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Francesco Feletti
Editor
Extreme Sports
Medicine
123
Extreme Sports Medicine
Francesco Feletti
Editor
Extreme Sports
Medicine
Editor
Francesco Feletti
Local Health Trust of Romagna
Department of Diagnostic Imaging
S. Maria delle Croci Hospital
Ravenna
Italy
Department of Electronics
Information and Bioengineering
Politecnico di Milano University
Milan
Italy
Extreme sports are no longer a gimmick or a niche field. Despite of the inher-
ent risks, extreme sports have evolved tremendously and gained enormous
popularity over the past decades, involving both elite and recreational ath-
letes. The impressive film footage generated by extreme sports participants
including breathtaking stunts (and spectacular crashes or near misses) has
attracted not only sports fans but also major television networks, their audi-
ences and advertising, with its associated financial gain. To the general public
the challenge and associated risks may seem unreasonably high, and yet each
event may be the culmination of hours of training and preparation, similar to
every other professional and more common sports pursuit.
As more and more people are enjoying extreme sports, unfortunately
increased numbers are becoming injured as a result. Future research is pro-
gressing alongside the sports development to allow the sports mechanisms,
injury patterns, and predisposing factors to be better understood. It is the hope
of all researchers and athletes involved to make the sports safer without
detracting from its adventurous nature. Researching extreme sports requires
thorough understanding of the activities, preferably from within, as every
small detail related to the technique and equipment utilized is instrumental to
the global picture.
Dr. Feletti’s passion as a physician and as an extreme sports athlete is
transparent throughout this comprehensive collection, spanning over many
medical subspecialties and fields, which were not previously discussed or
presented in this context. I believe that this will be a great source for the
health-care provider, both for the understanding and when approaching the
extreme sports athlete.
v
Preface
• People’s drive to overcome their own limits and to break free from their
daily routine.
• The role of environmental and meteorological circumstances since many
extreme performances depend on natural forces and are undertaken to
challenge physical laws; environmental variables are in sharp contrast to
the controlled circumstances of traditional sporting events.
• The importance of high-tech equipment and the implementation of inno-
vative approaches to the specific performance conduct (e.g., particular life
pace management in solo oceanic sailing races).
• A marked influence on the collective imagination and the attraction of
media interest – a strong appeal that is exploited in marketing campaigns
and by the fashion world.
Albeit with some exceptions, extreme sports also share the following
features:
vii
viii Preface
Extreme sports have never been so popular. Today, they are practiced by
millions of people worldwide, and this is a phenomenon that medicine needs
to face.
The fact is that medicine has, so far, only been involved in these sports on
a limited basis, dealing mainly with their sudden onset injuries.
However, overuse injuries and illnesses, specific psycho-physical training,
preparation and rehabilitation programs, and specific diet and supplements
also need to undergo evaluation.
Professionals working in the field must gain the knowledge and skills
needed to intervene in remote and adverse environments.
A multidisciplinary approach involving many medical specialties – phys-
iotherapy, psychology, physiology, and branches of engineering, ergonomics,
physics, and materials science – is necessary.
Research encounters many difficulties. It requires distinct methods. On the
one hand, extreme sports participants may be reluctant to take part in medical
research because of their cultural conditioning. On the other hand, pursuing
these studies is difficult due to the many variables involved, and the assess-
ment parameters adopted in traditional sports may not be adequate for many
extreme ones.
For instance, the injury rate appraisal in terms of hours practiced may not
be completely accurate since many of these sports are intermittent – the time
in the field is not necessarily spent in action.
Consequently, medicine should approach extreme sports in a new, more
meaningful way in terms of research, support, prevention, diagnosis, and
treatment.
This compendium includes the open contribution of the most authoritative
experts in key fields of extreme sports medicine worldwide.
This book is not structured systematically; the authors have been allowed
to discuss their subjects freely. The editor took this approach deliberately due
to the vastness of the theme and the variety of relevant subjects. This pioneer-
ing work conveys the energy of a new scientific field that will definitely con-
tinue to develop and expand into the future.
ix
x Contents
xiii
The Use of “Accident” and “Incident”
An editorial decision was made to allow authors to use the term “accident”
rather than “incident” as they saw fit throughout the text.
