"Advising Nutritional Supplements" with Dr Floris Wardenaar

EPISODE 182

[INTRODUCTION]

[00:00:00] LB: Hi, and welcome to episode 182 of The Institute of Performance Nutrition's We Do Science podcast. I am the host, Dr. Laurent Bannock. And my guest today was Dr. Flores Wardenaar, who hails originally from the Netherlands, but is now based in the US, at the University of Arizona State University to be correct. 

Now Dr. Wardenaar is a sports dietitian with a PhD. Has great experience both as a practitioner working in applied settings. And now, of course, is based primarily in the university environment. 

And what we talked about today, it's a really interesting topic. It may not be sort of the sexiest topic. By that, I mean, I know you guys love conversations about protein. I know you love conversations about things like energy availability, body composition, so on so forth. But you all have heard me talk many times about tools in the toolbox. Sort of translational issues from taking science into practice. And of course, the problems there are associated with supplements. In fact, we've had numerous conversations about supplements. Do we need them? Don't we need them? Food first, but not food only, and so on. 

Well, this conversation today revolves primarily about the concept of supplementation. But from the perspective of how sports health professionals. Not just sports nutritionists. But also, the various professionals that would be involved in your community of practice as a sports nutritionist. For example, in team setting, there are going to be doctors, and physios, strength conditioning coaches, massage therapists and all sorts. In non-team settings, you'll have the same professional networks in your community, all of which are going to be people who will have a perspective on supplements. What supplements should be taken, shouldn't be taken, may communicate that information to your mutual athlete, your mutual client. Not to mention, of course, what people read on social media, friends, family, buddy down the gym, and so on. 

And this concept of how they perceive and prescribe nutritional supplements to elite athletes as well as recreational athletes, gym goers and so on, collegiate athletes, big one of course in the states, is really important when you are the practitioner who should be the go-to expert on this area. We talk about how we should better understand the expertise, the knowledge and attitudes of these various stakeholders as it relates to supplements. And how that might ultimately impact the buy-in of supplements? The risks of doping violations. Just taking supplements that may not have the positive impacts on training adaptations and just potentially can result in confusion and so on is the sort of things that we got into today. 

I know for myself as a practitioner, working in those environments just how topical this conversation is. Hopefully you'll get a little out of it as I did. We referred to a number of papers, and that will be found in the show notes, which you can find on our website at www.theiopn.com. Just click on podcast and go to this episode, episode 182, and you'll get that information there. 

While you're there, check out our new online diploma in sports nutrition. It's a level seven program. Very close to the publication of this podcast. You're going to hear some massive news as it relates to that diploma. And I'll let you find out about that news soon. But it is a unique program at the advanced postgraduate level all about applying sport and exercise nutrition science into practice. And particularly how to coach change behaviors, establish nutrition strategies, protocols and so on. Very much about being the practitioner of sports nutrition. The applicator of sport and exercise nutrition is what that diploma is all about. 

And of course, our software, SENPRO, which helps you communicate with your clients, your athletes. Helps you coach your clients, your athletes, whether it's face-to-face, in clinic settings, or online coaching, or in team settings, that is what SENPRO is all about. And a whole bunch of other things that we're going to be launching soon at The IOPN. Jo just come back. Check out our website periodically. There will be lots of changes. 

Anyway, that's enough of that in my intro. I hope you enjoy this episode about how professionals perceive and prescribe nutritional supplements. 

[INTERVIEW]

[00:04:44] LB: Hi, and welcome to The Institute of Performance Nutrition's We Do Science podcast. I am super excited to bring this discussion to you today where my guest is Dr. Flores Wardenaar. Wardenaar? Is that right? Did I get that right? 

[00:04:59] FW: Yeah, that's correct. 

[00:05:01] LB: Yay! I'm getting better at this stuff. Flores, despite your accent, you're actually in a completely different part of the world. And since you're new to the podcast, let's kick this off like I normally do anyway. But it would be really interesting to hear about you, and your background, and your journey literally to where you are now. But also, tied in with your work from leading into your PhD and then to what you're now doing as a researcher, and a lecturer and so on.

