will help to optimize this non-pharmacological treatment for sport-related concussion in future studies. 

Dr. John J. Leddy is professor of clinical orthopaedics and rehabilitation sciences at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences. He is a Division 1 team physician and medical director of the University at Buffalo Concussion Management Clinic. He is a member of the expert panel for the Berlin Fifth International Consensus Conference on Concussion in Sport. In conjunction with Dr. Barry Willer, he developed the Buffalo Concussion Treadmill Test. He is a fellow of ACSM, AMSSM and of the American College of Physicians and is director of outcomes research for the Department of Orthopaedics.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

The positive effects of aerobic exercise training on skeletal muscle metabolism are well recognized. Exercise also leads to beneficial metabolic adaptations in other organs, including the brain, liver, kidneys and adipose tissue. However, the effects of exercise on immune cell metabolism are largely unknown. Immune cells that circulate throughout the body are exposed to exercise-associated changes in levels of metabolites, neuroendocrine factors and myokines, all of which may impact cell function. Previous studies have shown an upregulation of metabolism-related pathways in the immune cells of endurance athletes, but which specific cells are impacted and how this affects cellular function is poorly understood. There is a particular lack of knowledge concerning cells belonging to the adaptive immune system (T cells and B cells).

Within the adaptive immune system, T cells are critical for mounting effective responses against abnormal or virus-infected cells, secreting cytokines that assist other cells and conferring immunological memory following infection or vaccination. T cells may also contribute to inflammatory processes that accompany many chronic diseases. This is a vast job description, but T cells share the workload, with specific cellular subsets performing specialized tasks. Importantly, metabolic differences exist between T cells with different specializations. Because mitochondrial characteristics often underlie these phenotypes, changes in mitochondrial bioenergetics caused by exercise would likely have implications for T cell function. Given the incalculable value of a healthy immune system throughout the lifespan, it is important to understand the role that exercise plays in mediating T cell metabolism and function.

In our study published in Medicine & Science in Sports & Exercise_®, we investigated the effects of aerobic exercise on naïve T cells. These cells are responsible for initiating adaptive immune responses to novel pathogens and serve as the precursors for effector and memory T cells. We collected blood from young adults who either participated in > 6 hours or < 90 minutes of moderate to vigorous exercise per week. Additionally, participants’ cardiorespiratory fitness was assessed, and each wore a physical activity monitor for one week.

We found that the active group had greater mitochondrial mass within one T cell compartment known as naïve CD8⁺ T cells, along with higher cardiorespiratory fitness and a leaner body composition than their less-active counterparts. The mitochondrial mass of naïve T cells was positively associated with cardiorespiratory fitness and energy expenditure. We did not observe a difference in naïve T cell energy production rates between active and inactive adults. These findings could suggest that increasing physical activity level may lead to increases in immune cell mitochondrial mass and, potentially, improved function. The potential benefits of increased mitochondrial mass in T cells include enhanced antitumor immunity or an increased ability to buffer damaging reactive oxygen species associated with aging. In future studies, these functional measures may be assessed. Because our design was cross-sectional, additional longitudinal studies are required to establish causality and delineate the individual effects of physical activity volume, cardiorespiratory fitness and body composition on T cells. Overall, these initial findings suggest that exercise may confer metabolic adaptations in T cells, opening new avenues in identifying how exercise may improve health.

Jessica Alley, Ph.D., earned her doctoral degree in kinesiology and immunobiology from Iowa State University, where her research focused on the modulation of adaptive immunity through exercise and metabolism-targeting pharmacological agents. She is currently a research specialist at the University of North Carolina Lineberger Comprehensive Cancer Center.

Marian Kohut, Ph.D., is the Barbara E. Forker Endowed Professor of Kinesiology and member of the Nanovaccine Institute at Iowa State University. Her research lab is interested in understanding how variability in host phenotype impacts the immune response to respiratory viral infection, vaccine response, and inflammation-related chronic disease. Fixed factors of host phenotype that influence immunity include age and sex, whereas flexible factors such as health practices also have a considerable impact on innate and adaptive immunity and may be manipulated to improve disease outcome or vaccine efficacy. We also aim to improve vaccine efficacy and health outcomes by developing vaccines or therapeutics that target host phenotype deficiencies.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.