In many industries, government agencies, legal and scientific fields, the
term “accident” is not used, or its use is debated because it could imply that
the event was unavoidable (i.e., a chance occurrence or an “act of God”) and
therefore could not be prevented.
This is the reason why the British Medical Journal (BMJ) banned the term
“accident” in an editorial in 2001 [1] consequently arousing fervent discus-
sion [2].
However, in some ambits such as in aviation, “accident” and “incident”
are both currently used to mean different feature events with the aim to high-
light such aspects that may practically affect risk management [3].
In particular within this context, both terms refer to events that may be
subjected to preventative measures; however, “accident” is adopted for any
occurrence actually resulting in injuries, material damages, or fatalities, while
“incident” more generically refers to any occurrence that affects or could
affect safety [3].
The term “accident” is still common in scientific medical papers [4], and
it is widely used in medical literature regarding extreme sports in particular.
Extreme sports medicine requires special methods and terminology, and,
as already observed, the choice of the most appropriate terms in the field of
extreme sports injury prevention may be particularly complex [2] due to the
special features of these activities.
Within the sphere of extreme sports medicine, the use of both “accident”
and “incident” may therefore help to distinguish events of different features.
What is more, the use of “accident” could be difficult to replace.
In particular, the term “accident” is often preferred for an event which:
xv
xvi The Use of “Accident” and “Incident”
References
1. Davis RM, Pless B. BMJ bans “accidents” Accidents are not unpredict-
able. BMJ 2001;322:1320. doi:10.1136/jech.2003.017715. PMCID:
PMC1733021.
2. Pless IB, Hagel BE. Injury prevention: a glossary of terms. J Epidemiol
Community Health. 2005;59(3):182–5.
3. International Civil Aviation Organization. International standards and rec-
ommended practices. Annex 13 to the Convention on the International
Civil Aviation. Aircraft accidents and incidents investigation. http://www.
cad.gov.rs/docs/udesi/an13_cons.pdf.
4. PubMed. US National Library of Medicine National Institutes of Health.
http://www.ncbi.nlm.nih.gov/pubmed?term=(Accident%5BTitle%5D)%20
AND%20(%222015%22%5BDate%20-%20Completion%5D%20
%3A%20%223000%22%5BDate%20-%20Completion%5D). Accessed on
5 April 2016.
Francesco Feletti
Local Health Trust of Romagna, Department of Diagnostic Imaging,
S. Maria delle Croci Hospital, Ravenna, Italy
In this chapter, we define extreme sports as else would someone willingly undertake a leisure
independent adventure activities where a activity where death is a potential outcome?
mismanaged mistake or accident is most likely to Proffered explanations suggested that participants
result in death [4]. Activities that typify this defi- were ‘crazy people’ with ‘deviant’ traits that
nition include BASE jumping, extreme skiing, predisposed them to deviant risk-taking behav-
waterfall kayaking, big-wave surfing, high-level iours, due to deep, unfulfilled psychological
mountaineering and ‘free solo’ climbing. BASE needs and/or adrenaline addictions [14–21].
jumping is a parachute sport where participants These assumptions have even led some theorists
jump from solid structures (e.g. bridges, build- to assume that extreme sport participation is akin
ings, cliffs) that are only a few hundred feet from to drug addiction or other socially deviant
the ground [5, 6]. In extreme skiing, participants behaviour.
ski down sheer cliffs where a fall would most The increase and differentiation in extreme
likely result in an out of control tumble. Extreme sport participation also gave rise to psychological
kayakers tackle waterfalls rated as either ‘por- theories and models seeking to explain these
tages’ or the most difficult to navigate (i.e. grade seemingly ‘paradoxical’ pursuits. Some of the
six) on the international white-water grading sys- dominant theories that are still used to address
tem [7]. Big-wave surfers ride waves over 20 feet extreme sport motivations include sensation
tall, a pursuit which has even resulted in deaths of seeking [22, 23], psychoanalysis [24], type ‘T’
surfers renowned for their competence [8]. High- personality [20], reversal theory [25, 26] and
level mountaineering takes place above the death edgework [27]. The following sections briefly
zone (8000 m) wherein mountaineers’ bodies are outline and critique these theoretical assumptions.
extended to their limits [9]. Free solo climbing
involves climbing without rope protection or
other aids on high rock structures, such as the 1.2.1 Sensation Seeking
Half Dome in Yosemite [9].