[00:05:33] FW: Yeah, first of all, thanks for having me. It's an honor. Very much looking forward to this conversation. And I knew I think I was 14 or 15-years-old, I knew that I wanted to become a sports dietitian. And I had in mind that I wanted to work with the best athletes at the same time, then be the best sports dietitian, that that was sort of the goal. 

I ended up doing dietetics in Amsterdam. And pretty quickly after that, I did my masters in nutrition physiology in Wageningen University, one of the world top agricultural universities, which is in the Netherlands. Pretty normal to go there, because it's the only one that we have for that purpose. But it's fun to learn that it is such a good university as well. 

Pretty quick after that, I started a job at the HAN University of Applied Sciences at the east side of of the country. And then I had a great mentor, [inaudible 00:06:27]. He was at that time the lead for, I think, the Olympic nutrition team that we had. 

Sports Nutrition was getting more and more a real profession. And he gave me some opportunities to work, first, with professional speed skaters. And then pretty soon also, the opportunity to work with Olympic athletes. I got a lot of opportunity to work with the athletes and learn a lot.

To be honest, when I started, when I did my internship at my bachelor's education, I wrote a brochure for the Dutch Olympic Committee about a nutrition in Sydney for the Olympic Games at that time. And at that time, there was no nutrition team at all. That was 2000. We're talking here now 2022. So in 22 years, a lot has changed. At that time, it was the physician, the lead physician that was in the lead of nutrition. And I said, "You know, why don't we do something like a booklet or a brochure?" And he said, "Yeah, okay, okay." So, I was able to dive in. And it was my first step to show what I knew about sports nutrition and trying to translate it to the athletic population. So, that means that all the athletes received the brochure, the Dutch athlete, and all the staff as well. For me, that was a very first nice step. 

I worked at the university, teach. And at the same time, I worked with the athletes. And then from that moment on, our university was more and more becoming also research-focused, but more applied research. In 2012, I was able to start my PhD. And I did that again at Wageningen University. I had a couple of good people around me, [inaudible 00:08:23], all people that had their own expertise especially also in dietary assessment. And I really wanted to stay on that side because I often see that there's a lot of sport nutrition research. And often, it's done by people with a training background an officiality background. And I thought, "Okay, what if I take time to better understand what the pitfalls are of nutrition research?" 

I state on the nutrition side with obviously an interest in performance and in sports. And in four and a half years, I finished that. At that time, I was also the team lead of sports and exercise nutrition at my university. And then I had the opportunity to cross over to real academics. I said real academics. But a different university, different country. I ended up at the Arizona State University at the College of Health Solutions. Have there now been for five years. Yeah. And very happy to do the work that I do currently.

[00:09:27] LB: Yeah. Well, that's great. I mean, you've obviously got a lot of passion behind you. And in fact, that passion's taken you on the other side of the world. Well, not quite the other side of the world. But it's taken you a long way, hasn't it? I mean, I have quite a few US-based, North American-based guests on this podcast, some of which are very close to you like Professor Stavros Kavouras, where we've talked about hydration. Big surprise. An area I know that you're also working in. 

Just because I think it's interesting for the listeners that are researchers, PhD students, practitioners, how have you found that in terms of relocating to another country, another university setting? We talk about this a lot on this podcast in terms, because our interests, as we were discussing offline, is about translational stuff, translating science to practice and so on. But in the area of science, English is used a lot. But it doesn't mean that everything is going to make translational sense. I.E., things are lost in translation. How do you find that as a practitioner and a researcher in another country? Just out of interest. 

[00:10:35] FW: It was really refreshing. It was totally you put yourself in a totally different setting. It's not only the situation on a work basis, but it's just your whole life changes. Because at that point, you are the immigrant. That was very interesting. I think Arizona State University is a very applied-focused practical university. It's really appreciated. Obviously, there is world-breaking science there too. Very mechanistic. But there is a such an appreciation for the applied side of things as well. That felt very welcoming. 

