Health assessment: Julie

Our nutrition and exercise expert looks at Julie's eating and exercise habits and gives her some advice.

Subject

Julie is a 22-year-old marketing consultant. Her lifestyle is very busy; juggling a full-time job, her fiancé and his son, as well as sporting and social commitments.

• Age: 22 years
• Height: 1.75m (5'9)
• Weight: 87kg
• BMI: 28.4 (this puts her in the 'overweight' category; healthy weight range is 18.5-25)
• Waist circumference: 81.4cm (low risk)

Julie's goals

• Tone up for her wedding
• Get fitter and eat well for soccer
• Eat for health and energy levels

At 22, Julie tries to be healthy but she feels she needs to step up if she really wants to perform in her workplace and on the soccer field! She also knows the habits she forms now may affect her health later in life.

Julie's current eating habits

• Breakfast: Coffee or tea, muesli or porridge (large bowl with milk). Sometimes a protein shake or fruit.
• Morning tea: Protein shake most often, one or two snacks, e.g. rice wafers and tuna, cake, fruit.
• Lunch: Leftovers such as pasta dishes (medium plate) or takeaways such as sushi or sub sandwiches. They normally contain a moderate serve of meat, carbohydrate (such as bread or rice) and some vegetables.
• Afternoon tea: Fruit or fruit toast, chocolate or lollie fix on occasion, protein shake if around gym session.
• Dinner: Sometimes snacks through dinner, e.g. rice crackers, salsa, cake and toast. Mixed dishes such as stir-fries, ratatouille, pasta. Most often contain some vegetables. Takeaways such as pizza, burgers and chips up to two times per week. Every second night wine, fruit juice or diet soft drink.
• Dessert: Something most nights. Ice cream and chocolate sauce or brownie few times a week, yoghurt, coffee and chocolate.

Julie has a good knowledge of good nutrition and includes plenty of vegetables and fruit in her diet. However, she finds she is often eating in different places; at work, at home, at her fiancé's home, and out. As a result her intake is very variable and although she doesn't skip meals, she may 'snack' her way through a meal time. She eats takeaways a few times per week. She also has a relatively healthy appetite – she is in the habit of enjoying a good, large meal. She often craves sugar and enjoys a caffeine or energy drink every day. She has a good water intake at 1.5L per day plus other fluids.

Julie's current exercise regime

Exercise has always been an important part of her life. She plays soccer, is trialling at a premier level and is very competitive! She is currently going to the gym 2-3 times per week to do weights (on good weeks). She does soccer training three times per week and sprint training one night a week. She wants to improve her fitness to keep up (or surpass!) the other girls trialling for soccer and ensure her weights program is appropriately targeted to soccer. In her exercise test and assessment her VO2 max is 45.9ml/L/min (average).

Julie's medical assessment

A thorough medical assessment picks up that Julie has low serum ferritin (17ug/L Reference range 20-160ug/L). This came as a surprise and was an important find as low serum ferritin indicates a state of iron depletion that, if not controlled, will influence her capability to perform endurance exercise and thus her cardiovascular fitness. This could also potentially influence her energy levels leading up to her wedding.

Expert assessment

Kristen MacKenzie, health and nutrition consultant at Millennium Institute of Sport & Health, comments:

Julie, overall, has a good vision when it comes to nutrition and exercise choices. She knows that as long as you do most things right and have a good exercise regime, then you have room to enjoy some treat foods and takeaway or convenience meals on occasion. However, with her busy schedule these treats move from 'sometimes' to 'regularly' and 'always!' She relies on some quick fixes, such as caffeine and sugar, because she has built up some bad habits over time. I think she is doing very well but just needs some of these habits broken to get back to a good nutrition and exercise program!

Finding that her serum ferritin stores were low was a real discovery. Lack of iron is the single most common nutrient deficiency in the world. Those particularly at risk include women, vegetarians, children and athletes. Many cases go undiagnosed as the fatigue it causes is considered 'normal'. Possible signs of iron deficiency may include a lack of energy, pale skin, inability to do physical tasks or exercise, difficulty concentrating, headaches, irritability, or being more prone to infections. In some cases, however, there are no symptoms. It's important to see a doctor if you suspect an iron problem. There can be some negative side effects of supplementation.

Recommendations

Food

Removing the protein shakes from Julie's intake: She has a sufficient protein intake and protein shakes are potentially energy-rich, which means if you're not burning it off it's converted to fat! As her main goals are fitness related, it is important that Julie focuses on good carbohydrate-containing foods. She'll be better off if her protein intake comes from lean meat sources, which are also rich in iron.

