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Optimizing Performance on Every Stage

Abbey, Elizabeth L. Ph.D., RDN, CDN

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doi: 10.1249/FIT.0000000000000418
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As a collegiate runner in the early 2000s, I and my fellow teammates lived by the mantra “train to eat.” Food was our reward for the many miles we ran, and little thought was given to its impact on our health and performance. We didn’t have access to a sport nutrition professional and were flying blind. In the years since then, the field of sport nutrition has seen significant growth, particularly in the realms of collegiate and professional sports. The deregulation of NCAA feeding restrictions in 2014 has led many Division I (DI) institutions to pour resources into nutrition services for their athletes (1). Many DI universities have a registered dietitian nutritionist (RDN) on staff, of which most have, or are working toward, the criterion standard credential of a Certified Specialist in Sports Dietetics (CSSD). The days of “training to eat” are being replaced with an understanding that athletes need to “eat to train” to achieve optimal performance. Although this shift in mentality is encouraging, there are still many athletic venues and professions where the expertise of the sports RDN is ignored or underused. In this article, we will explore less “traditional” populations in the field of sport nutrition by profiling RDNs who are expanding the arenas of the profession.

Derek Hughes, M.S., RDN, CSCS, ACSM-EP®: Fueling First Responders

Derek Hughes has worked for the Broward County Sheriff’s Office in Fort Lauderdale, FL since 2006. He began as a fitness specialist and is now the safety and wellness program manager in charge of coordinating health programming for more than 5,400 law enforcement and corrections officers, firefighters, paramedics, and civilian personnel. In his role, Hughes wears many different hats and is able to integrate his nutrition and exercise science training in a variety of ways. One of his key responsibilities is to review research and internal data to improve modifiable behavioral risk factors among personnel. In particular, this population is at a high risk for developing cardiovascular disease and cancer (2,3). Sudden cardiac death is the leading cause of on-duty death in firefighters (45% of deaths annually) (2). Many factors may contribute to this increased risk. First, the activation of the sympathetic nervous system when the alarm bell rings puts the body on high-stress alert (3). Heart rate and blood pressure rise before the first responder even leaves the station. The physical demands of firefighting are further exacerbated by heavy personal protection equipment (PPE), which can quickly elevate body temperature and lead to heat stress and dehydration. Smoke exposure not only has a negative impact on respiratory health but also is associated with arrhythmias, decreased heart rate variability, increased blood pressure, myocardial ischemia, proliferation of certain cancers, and activation of proinflammatory and prothrombotic pathways. Even in a healthy individual, these risks are of concern. Also consider that firefighters (career and volunteer) and police officers have been found to have higher rates of obesity than the general population (4,5). In one study, obese firefighters (body mass index ≥30 kg/m2) were found to have injury rates 5.2 times higher than their normal-weight counterparts (6). In addition to cardiorespiratory disease and cancers, other health concerns for this population include poor sleep hygiene due to shift work and stress, depression, posttraumatic stress disorder (PTSD), substance abuse, and suicide (7).

Although the stresses of the job of a first responder cannot be avoided, Hughes sees several areas for lifestyle improvements among first responders. “Police officers nationwide tend to eat poorly, often eating out and in their cars at all hours of the day and night due to road patrols and shift work. As a population, firefighters eat badly as well, but in different ways. Our firefighter/paramedics frequently prepare oversized meals together in the firehouse kitchens.” Well-meaning community members frequently drop off sweets, baked goods, and meals that are energy-dense but nutrient-poor. Hughes has used his expertise as an RDN to promote healthy eating habits through nutrition education programs, cooking demos (Figure 1), activity challenges, environmental and policy changes, and securing grants for wellness programming. His efforts have produced some encouraging results. “We have seen officers lose more than 100 pounds, take back their health, engage in every type of sports competition, and totally transform their lives. I feel even more proud that our organization is growing healthier as a whole, and that more than 200 of our health-conscious employees are now serving as wellness champions to help guide their peers to greater engagement in healthful lifestyle habits.”

Figure 1
Figure 1:
Derek Hughes and Isabella Bregante at a cooking demo for first responders.

Laura Moretti, M.S., RDN, CSSD, LDN: Putting Food Into Focus for Dancers

What do professional ballet dancers and firefighters have in common? If you live in the Boston area, the answer is Laura Moretti (Figure 2). In 2015, she joined the team at Boston Children’s Hospital Division of Sports Medicine and their Female Athlete Program. In her role there, she works with athletes of all levels (i.e., youth, Olympic, collegiate, elite, professional, and masters level). Her primary focus is on female athletes, particularly the treatment of low energy availability (EA), disordered eating, and Relative Energy Deficiency in Sport (RED-S). Moretti also has her own private practice, is the consulting dietitian for the Boston Ballet Company and Schools, and she works with the New York Fire Department Triathlon Team. If that didn’t keep her busy enough, she is a consultant for O2X, where she provides training and education to tactical athletes.