Sensation-seeking theory explains involvement in
extreme sports through a personality trait that
1.2 Traditional Perspectives causes some individuals to seek out higher levels
on the Psychology of novel sensations. Therefore, individuals ‘born
of Extreme Sports with a general sensation seeking motive’ are more
likely to seek risks, such as those inherent in
Until recently, prevailing assumptions presented extreme sports [28]. Sensation-seeking theory
by researchers and theorists presupposed that seeks to explain why some individuals seem to
people undertaking extreme sports were abnormal have an inherent need to continually search for
individuals that had a ‘death wish’, were risky, complex or novel experiences [22, 29].
motivated strictly by the desire for thrills and Zuckerman defined sensation seeking as ‘the
risk-taking and/or were ‘wired’ differently to the seeking of varied, novel, complex and intense
general population. Participants were generally sensations and experiences, and the willingness to
portrayed as selfish young adults, generally take physical, social, legal, and financial risks for
males, ‘fascinated with the individuality, risk and the sake of such experiences’ [28]. This theory
danger of [extreme] sports’ [10]. Media and postulates that individuals with a sensation-seek-
advertising representations have mirrored these ing trait require an arousal level that is higher than
presuppositions [3, 11–13]. The assumption nonsensation seekers in order to maintain an opti-
underlying these portrayals is that participants mal level of stimulation [30, 31].
are risk seekers, who may be unskilled, with a There are four different types of sensation-
desperate desire to connect with the image of seeking behaviour proposed in this theory: thrill
glamour associated with extreme sports. and adventure seeking (TAS), experience seeking
Researchers and popular press have argued, why (ES), boredom susceptibility (BS) and
1 Psychology and the Extreme Sport Experience 5
disinhibition (DIS). Psychological scales have letes, scored significantly higher in TAS and ES
been developed to measure the extent to which than the general adventure sport group might
individuals are positively or negatively inclined suggest that the concept of sensation seeking, if
on each of these behaviour types. In order to at all useful, has a ceiling effect.
holistically measure the sensation-seeking trait, Slanger and Rudestam [35] examined sensa-
an individual’s score on each of these scales is tion-seeking differences amongst participants in
cumulatively summed to give an overall sensa- extreme, high-risk and traditional sports by com-
tion-seeking score (SSS) [29] The TAS scale paring rock climbers, skiers, small-plane pilots
refers to an individual’s need to seek out risky and white-water kayakers with traditional sport
and exciting sports or other activities and is the participants (e.g. bowlers and gym-based fitness
scale most often associated with extreme sports. participants). In line with the definition in the
The ES scale relates to the seeking of sensations current chapter, the proposed difference amongst
through the mind or senses and the need for non- groups was whether or not the likely consequence
conformity. The DIS scale measures a person’s of an error was death. The study found no signifi-
need for social stimulation and search for experi- cant differences amongst the extreme-, high- or
ences that might produce experiences of disinhi- low-risk groups. The authors reasoned that these
bition. The BS scale refers to an individual’s findings might reflect a number of factors. One
aversion to monotony and general experience of conjecture was that sensation-seeking theory was
restlessness [30]. not useful in differentiating between extreme
Numerous studies have been conducted on sports and non- extreme sports. An alternative
sensation seeking and ‘extreme sports’ [32, 33]. interpretation was that the theory is valid, but the
However, two factors often cloud the interpreta- scales may need further refinement to reflect indi-
tion of results: diverse definitions of extreme sport vidual differences in sensation seeking.