And it challenged me to think differently instantly just about the things that I have been doing. And just because there is so much opportunity and there are so many facilities, there's so many colleagues and staff that can help. And it started with I wanted to do a hydration study. I didn't really – I did some hydration observations with runners, ultra runners. And then I wanted to do hydration study. 

And then one of the people in the lab asked me, "Okay. But what's actually the precision or the accuracy of this measurement?" And I thought, "Ah! Yeah, of course. Yeah, we need to think about that." That ended up in doing a study comparing different urine specific gravity tools to see what the accuracy actually was. 

And I was interested in to see if there's a difference, for example, temperature based. Because the manufacturers often say that it is a self-regulating mechanism. I figured out why. Because, obviously, if you have a tool and you only place a small drop on the tool, the tool will bring back the temperature of the drop to the actual temperature of the tool. But what if you are, for example, an athletic trainer and you put the tool in your bag and then you're going to assess the hydration status of your athletes at the start of practice? But you are on the field a couple of minutes before and your back is in the sun. Will that affect your measurement? I was just, again, pretty practical thinking about that kind of stuff. 

I was coming from I think the most – probably the greatest job that I could ever had at the HAN University. I had a great team of minds alike. We were teaching on sports nutrition. We were helping the fields. We were consulting for sports teams for a national sports associations. And we were doing research. And it all great. And still now, they do really awesome research that is really I think top-notch from an applied and practical perspective. 

But just moving out that setting allowed me to further develop. I have done now things that I wouldn't have done if I would have stayed. Yeah, that's what it did for me. And at the same time, you need to be aware that when you move to another country – my oldest kid was fluent in in Dutch. And she's now fluid in both languages, Dutch and English. 

My youngest kid, she is fluent in listening Dutch. And she's fluent in English. We have now this mixed approach. Half of the time we're speaking English at home just because my kid is doing that too. Yeah, these are just changes that happen because she moved to another country. And obviously, that influences me too. 

[00:14:11] LB: It's fascinating having lived in various countries myself. You mentioned something there that I thought was particularly interesting about the use of tools. And particularly in applied setting, there are some practical aspects to that. Like, having to put it in a bag or in a pocket. It's not the specific environment of a lab where it's got a specific home and the environmental nature of that laboratory is quite well controlled in many ways. Because it's a lab, and it's science and so on. 

But we get into this a lot on the podcast where, yes, that stuff's all incredibly important because we want that that science. We want that evidence to add to the body of knowledge that we as practitioners use to inform our decision making and help our clients, our athletes, get bigger, faster, stronger. 

However, in the process of that translation, that taking that knowledge tool from the lab to the field, to the pitch, there are those interesting quirky things like the fact that those tools are used differently in reality. And therefore, that might influence how we should interpret that information. 

When we talk about tools, it could be gadgets, it could be knowledge, and absolutely could be beyond food strategies, things like supplements. And one area of research that you have gotten into, and hopefully we'll – I think we'll have a bit of a mixed bag conversation here if I'm judging this right. But the first thing is this area of supplements. We've talked about this with various experts in the past. How we should critically think about supplements and decide to or not use them. We've talked about the sort of the food first but not food only. In fact, both times was Professor Graham Close, who you of course know of very well. 

But what I'm what I understood to get into first here is this idea of how sports nutritionists and allied professionals in that environment perceive the use of supplements and ultimately prescribe those in the various athlete sort of context. Not just Olympic, sort of ultra elite pros. But athletes in general. I'm very interested to know why you did that research. And maybe discuss some of the findings.

[00:16:38] FW: Yeah, we recently looked into a data set that I actually collected. I think it was 2012 up to 2015. I did that together with Dan [inaudible 00:16:50]. He is a former student and actually now a research fellow, colleague. We have been written already so many papers together. And at that time, I was collecting dietary supplement data because I was interested in the behavior of our Dutch athletes. I tend to say Elite athlete. But obviously, we can have discussion about that definition. 

