Discussing Nutrition With Podiatric Sports Patients

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Jennifer Spector, DPM, FACFAS: Welcome back to Podiatry Today podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. Today we're thrilled to have Dr. Elizabeth Piselli with us today to talk to us a little bit about nutrition when it comes to athletes that present in podiatric practices. I'll have her introduce herself and her credentials so that we can get started on this important topic.
 
Liz Piselli, DPM: Hi, I am Liz Piselli. Thank you for having me, Dr. Spector. I'm currently a Diplomate of the ABPM, president of AAWP. I co-founded Balanced Podiatry, which is in Long Island. We have two locations, one in Rockville Center and one in West Babylon.

Dr. Spector: You've lectured regionally and nationally on this topic, but why don't you tell us a little bit about what got you interested specifically in treating athletes, specifically female athletes and nutrition as it relates to optimizing care for them?

Dr. Piselli: Sure. Obviously this is, you and I've talked to you about this before, but it's something I'm very passionate about from my background as a Stanford lacrosse player, I was part of the US under-19 team. I've coached at all levels from youth all the way up to college, including clubs which are very competitive, for lacrosse if anyone's in that lacrosse world. I've seen some things later on, with my friends who were fellow athletes dealing with issues that really could have been helped when they were playing athletics. So that's really where, this is all my passion. My really obsession comes from with just nutrition and how it can really help fuel the body and how it's an underutilized tool in our belt.
 
Dr. Spector: So, for some providers who may not treat as many patients in this world or who may just be introducing themselves to this topic, they may think, is this really in our scope? What does this have to do with me? So why don't you share with us a little bit about why nutrition should be an important consideration for podiatrists that treat athletes?
 
Dr. Piselli: Great point. I think if you are a podiatrist and you're discussing sugar control with diabetics, the fall risk patients, you're discussing their home and if they're, and the safety of their furniture and pets and their home life, then nutrition is something you should be talking about as well. It's something that is in your scope. If you are discussing any of those other things, and if you're doing your due diligence as a podiatrist, I believe, which you should be, with the sugar control as I've mentioned, et cetera, then nutrition needs to be one of those things that you discuss with athletes, because often the first person they're coming to is you, their primary care doctors, if they're going at all, and not just going into urgent care, because that's what a lot of people do: They just go to urgent care. They don't even have a primary care, but if they do, the primary care is so overscheduled that they're not going, they're barely doing blood work, let alone talking about what they should and shouldn't be eating.
 
So sometimes they're getting these antiquated handouts that are just really outdated information, and then when it comes to female athletes or female patients versus male patients, there are different nutritional needs to base based on time in their cycle time in their lives. So that's also very important, in general and will have to do with their injury profiles and really have to do with your practice and what you're gonna be seeing in your patient chairs.
 
Dr. Spector: So that being said, what do you find are the top couple of nutritional concerns that athletes in your practice are experiencing? What are you seeing in from a day-to-day standpoint?
 
Dr. Piselli: I think the biggest concern that I have is that people are using caffeine for energy instead of food and sleep. They're really not hydrating, they're not resting and they're not listening to their bodies. Instead of saying, “Hmm, there could be something I really need,” they're just, you know, either taking that 5-hour energy, they're drinking more coffee espressos instead of filling those nutritional gaps that really would help long-term. Another thing that's a big deal, and you'll see this with the female athletes, is they're eating these very low-carb diets. And that's really bad in general, especially for females, but anybody that's doing any sort of cardiovascular workouts is they really need those glucose and that carb load, otherwise they're going to be increasing their cortisol levels, astronomically, really. And there is an issue now with a lot of high performing athletes being on antidepressants because really all they need is that carb source, but they're burning through it. So the cortisol levels are high, high. When I'm speaking with a patient, I'm not mentioning cortisol, I'll say your stress hormone, but for this audience, you understand what I mean when I say the cortisol levels are very high. So that's also going to increase their injuries. It's going to decrease their ability to recover from injury. So that's a big one because the all the fads out there with these low carb diets, you really do need that.
 