Figure 2
Figure 2:
Laura Moretti, M.S., RDN, CSSD, LDN.

The most common issue that Moretti encounters in her work with dancers is inadequate nutritional intake to support the volume and intensity of their training. Among different styles of dance, ballet dancers tend to be the leanest and have the lowest body fat percentages (8,9). They generally have low energy intake (70% to 80% of recommended) and high rates of eating disorders (EDs) or disordered eating behaviors. It is estimated that their risk for developing an ED is three times that of nondancers (10). The RED-S model was introduced by the International Olympic Committee in 2014 to expand the Female Athlete Triad to include a wider range of impaired physiological functioning and recognize the fact that male athletes may be affected (11). The foundation of RED-S is low EA (see sidebar). The most common manifestations of low EA that Moretti encounters in her practice are menstrual irregularities, iron deficiency, gastrointestinal issues, and bone stress injuries. She explains that, “dancers are aesthetic athletes, which means there is a delicate balance between maintaining a strong body and supporting the aesthetic ideals of the profession. My role is to help these dancers achieve both.” Even when dancers understand the importance of adequate energy, fitting meals and snacks into hours of rehearsals can be tricky. Moretti works closely with the athletes to customize energy-dense meals to optimize performance and promote recovery. She often sees dancers with anemia as a result of low EA and/or specific eating patterns (e.g., vegan or vegetarian) that are poorly executed. Young dancers are at a particularly high risk of nutritional deficiencies because of their increased energy demands while growing and the psychological desire to achieve the ideal dancer body. Moretti notes that vegan diets have become increasingly popular among this population, but she often discourages this pattern of eating among growing dancers because of the low energy-density nature of the diet and subsequent risk of nutrient deficiencies.

Sidebar: Energy Deficiency Terminology (11)
  • Energy Availability (EA): energy intake minus the energy cost of exercise relative to fat-free mass
  • Female Athlete Triad (Triad): combination of disordered eating and irregular menstrual cycles eventually leading to a decrease in endogenous estrogen and other hormones resulting in low bone mineral density
  • Relative Energy Deficiency in Sport (RED-S): syndrome of impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health caused by relative energy deficiency (i.e., low energy availability); expands on the Female Athlete Triad

Besides recommending that clinicians become more aware of the effects and treatment options for low EA and RED-S, Moretti also wants practitioners to understand the potential risks of taking “clean eating” to an extreme. She has seen a significant rise in the number of patients with orthorexia, which is “a subclinical eating disorder characterized by an obsession with healthy eating, which interferes with activities of daily life.” When working with an athlete who has an ED or who engages in disordered eating behaviors, Moretti emphasizes the importance of seeking out a professional who specializes in this line of practice. Without proper guidance and supervision by an experienced practitioner, inexperienced health care practitioners may actually do more harm than good.

Although Moretti’s work may sound physically and emotionally exhausting, she reenergizes by practicing good self-care and reminding herself of the success stories. “Two years ago, a 13-year-old dancer presented to my clinic with anorexia nervosa characterized by a sudden significant weight loss due to restricted eating, secondary amenorrhea, and fear and anxiety around weight gain. Due to her low weight and clinical presentation, we had her admitted to an inpatient eating disorder program on the day of her first appointment. After medical stabilization, she returned to my clinic as an outpatient. Through many months of very close work with an interdisciplinary team consisting of a psychologist, physician, and myself the dietitian, she began to understand her caloric needs and how they supported her performance and overall health. She began to realize that as she fueled better, her energy improved and this directly correlated to her dancing. I can happily say that after two years, the patient has resumed menses, restored weight, and is back to dancing on her full schedule. Her relationship with food has vastly changed, and she is able to consume a balanced diet, complete with foods that had become forbidden to her when she was struggling with her eating disorder. Our work shifted and changed over the course of her treatment, from restorative eating up through intuitive eating, which we continue to work on today.”

Alicia Fogarty, M.S., RDN, CSSD, LDN: Giving High School Athletes the Foundation for Long-Term Health

With the increase in sports RDNs practicing in collegiate and professional settings, high schools are the next frontier for many RDNs wanting to gain experience in the field. Alicia Fogarty (Figure 3) is at the frontline of this push in her role as an RDN for Atrium Health (formerly Carolinas Healthcare System) in Charlotte, NC. At the beginning of 2016, Fogarty and a team of RDNs at Atrium Health transitioned into supporting the athletic training and sports medicine staff at the high schools in the Charlotte Mecklenburg School District. The program has expanded to support three other school districts nearby for a total of 19 high schools. They provide a variety of services including large and small group education (Figure 4), individual counseling sessions, team meal and snack menu suggestions, a 4-week class series on eating to build muscle, and educational support for athletic trainers, coaches, and parents.