Low GI (or slow-acting) carbohydrates at every meal and a protein and iron source at lunch and dinner: Julie needs easy ideas that fit into her lifestyle. Things like cooking large meals in advance on the weekend to be available throughout the week. Some lunch options for her include grainy toast, tuna and salad; chicken, lean ham or tuna and salad rolls or sandwiches; pasta and chicken in a vegetable-based sauce; and some healthy takeaways such as a panini with lean meat and salad.

Having healthy choices on hand when the 'sugar fix' cravings set in: At work and in the car these will be useful, including fruit, high-fibre muesli bars, low-energy 'sweet' items such as sugar-free gums and sweets, yoghurt and low-kilojoule drinks and light hot chocolate drink mixes (instead of chocolate).

Appropriate fuels around the exercise sessions: To get the most out of sessions, Julie is advised to always have a snack within two hours before training and within a shorter time-frame after training. These should be based around carbohydrate, and after weight sessions they should include a bit of protein as well.

Fewer takeaways, sweets, extras and desserts: In Julie's case it is useful to give her some numbers to challenge her – like no more than one takeaway dinner per week and no more than two desserts per week. Other nights, instead of dessert she could enjoy herbal teas, low-fat hot chocolate, fruit or yoghurt.

Iron supplementation and intake: Julie will be on a low-dose iron supplement to help boost her serum ferritin in the short term. I also recommend iron-containing foods such as red meat and chicken (these contain haem iron – the more easily absorbed form) and non-haem sources such as muesli and bran or whole grains and green leafy vegetables. Fortified foods may be useful – these days we see iron-fortified breads, juices, cereals, and also some hot chocolate mixes! Where possible we will ensure that non-haem sources of iron are teamed with things that aid iron absorption, such as vitamin C (some fruits and vegetables), meat protein or acidic foods. We also aim to reduce iron-binding foods, such as polyphenols in tea and coffee – so no more tea with her muesli!

Exercise

As Julie already has a good exercise program in place, Joe McQuillan, sports scientist and strength and conditioning coach for some of NZ's elite athletes, was brought in to ensure the program was appropriately tailored for Julie and for soccer.

Her resistance training program, aimed at three times a week, includes exercises targeting the lower body as this is of particular importance in soccer.
Exercises such as squats, cable abductions and calf raises are included. These are both functional for soccer and good for injury prevention. The program also includes a range of upper body exercises (Julie has a strapless wedding dress for her wedding and wants to tone up for that). Julie attends her normal soccer training sessions, which are very good for improving her soccer skills, fitness and specific training in game situations. Realistically she is only able to do 1-2 more cardiovascular-based trainings around her other commitments. These are based largely around running, but also at different intensities. While one of these was a long, easy run, the other was a fartlek run (see below for more information on this).

Julie's reaction

After 2 weeks

When Kristen first went over the plan I thought: "This is do-able and seems pretty simple. I just need to make the right choices and have a bit more planning." But then that week I became totally stressed out and hit the wall. When I'm stressed and tired I make all the wrong choices with food, and I do it on purpose. Bring me junk and bring lots of it! The training plan was to an extent in place already and I'm happy with it – I just needed to stick to it and it was good to know that it is more tailored towards soccer. I'm not so stressed out now, so it's all good and I'm making the right choice 90% of the time."

5 weeks later

This story was always going to have a happy ending! Julie had an amazing wedding and honeymoon and looked gorgeous for the occasion. Weighing in at 84.9kg, Julie had a good weight loss of just over 2kg (or just under ½ a kilo of weight loss per week). Her body fat assessments show that some of that weight loss is from a slight drop in body muscle, as Julie had some difficulties with all of her commitments to stick to the weights portion of her program. However, she is happy with the change. She has managed to maintain some of her fitness program.

We will continue to work with Julie, post-wedding, to ensure her soccer goals are realised as she continues to trial for the team.

Julie's serum ferritin results have improved considerably. Most people, depending on the degree of the deficiency, may take a few months to normalise stores; as Julie had only slightly depleted levels we saw a normalisation of her stores in five weeks, which was great!

Nutrition posed some issues with pre-wedding commitments (lots of drinking and eating) to contend with. But we have seen some great improvements. Her overall energy intake has dropped from 8700kJ (which would likely have been weight maintenance) to 7200kJ (which would help promote a slow weight loss). This was largely due to a drop in protein intake from removing the protein powders and from a decrease in fat intake. We also saw a gain in her iron intake. Her carbohydrate intake was almost exactly the same – which was ideal – but she included more low-GI and whole grain carbohydrates to promote lasting energy.

We were perhaps optimistic in Julie taking on some elements of the program with a wedding to plan, but she managed to get some very positive initial results. Her awareness of the link between her lifestyle habits and her practices became much more apparent, which in the long term will help promote healthy choices. Julie is looking forward to continuing to improve her own health and lifestyle.

A few months on…

Health assessment follow-up: Julie