Also under nourishing themselves just in general, and I guess that goes with the first two really. A red herring could be body types. You could see, you could think you could have someone's issues pegged, but let's say they're a very muscular, very fit person, but they're, actually very low energy, and that could be from just not eating correctly. And I don't mean diet guiding, I just mean eating in general. The rule is eat whole foods, try to eat mostly plants. That's just in general. So really they're under nourishing and don't go by how someone looks to think If they're adequately nourished, they probably need the talk of make sure you're focusing on your diet, your rest and your hydration.

Dr. Spector: So how do you approach these issues with patients, especially if it's not something that they're necessarily aware of? How do you open up that, that educational conversation?
 
Dr. Piselli: Yeah, that's a very good point, Dr. Spector. So my biggest goal when I have someone in the chair, especially if I have a young athlete who has a parent in the room, I'm looking at both of them and I make sure I turn so I can really swivel my head to both patient and parent, and I increase their awareness about the issue. And I bring up the main 3 things. They said, you're injured now, you need sleep, you need food, and you need water. Those are your 3 things. And often the kids nowadays really are surprised that you would say those things. So once you start increasing their awareness, you say, how do you feel throughout the day? And now you're getting them to tune into their moods, maybe your mood, even if, even if you're getting nine hours of sleep and you're still sluggish, your food is probably the issue. You're not getting, whether it's enough nutrients or the right nutrients to fuel you throughout the day. Because if you're getting enough sleep, you should be feeling great. You shouldn't be falling asleep even in a boring lecture. So that means you're not getting the right fuel.

So that's where I start is just how, how are things throughout the day, and then they're usually taken aback and that's when you start talking about food with them, even if it's an overuse injury like p plantar fasciitis, Achilles tendonitis, PTTD, that's when I usually, at that point I'm really speaking to an adult by themselves and I'm talking to them like, how is food? If I think that still if they are, if they're telling me that they, you know, they're eating well, they feel energized and they're, we're still dealing with a chronic issue, let's say a stress fracture or plantar fasciitis, I will actually put them on EBM supplements, specifically I like them because of the, it's a medical food, so it's graded by the FDA, so the bioavailability is there. And I only put people on medical food for a short amount of time because I really want them to train themselves to look for the nutrients in food as opposed to look for it in the quick fixes, because often those aren't absorbed as well. Your body doesn't know how to tolerate it. There's, there's things in food that we don't even know are helping us because they haven't been isolated out by our food scientists. So food is the most important thing.
 
Dr. Spector: Obviously these athletes have different nutritional needs than, say, our older population or a non-athletic population. Do you ever utilize registered dieticians as part of your armamentarium and are they specifically specializing in sports nutrition?
 
Dr. Piselli: Yes, actually I do have one friend of mine, and she does virtual visits with my patients. What's nice about her is she'll do blood work as well, so I try to put people, even if they're not going to her put you in a direction where they're getting blood work, sometimes even stool samples to see what is lacking in their diet. I've had patients with MS talk to her just to see where they can fill in some gaps nutritionally, even though, you know, that's whole more of a chronic disease issue. So yes, registered dieticians are a part of it. I frequently use my, the people that I know and ask them. And then the books that they recommend, one book for, let's say, female athletes is Roar by Stacy Sims. She's a PhD. she is a nutrition scientist and exercise physiologist, so that's a really good source if you're looking to learn any more about this.

But yes, it's really important to have registered dieticians if you're dealing with athletes that actually understand the load and the caloric differences that are needed for different sports. So for instance, ultramarathoning is gonna need different nutritional profile than a sprinter or a lacrosse player or someone that's gonna be a triathlete. It's gonna have different nutritional needs even throughout the race, and that's something that you want to key into, listen to the patient about their sport needs because a lot of stuff you can extrapolate out, but a lot of things you can't. And like with anything else, if you feel like you're out of your depth, refer them to someone that really knows what they're doing and specializes in that because, it's not a quick fix or the same fix for everybody.
 
Dr. Spector: You alluded to this before, but there is a lot of misinformation out there or incorrect information, and certainly we don't receive a whole lot of in-depth education on these topics during our training. Other than the book that you mentioned and the resource in your potential colleagues in your area, are there any websites or journals or anything like that where you find good information on this topic?
 