and the a priori assumption that participation is Sensation-seeking explanations might be
predicated on risk-taking. Many of the sports in useful to explain certain patterns of behaviour or
these studies do not meet the definition of extreme aspects of high-risk sport participation, but this
sports provided herein, and those that do fit this theory may not holistically account for the
definition have inconclusive findings. motivations of extreme athletes. Sensation
For example, a study by Goma [34] investi- seeking may indicate potential interest in ‘high-
gated alpinists (n = 27), mountaineers (n = 72), risk’ sports, but the trait may not necessarily
general sportspeople who undertook adventure predict involvement in an extreme sport. The
sports such as white-water kayaking and caving mixed results of sensation-seeking research
but that were not related to mountaineering suggest that participation in extreme sports may
(N = 221) and individuals not involved in an be motivated by a range of factors in addition to,
adventure sport (n = 54). Goma considered alpin- or separate from, sensation seeking.
ists to be extreme sportspeople with regard to
their potential for death during this activity. The
author found no significant difference between 1.2.2 Reversal Theory
alpinists and either the mountaineer group or the
general sport group terms on any of the sensa- Reversal theory [25, 36] is a general theoretical
tion-seeking scales. However, the mountaineer model of motivation and emotion, which posits
group scored significantly higher than the general the existence of opposing metamotivational
adventure sport group for both TAS and ES. This states. Metamotivational states are frames of
result suggests that extreme sport participants do mind, or higher-order motivation levels, that
not have higher sensation-seeking tendencies determine how a person interprets their situation
than ‘non-extreme’ adventure participants. at any given time. A metamotivational state can be
However, the fact that the mountaineering group, conceptualised as a proverbial pair of
who were not considered to be extreme sport ath- rose-coloured glasses [25]; a person always ‘sees’
6 E. Brymer and S. Houge Mackenzie
or, more aptly, feels an experience in the context Investigations of paratelic dominance amongst
of their dominant metamotivational lens. Changes athletes have supported the validity of this model.
in an individual’s mood, motivations and emo- Studies by Kerr et al. [26] generally support the
tional experiences are instigated via regular alter- hypothesis that participants who regularly
nations, or reversals, between these opposing participate in sports deemed risky are arousal
metamotivational states. Although there are four seekers (i.e. paratelic dominant). For example,
pairs of opposing metamotivational states, the significantly lower levels of arousal avoidance
majority of reversal theory research in extreme were found amongst surfers, sailboarders,
sports has focused on the telic/paratelic states. motorcycle racers and parachutists in comparison
These states are considered highly relevant to to marathon runners, weight trainers or the gen-
extreme sports as they provide an explanation as eral public [26]. Shoham et al. [40] also docu-
to why people interpret intense emotional arousal mented low arousal avoidance (i.e. paratelic
in very different ways, such as feeling excitement dominance) amongst skydivers, rock and
versus anxiety in the same external situation. mountain climbers and deep-sea divers (n = 72).
The telic state is primarily serious, goal- However, these studies did not explicitly
oriented and arousal avoidant, whereas the para- differentiate between extreme- and high-risk
telic state is characterised as spontaneous, playful sports, and as a result, extrapolating findings to
and arousal seeking [37]. In the telic state, current participants in typical extreme sports might not
activity is seen as a means to an important end be appropriate. Further, one issue that cannot be
beyond the present moment, and thoughts are ori- addressed by these studies is whether participants
ented towards planning for the future [38]. entered their sports with this disposition or
Excessive arousal results in feelings of anxiety or whether they learned to enjoy high arousal as a
fear, whereas low arousal is relaxing and pleasant. result of participation. Thus, the issue of initial
In the paratelic state, arousal levels are experi- participation motives remains.