I was trying to get a very broad sense of dietary supplement behavior in a very large group of athletes that were performing at the top level of in our national basis. That means that we had – We actually had young football players that were part of our professional development teams, right? They're not elite yet. But at least they were top in their age category. That was the approach that I took. 

And I published the data a couple of years later together with Dan and other colleagues, we published some additional data about their perception on third-party testing. Because the interesting thing that we have in the Netherlands is that we have our own third-party testing system. Because when supplements came often in the news, and it started in the 90s, we had multiple Dutch athletes, football players, but also other athletes, that were testing positive. And then it was blamed on the supplement often. And to be honest, there are many cases where supplements have been shown to be contaminated. 

At that time, there was a big push from the Dutch Olympic Committee, and the doping authority, and some other organizations, and even the Dutch government, to set up that third-party tested system specifically for the Dutch community. And because there was such a large push and me working for years in elite athletics and in elite sports, we sort of assume that everyone knows about it. And that people are compliant about it. Because they are so often focused in that direction. You need to do that just for your own safety.

And we found out that depending on the level of the athlete, between 80, especially at the highest level, but going down to 50% of the athletes on a high level, but not necessarily elite, that they were reporting the use of third-party tested products. In some cases, only 50%. Only one out of two. And these are athletes that probably not regularly need to do a doping test, but potentially can. Because, for example, these are athletes that can do a national championship. And if you end up on stage, on the podium, you can expect to be tested. There is a risk always. 

I sort of at the same time did the same type of analysis with our collegiate athletes here at Sun Devil Athletics, our athletic department within Arizona State University. And I saw the same type of trend. And I wondered, "How can it be that we educate so much and there is so much information, and that there is a specific group that is not compliant?" At that time, I thought, "Okay, but I still have this data set that I collected in sports professionals." 

And the reason was is because we wanted to have a sort of more practical approach of some workshops that we were giving because it's always fun to show data from athletes. But we thought it might be even interesting, more interesting, to show data from the sports professionals themselves about how they perceive certain things and then just start at the root of things. 

We collected that data. We analyzed the data. We had almost the same type of questions that we asked the athletes. And that's an interesting part, because you can sort of compare the results of the sports professionals with the athletes. 

We published recently a paper about the perception of nutritional supplements in sports professionals working with Olympic and non-Olympic athletes. And we saw some interesting things. I'll give you a break just to focus and target on what would you want me to talk about, because I have very long answers, I see.

[00:21:29] LB: Yeah. No. No. Well, that's fine. I mean, because when I listen to these things, you're making me sort of cast my own mind back to the environments that I've been in myself, the testing side of things. I know when I've worked particularly with national teams, particularly football, vast amounts of testing was done. Like, World Cup murals and World Cup qualifiers and so on. I mean, every single game, pretty much the reason why we would never get back to to our hotel or catch our flight, although it was our own airplane, so it wasn't such a big issue, but it would always be because athletes were being tested. And it is something that isn't just a possibility. It's going to happen. There are no doubts to be had that this testing is going to happen. 

And yet, it costs me to another reflection, which is just how autonomous players can be when it comes to things like supplements. Because you as a nutritionist, hopefully, you're impactful. Hopefully, you get buy-in. Hopefully, you've got influence. But nonetheless, the athletes are still individuals. They're still human beings. 

And it's like you just mentioned with your own national team now out in Qatar, the nutritionist isn't – Did I get this right? The nutritionist isn't actually with the team. That's a classic example of how they may not have as much in your face influence as you might had. It still comes down to the individuals. And like you say, the perception tons of these things and then the impact of that perception and how serious it may or may not be. 

What were your experiences of that? Because the word perception is a word I'm particularly interested in. It's a very meaningful statement now. What do you define as perceived anyway? 

[00:23:13] FW: That's a good question. Let's start with trying to build up this a little bit. One end of the spectrum is, okay, am I capable of providing advice? We actually asked the professionals if they felt that they were, for example, knowledgeable on the level of general nutrition, sports nutrition or supplements. And what you see is that that gradually goes down. 