Dr. Piselli: I actually find livestrong.com to be pretty well researched and a lot, and, they'll have very good references at the bottom where you could really actually look up the articles to see if they're even quoting them right. Another resource I use just for podiatry in general with athletics is Bartold Clinical. He'll do really good, summaries on different articles because you just can't possibly read all the articles that you can. So I'm typically looking for books, websites that just, filter it down. Then the other one was nutritionsqueeze.com. She's more of just general nutrition for female patients that are going through menstrual cycles. So the post-menopausal crowd that really isn't gonna help as much. But yeah, there's a few different, those are a few different resources. Dr. Axe was someone I'd gone to who was very into nutrition. I find that he has very good what am I, he's very good summaries of different diet types. So if you're just looking for a general overview, sometimes he can get a little bit preachy about his supplements that he tries to push. But that being said, in general, if you're like, oh, what is keto? What is paleo? What is this new fad diet that people are talking about? What's intermittent fasting? He is another one. Alisa Vitti is another one that talks about fad diets.
 
And so if there's something new that you're hearing a lot and you just feel a little embarrassed to ask your patient what that means, then I would go to those two resources just for general, up to date information,
 
Dr. Spector: How do you feel that using nutritional advice can be a positive force for your patients?
 
Dr. Piselli: Nutrition is a hard thing to discuss with patients in general because often they do think it means dieting and restricting. And usually it's not that it's just pushing them from going left to going right. It's really pushing them more in a direction of thinking food as fuel instead of food as something as the enemy, and the numbers on the scale as the enemy, it's really hard with young athletes. And I think sometimes we forget that boys experience this too, where they're concerned about the way their body looks instead of thinking that this is gasoline.
 
One of the most powerful images that someone gave me when I was very upset that I just felt like I was a little higher maintenance in the food and sleep department than my fellow athletes is they said “You're a Ferrari and you don't use regular gasoline in a Ferrari. You don't bring it to the car wash down the street, you wipe it with a cloth diaper, you put in premium gasoline and why should your body be any different?” You're living with your body for hopefully 90 to 100 years. So think changing that mentality from food being the enemy to food being fuel, and you're putting premium gasoline in that tank because you should treat yourself like a Ferrari or Lamborghini or your luxury car of choice.

I think that is a really important image and an important thing to tell, especially young people. Because often when we bring up nutrition, everyone always thinks, “Oh, the number on the scale,” and it's truly not. It's truly, let's get you the fuel to get you feeling right, for you to be alert throughout the day for you to heal whatever those needs are. And just to really tune into your body and start listening again, and stop listening to some of these outside influences and listen to, “What am I feeling? What is going on? What could this be? Am I, is it a cold that's not going away? Am I feeling more depressed lately than usual?” It may just be the easy, simple choice of “I need different foods—not less, just different.” And that would be something I would say is a major takeaway message for all of your patients, let alone just athletes.
 
Dr. Spector: Speaking of taking away messages, what one thing do you hope that listeners will take away from this topic and be able to implement in their practices today to improve outcomes for patient athletes?
 
Dr. Piselli: If nothing else, I would say at least start the conversation of nutrition as a tool to help yourself heal. especially with the more chronic injuries. Often it's something overlooked. You know, you've given the shots, you've breasted, all the other things you've used, why not also think nutrition? It's something that is underutilized and is really, really important factor in healing in general. So it should be something that we talk about, I hope you talk about with all your patients, including your at-risk foot care patients, because it is that important, and just getting them to feel more optimally. And if they're talking to you about that, they're gonna bring up something else that they didn't and then maybe you get them that referral that they needto help them just live better. And that's really what we want for everybody, is just to live stronger, live better, have a better quality of life.
 
Dr. Spector: Well, this podcast today is being created in partnership with the American Association for Women Podiatrists. We'd like to thank them and Dr. Piselli for joining us today and sharing her insights with us. This podcast and other episodes can also be viewed or listened to on podiatrytoday.com, SoundCloud, Spotify, and Apple Podcasts. We hope you'll join us for this and future episodes.

This podcast was produced in partnership with the American Association for Women Podiatrists.