enced in direct opposition to the telic state pattern. Recent research in reversal theory has further
In this playful state, activities are pursued as ends expanded this somewhat narrow view of extreme
within themselves, and attentional focus is sport participation. For example, Kerr and Houge
absorbed in the process- oriented goals of the Mackenzie’s [41] in-depth qualitative study of
activity. High arousal is experienced as excite- adventure sport experts highlighted the multifac-
ment, whereas low arousal is boring. eted nature of participant motivations. Experts
Reversals between the telic and paratelic identified diverse motives that included goal
states are contingent upon the presence or achievement, connection to the natural environ-
absence of ‘protective frames’ [39]. As the name ment, social motives and pleasurable kinaesthetic
implies, a ‘protective frame’ provides feelings sensations (from moving through water or air), in
of protection from the presence of danger (e.g. addition to more widely discussed motives, such
due to confidence in oneself, others or equip- as escape from boredom, risk- taking, pushing
ment). When the protective frame is active (in personal boundaries and overcoming fear. The
the paratelic state), heightened arousal and chal- authors concluded that motivations extended
lenge are experienced as exciting; when the pro- beyond excitement or thrill-seeking explanations
tective frame is lacking (in the telic state), and identified the need for more comprehensive
heightened arousal is experienced as anxiety. models of participation motives.
Although reversal theory is more state than trait
based, individuals are thought to have dominant
states that they tend to reverse into more often 1.2.3 Edgework
than others. For example, individuals who
spend more time in serious, telic states are ‘telic Edgework describes social factors that stimulate
dominant’, whereas individuals who tend to the desire for voluntary risk-taking and the sensa-
operate in playful, paratelic states are ‘paratelic tions and feelings resulting from these experi-
dominant’. ences [42]. It also highlights diverse motives for
1 Psychology and the Extreme Sport Experience 7
the contrary, these are people who are pushing the their strengths and limitations in the face of clear
envelope and that’s their life. They would not want dangers. Findings of extensive research in climbers
the life of someone who never pushes the enve- suggest that the individuals do not want to put their
lope. To them, that is an unlived life. [51] lives in danger by going beyond personal capabili-
ties. [2]
1.3 Beyond Risk and Thrill A myopic focus on the desire for risk also
makes it difficult to explain why a person chooses
Milovanovic [52] suggested that risk-focused skiing or BASE jumping above surfing or moun-
explanations of extreme sport participation were taineering. These are purposeful choices often
overly simplistic and based on naïve non- made years in advance of participation [5]. If risk-
participant viewpoints, as opposed to the experi- taking were the sole aim of these activities, it is
ences of participants themselves. In addition, questionable whether participants would spend
risk-focused accounts of participation are often years preparing to ensure relative ‘safety’ before
driven by theories based on deficit models of undertaking their chosen pursuit [61]. For instance,
behaviour. These theories may rely on prior there are examples where participants have take
judgements or assumptions that are unsupported approximately 6 years to plan one BASE jump
by the participant reports [4, 5, 53–59]. [62] and 14 years to plan one expedition [63].
For instance, Celsi et al. [5] cited numerous Therefore, it is likely that participants strictly
examples of well-respected extreme sportspeople motivated by risk or prone to impulsivity would
who participated well within their personal capa- opt for alternative, more immediately rewarding
bilities; these participants preferred to defer their means of pursuing risk and experiencing thrills.
activity to a later date if they felt the limits of In summary, researchers following the tradi-
their control were being overextended. Pain and tional theory-driven perspectives on extreme
Pain [2] observed that extreme athletes expend sports have generally assumed that participation
considerable time and effort honing high-level is motivated by risk and thrills. Participants are
skills, conducting extensive planning and devel- often portrayed as self-deceivers searching for
oping a deep understanding of their particular thrills and uncertainty. However, evidence reveals
activity. These athletes deliberately study all that these assumptions may be largely inaccurate.
potential variables, such as the environment, their The traditional risk focus may in fact be a func-
equipment and the weather. tion of our modern aversions to risk or obsessive
Interestingly, statistical comparisons amongst desires to be liberated from risk. The notion of
the death rates of motorcyclists, BASE jumpers ‘risk’ has always been a part of life; it is only rela-
and climbers show that BASE jumping is far less tively recently that the lack of certainty and need
likely to result in serious injury than motorcycle to control our surroundings have been boxed as a
riding [6, 60]. Perhaps, as Storry [60] recognised, construct and labelled as something deviant. The
the tendency to focus on ‘risk’ or ‘thrill’ motiva- extreme sport experience might be a function of
tions misses the point entirely. Extreme sports are many factors that have been overlooked due to
not necessarily synonymous with risk, and par- this societal aversion to risk. Furthermore, risk-
ticipation may not be focused on risk-taking. On focused explanations of extreme sports concen-
the contrary, research suggests that extreme trate exclusively on potential negative outcomes.