In general, people feel pretty confident that they know enough about general nutrition. If it becomes sports nutrition, it becomes already more something that they perceive to be probably for a specialist. And then for supplement, the actual knowledge level is a little bit lower. 

But there's an interesting thing that is happening, is that even though they self-score their perceived level of knowledge on supplements the lowest, in some cases, you see that professionals, other than the sports dietitian, very often are in a high number advice specific supplements. And then you can obviously question, "Are there supplements backed by science? Are they practical? Are they needed?" 

And especially if you work with a team of multiple professionals together, I think you really need to make it sure that you have a good conversation about that. Because what athletes do when they have something in mind, they want to use a specific supplement. And if they don't get the right answer with one of the professionals, then there's the risk that they are going to shop. And then they shop for the right answer. And after that, they are confirmed in what they want to do. And then they do it either way. And that's a risk what is I think happening in sports teams. And we as professionals or practitioners really need to be aware of that part. 

The other thing is, is that if you ask sports professionals about who is the expert, then you can really benchmark the sports dietitian, the nutritionist. They get the highest score. But at the same time, in each category that we ask, there's a small group, between six and two, one percent, of professionals that is actually identifying themselves as the specialist. 

And to be honest, that's certainly possible. I had students that were not having an attrition background that came from exercise science that were great sports nutritionists that had so much knowledge, that were so capable. But at the same time, we need to appreciate that the dietitian has at least four years of education in most ways. Then, often, there is the additional education that you, for example, provide yourself with your institute. And then there's all the certification. There's all the development that people make through. 

A lot of the self-made sports performance nutritionists step in a little bit later. And then there's the side of the clinical things, right? Some supplements that you would like to provide from a clinical perspective, normally that's something that lies with the decision with the physician and the dietitian, for example. And that is not something that you can attract lightly. 

The dietitian overall is seen as the expert by the profession. I think we have two things that we now can do, is that we can say, "Okay, based on science, we have a sort of consensus about what type of supplements could work." And at the same time, you have a sort of benchmarked situation where you could say, "Okay, what do the experts say?" And then you see that the experts, the dietitians, are operating in that same direction, but not always consistently. That means that even within the field of sports nutrition dietetics, not all colleagues even think alike about something. There's some variety over there. 

I think in the end, if you look and ask professionals about, "Okay, do you feel that a certain supplement is aerogenic?" Then you see some interesting differences, right? For example, dietitians score magnesium as low, as ergogenic. While professionals more often report that they think that it might have an ergogenic influence. And as a result, you also see that it is more frequently advised by those professionals.

And then you get some professional disconnection, right? Especially if you have two people at the team and the one says, "Probably you should use magnesium." And the other doesn't feel about it. I think what we really need to do in a professional setting is take time to have that communication with each other about what we feel that is right and what needs to be done. Because in the end, you always see that when you provide an advice and it trickles down, the effect becomes less. 

And we have an issue – we started with adherence to third-party tested supplements. I think it works there in the same way. But it is the same with supplements. Obviously, you want your athletes to use the most effective supplements that are part of their personal plan. And you don't want to have a lot of noise in the messaging there. 

[00:28:54] LB: Yeah. I mean, there's so much in what you said that I think it's sort of the minefield that is the reality of the practitioner, the specialist, in sports Nutrition. Let's say, with years of training and experience in sports nutrition, we'll still walk into an environment where almost everyone perceives nutrition as something that they have at least some degree of right to not just have an opinion about, but have their understanding of what they feel is their own level of expertise on a particular topic. 

And I guess the particular problem I've seen with supplements is they sort of seem like pretty safe sort of things. They're packaged up in bottles. They've got instructions on the back. It doesn't appear to require somebody with a four-year degree and so on. But of course, that isn't necessarily the case for a variety of reasons that we could explore. But it is that. It is that need to understand the strengths and weaknesses of the tools that we use. But also, to understand that, "Yeah, they may not be harmful." But taking it away from that athlete who has a firmly held belief in that product couldn't itself have damaging impacts, which is that minefield that we walk into, isn't it? It's the, "Should we use this? Should we not use it?" Well, the sort of the thinking process that goes around that's really rather complex. Particularly when, as you said, there are so many stakeholders in that environment who offer advice or opinion. It is very common. 