Figure 3
Figure 3:
Alicia Fogarty, M.S., RDN, CSSD, LDN.
Figure 4
Figure 4:
Alicia Fogarty talking about nutrition with high school football players.

The primary topics that Fogarty deals with in her practice are low EA, improper timing of meals/snacks, and poor nutritional choices overall. Although these issues are not unique to high school athletes, it is important to remember that young athletes aren’t just small adults — they have their own unique challenges. Adolescents are notorious for skipping meals, especially breakfast, and their consumption of total calories from fast food has continued to rise (12,13). Among the more than 11,000 high school students who participated in the 2010 National Youth Physical Activity and Nutrition Study, the prevalence of skipping breakfast, lunch, and dinner was 63.1%, 38.2%, and 23.3% respectively. Although students who engaged in greater amounts of physical activity were less likely than their sedentary peers to skip meals, they are still at a high risk for meal-skipping behaviors. This is not only concerning from an athletic performance perspective but also for proper growth and development and risks for disordered eating behaviors leading to EDs. Even if adolescents are consuming adequate calories, the quality of their choices may be questionable. In 2012, the average daily calories coming from fast food for adolescents was 16.9% — almost twice that of children under the age of 12 (13). Other concerns that Fogarty sees with this population are short lunch periods, not wanting to eat the food available at school due to taste preferences or social pressures, forgetting to bring lunch and snacks to school, the easy accessibility to fast food after practices and games, issues of food insecurity, and finally general misinformation about nutrition. Fogarty has found that this population is very aware of nutrition trends through social media and the internet, and she is frequently dispelling myths and misconceptions about nutrition fads and supplements.

Despite the challenges, Fogarty is optimistic about the potential for sports RDNs to partner with high school athletic staff. “High schools are an untapped opportunity to provide and support both the development of good eating habits for performance but also for lifelong health and wellness. The reality is that only 6% to 8% of high school athletes will continue with their sport in college, and providing education to this group will hopefully set them on a path to become healthier and understand the role food has on their body, not just for performance but when sports end.” She describes the student athletes as primed and ready to receive education, and feedback from them seems to echo this sentiment.

“I am eating breakfast every day.”

“My performance has improved.”

“I feel more energized at practice and at school.”

“I am now eating more food and more healthier foods. These changes have benefited me so far as I am gaining weight and building muscle.”

Moving forward, Fogarty and her colleagues hope that these student athletes will be nutrition ambassadors to their schools and communities.


First responders, dancers, and high school athletes are not new targets for health promotion. However, they are groups that have traditionally had minimal access to the expertise of a sports RDN, especially one with the CSSD credential. Obstacle course racers, performing artists/musicians (e.g., marching band), motorsport athletes, athletes with spinal cord injuries, individuals who have very physically demanding jobs, etc. — think of who in your practice could benefit from working with a sports RDN. One professional organization that is working to promote the value of sports RDNs to new markets is Sports, Cardiovascular, and Wellness Nutrition (SCAN). SCAN is a dietetics practice group of the Academy of Nutrition and Dietetics, and its members are RDNs with nutrition expertise in sports, physical activity, cardiovascular health, and wellness. Many SCAN RDNs are experts in sport nutrition but also work across multiple disciplines. In June 2017, SCAN launched its Expanding the Arena Initiative to encourage RDNs and other health and fitness professionals to think outside of the box of traditional performance nutrition. SCAN has long been a source for nutrition education through webinars, fact sheets, and its annual Symposium. Two new projects to be launched this year are a series of podcasts to provide evidence-based information on a variety of nutrition-related topics and a high school sport nutrition program. SCAN already has relationships with several like-minded professional groups, such as ACSM’s Athletes in the Arts Initiative, and looks forward to collaborating with other organizations to make sure that athletes and active individuals in every arena are “eating to train.”


Registered dietitian nutritionists (RDNs) who specialize in working with athletes are an underutilized asset in many athletic populations and among physically demanding professions. To optimize patient/client health and performance, consider partnering with a sports RDN (especially one with the CSSD credential) for less traditional sports or groups (e.g., performing artists, first responders, high school athletes).


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Dancers; First Responders; High School Athletes; Registered Dietitian Nutritionist; Sports Nutrition

© 2018 American College of Sports Medicine.