sport participants are careful, well trained, well The problems with this approach are (1) literature
prepared and self-aware and prefer to remain reveals characteristics and statistics that do not fit
in control. This conclusion is supported by Pain with traditional assumptions of risk motivations
and Pain: [5, 6, 60]; (2) the focus on risk has largely
obscured other aspects of the extreme sport expe-
Despite the public’s perception, extreme sports
demand perpetual care, high degrees of training
rience [41, 55, 56, 59]; and (3) traditional theory-
and preparation, and, above all, discipline and driven perspectives often do not match the lived
control. Most of those involved are well aware of experiences of participants [56, 59]. Thus, holistic
1 Psychology and the Extreme Sport Experience 9
Maslow [72] considered peak experiences to Research on extreme sport experiences mir-
be almost mystical in nature and epitomised them rors many of the concepts identified in flow and
as ‘a “little death” and a rebirth in various senses’ peak experience research. For example, Brymer
[72]. Panzarella (1980) [73] maintained that peak and Schweitzer [57, 58] found that extreme sport
experiences were more likely to occur in people athletes described time slowing down and deep,
who are considered to be self-actualised. In a meaningful experiences epitomised by feelings
study with veteran skydivers, Lipscombe (1999) of freedom. Brymer and others [55, 75, 76] also
[74] found that all participants reported at least describe how extreme sports change the way
eight of Maslow’s [72] 19 peak experience char- individuals experience the natural environment
acteristics (Table 1.2). These eight characteristics through feelings of connection and integration.
were total attention, rich perception, awe or rever- Recent flow research further supports the notion
ence of the experience, fusion of dichotomies, that extreme sport participants are intrinsically
fusion of the individual, experience or object uni- motivated by flow dimensions and suggests that
fication, ego transcendence and intrinsically per- researchers should reconsider traditional charac-
fect experience. Lipscombe [74] argued that as teristics of ‘flow’ amongst extreme and adventure
few as three of these original characteristics may athletes. Studies indicate that, rather than a sin-
be required for a peak experience to occur. These gular state of flow, adventure participants may
results suggest that veteran skydivers’ peak expe- experience a range of flow states with varying felt
riences may not rely on perceptions of risk or arousal levels, perceived challenge and skill lev-
thrill but rather result from feelings of ‘acute well- els and phases, depending on their attentional
being, peace, calm and stillness, detachment, focus and goals [77, 78]. Participants in these
uniqueness, freedom, floating, flying and weight- studies reported experiencing both telic flow (a
lessness, ecstasy, being in the present, immersed serious, outcome- oriented state) and paratelic
in the moment, immortality, unity, altered percep- flow (a playful, process-oriented state). Although
tions of time and space, self- validation, and these flow states were equally enjoyable, they
awareness of other’. were described as qualitatively distinct experi-
1 Psychology and the Extreme Sport Experience 11
ences. For example, in situations of high chal- provide more motivation and inspiration
lenge, such as those present for extreme sport than experiencing short-term thrills through
activities, participants most often described telic risk-taking.
flow. In this state, participants sought to lower
their arousal levels and enjoyment resulted from
goal attainment, rather than sensations of excite-
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Nutrition for Extreme Sports
2
Mayur K. Ranchordas, Sean Hudson,
and Steve W. Thompson
tissue proteins that are essential for muscular furnish an increasing percentage of total energy.
maintenance, repair and growth, provide an unin- Therefore, a greater amount of CHO may be
terrupted supply of fuel to the central nervous required prior to exercise if competing for long
system as the brain metabolises blood glucose [2] durations. Also, simple CHO such as glucose can
and act as a metabolic primer for fat oxidation. be ingested during exercise to maintain supply of
The readily available carbohydrate sources are glycogen to the muscles. The type and timing of
fairly limited (i.e. 1500–2000 kcal) and become a CHO are also very important. More specifically,
restrictive factor in the performance of prolonged CHO can be determined by their complexity
sessions (>90 min) of submaximal or intermittent (mono-, di- or polysaccharides) and by their gly-
high-intensity exercise [2]. Thus adequate intake caemic index (GI). Despite a lot of conflicting
of carbohydrates prior, during and after exercise research, it is thought that lower GI foods are
is essential for extreme sports lasting longer than more advantageous prior to exercise as they lead
90 min. It should be noted that carbohydrate to an increase in free fatty acids, better mainte-
guidelines will differ depending on intensities nance and slower release of plasma glycogen,
and duration of activity undertaken. resulting in more sustained carbohydrate avail-
ability during exercise [3]. It is also agreed that
2.2.2.1 Intensity during and directly after exercise, high GI and
As intensity increases, so does the release of glu- simple CHOs are advantageous (glucose and
cose from the liver to the active muscles. sucrose) as they are broken down quicker via gly-
Stimulation in muscle glycogen utilisation also colysis and promote faster muscle glycogen
occurs as the energy increases. This can be deter- recovery [2, 4].
mined via performing gas analysis and referring The American College of Sports Medicine
to the respiratory exchange ratio. If the RER rises (ACSM) [5] recommends 6–10 g/kg body weight
above 1.0, then CHO becomes the primary source of CHO per day (ACSM, 2009). However, this
of energy production. Therefore, the higher the may fluctuate dependent on the sport undertaken
intensity, the more CHO will be needed to main- as specified in Table 2.1.
tain that desired workload. Thus the extreme
sports that have short sharp bursts will have a
greater reliance upon carbohydrate for fuel. 2.2.3 Protein
glutamic acid. However, there are many essential protect vital organs such as the heart, brain, liver
AA that we are unable to synthesise such as leu- and kidneys. They are an essential source of fat-
cine, lysine and tryptophan. Therefore, it is soluble vitamins such as A, D, E and K and are
important that adequate ingestion of protein from important constituents of cell membranes.
the daily diet is undertaken to maintain protein Cholesterol, which is a type of lipid, is a precur-
synthesis and adequate recovery. sor for important hormones such as testosterone.
PRO is used primarily to promote muscle fibre In accordance with the ACSM [5] guideline,
repair, regeneration and growth [7]. They can fat consumption should range from 20 to 35 % of
however also be utilised as an energy source if total energy intake across all intensities and dura-
CHO and fat sources have reduced significantly. tions. This should include approximately 10 %
For most sports, this is not a desired outcome as saturated, 10 % polyunsaturated and 10 % mono-
it may lead to a decrease in AA available for unsaturated as well as including sources of essen-
recovery and regeneration [8]. Dependent on the tial fatty acids. Saturated fats should be avoided.
discipline of extreme sport, the recommended For certain extreme sports such as mountaineer-
daily intake and intake for recovery differ greatly. ing and extreme expedition-type events where
The ACSM [5] have recommended 1.2–1.7 g/kg/ competitors must carry their own food supplies,
day and that this is done via dietary intake. For foods high in fat may be advantageous as they
endurance athletes, 1.7 g/kg may not be needed if provide 9 kcal/g as opposed to carbohydrate and
adequate fuel is ingested through CHO and fat. protein which provide 4 kcal/g. In these situa-
But for any sport that requires strength and power tions, where large energy expenditure is preva-
(e.g. BMX, snowboard freestyle or free running), lent, foods high in fat can help maintain energy
more than 1.7 g/kg/day could be advantageous balance to an extent.
[5]. However, it has been suggested that there is
no harm in ingesting more protein than this. For
example, for some sports that require large 2.3 Weight Management
energy intakes (~6400 kcal), as much as 2.5–
3.2 g/kg of PRO may be necessary [7]. The principles of weight management remain
In order to utilise the dietary requirements, the same regardless of the sport. Therefore this
again, the timing of ingestion of protein is essen- section will focus on general methods for weight
tial. Studies have shown that ingestion of protein gain or weight loss. Weight change is best done
immediately before exercise promotes a greater during the off-season or a period outside of
net protein balance than ingestion postexercise competition to prevent any potential adverse
following resistance exercise (providing adequate effects on performance. For extreme sports such
CHO has been ingested) [5, 9]. It has also been as rock climbing and ultra-endurance sports, a
reported that net protein uptake is increased when high power to weight ratio is desirable so com-
a combination of PRO and CHO is ingested petitors may want to manipulate body composi-
oppose to either of them on their own [7]. Protein tion. Similarly, for other sports such as BMX,
ingested after training is still advantageous and canoeing and white-water rafting, competitors
should be in a simple form such as whey as it is may want to increase muscle mass and reduce
rapidly digestible. body fat.
Fat (lipids) is a necessary component of a normal Weight gain through increasing skeletal muscle
diet for any athlete. Large amounts of fat can be mass (hypertrophy) is often advantageous in
stored in adipose tissue and thus can be readily many sporting contexts and activities. To increase
available for prolonged exercise. Lipids also weight, an athlete must achieve a positive energy
18 M.K. Ranchordas et al.
balance with muscle hypertrophy only occurring performance of physical activities requiring the
when muscle protein synthesis exceeds the rate transfer of body mass either vertically (such as in
of protein breakdown for a prolonged period of jumping) or horizontally (such as in running).
time [10]. The two principal determinants of This is because it adds mass to the body without
skeletal muscle protein synthesis in adults are providing any additional capacity to produce
physical activity and nutrient availability [11]. force. Excess fat can also be detrimental to per-
Utilising protein ingestion with physical activ- formance through increasing the metabolic cost
ity, particularly resistance exercise, promotes an of physical activity that requires movement of the
optimal anabolic environment in the skeletal total body mass.
muscle compared to either stimulus alone [12]. Weight loss can occur when a negative energy
The addition of protein ingestion following a balance is created. Thus, weight loss can be
bout of resistance exercise has repeatedly been achieved by restricting energy intake, increasing
shown to augment the stimulation of muscle pro- the volume/intensity of training or, most often, a
tein synthesis, which over a period of resistance combination of both these strategies. It is impor-
training with increased protein consumption can tant for athletes and coaches to recognise that
lead to muscular hypertrophy. The anabolic with extreme energy restrictions, losses of both
effects of nutrition are driven by the transfer and muscle and fat mass may adversely influence an
incorporation of amino acids captured from athlete’s performance [17]. Therefore, in most
dietary protein sources into skeletal muscle pro- cases, it is important for an athlete to preserve
teins. The amino acid leucine has been high- their fat-free mass during periods of weight loss.
lighted to be particularly important in stimulating There is a growing body of evidence suggesting
protein synthesis and appears to have a control- that higher protein intakes during energy restric-
ling influence over the activation of protein syn- tion can enhance the retention of fat-free mass
thesis [13]. As such, rapidly digested leucine-rich [18, 19]. A reduction in dietary fat and carbohy-
proteins such as whey, in conjunction with resis- drate may allow athletes to achieve higher protein
tance exercise, are advised for individuals wish- intakes without the excessive restriction of a par-
ing to increase muscle mass. In terms of protein ticular macronutrient. Current recommendations
quantity, 20–25 g of high-quality protein with at advise athletes aiming to achieve weight loss
least 8–10 g of essential amino acids [14] has without losing fat-free mass to combine a moder-
been shown to maximally potentiate exercise- ate energy deficit (~500 kcal.d−1) with the con-
induced rates of muscle protein synthesis in sumption of between ~1.8 and 2.0 g.kg−1.d−1 of
healthy young adults [15]. In total, athletes are protein in conjunction with performing resistance
recommended to consume ~1.3–1.8 g.kg−1.d−1, exercise [14].
consumed as four meals while attempting to gain
weight through increasing muscle mass [16]. It
should be noted that these recommendations are 2.4 Nutritional Issues
dependent on training status and more protein and Challenges
should be consumed during periods of high-
frequency/high-intensity training. 2.4.1 Travel