You talk about magnesium. It might be the massage therapists are doing their work on the athlete who happens to mention they've been getting cramped. In their head, they're like, "Right, take magnesium. I get that all the time." And then the strength conditioning coach is like, "No, no, no, no. You should be taking creatine or something." 

And then you just get constant mixed messages. Even though the nutritionist or the dietitian is perceived as the expert, they're not necessarily seen as the fountain of information at that particular time. What are your thoughts on that?

[00:31:05] FW: Yeah. And I think you make a good point there, is that one of the limitations is, and I have been part of that direction too, is that, at a time, you get to be part of a team. You all – as a sports nutrition or as a dietitian, you really want to take on the direction and be in that directive role. 

As a result, it's often we're almost ready for the World Cup now. It's all balls at the dietitian. And the dietitian is asking for those balls too. Play them to me, and I will score. And to be honest, I don't think that that's always the best way that things work.

And very recently, a paper came out. It was written by Lambert. She is a sports dietitian and came out from CPSDA. So, the Collegiate and Professional Sports Dietetic Association in the US. And they have a very strong foot in collegiate athletics. And they were sort of showing that you have multiple models that can be applied. 

And from their perspective, from the collegiate – From CPSDA's perspective, I think it's a good paper, and it really shows, for example, the difference in education levels between an athletic trainer, strength and conditioning coach and, for example, sports dietitian, and that you have a difference when you are a young professional to a very seasoned professional. And that you can do more and different things with the years. 

But at some point, I think it is a slightly narrow approach. And the reason why is because many of those tasks that are sort of now associated with the more seasoned expert come also with the requests for having more dietitians and staff. And which is great for the profession of sports nutrition. But at the same time, we also know that there are so many programs that don't have the funds to get that organized. 

Does it mean that at that time, those specific tasks that are mentioned, let's say, in that final column that we all dream of to, be considered that it is fine that they are not performed? 

I wrote a book a couple of years ago with some colleagues. And it's in Dutch. But I think the whole thing about it, the title is Sports Nutrition as Team Performance. And I think that sport teams, when they know what to do, that they can decide on if they want to take on certain tasks that are sports nutrition related. 

And depending on the structure of the team, it will be more based on the direction of the dietitian or not depending on – maybe there are some teams that don't even have funds for a sports dietitian. Does it mean that you cannot do anything with sports nutrition? No. That's not true. Obviously, you can do a lot. But you need to think about it. Maybe you need to talk with people in the field and figure out, "Okay, what are we going to do?"

The book is breaking down multiple tasks that we have in four different categories. That's, for example, execute. That's the thing that we often think about. Like, providing nutrition advice and guidance to athletes. But it could also be, let's say, providing just some general information. And that's probably something that as a team you can organize without really having a nutritionist on the floor right away. 

I'm not sure if it is the most optimal way. But if there's nothing, and now you can implement that, then there's at least a little bit more, and you can create some awareness. And in case that there is more to do, you can always direct the athletes to go and access a sports dietitian on their own, right? That's execute. And then there is, for example, support. 

Often, nowadays, the support role – so that's about logistics, about organizing supplements. I know examples that dietitians were driving all over the country to get supplements or sports drinks from the one end to the other end. Why is that something that the sports dietitian need to do? Probably you have very skilled people that can do that maybe for even a lower wage. 

There are so many things that you can think about evaluate. Evaluation is probably something that is often forgotten. For example, we can think about, "Okay, technically, looking into literature and thinking about, "Okay, what focus are we going to put on specific supplements in the coming year? And what's the current status?" That is a form of evaluation. And that's something that the sports nutritionist can do. But if you don't have that person available, then maybe you have someone with a sports science background that can do that as well. 

There are so many things that can be done with or without the sports dietitian or the performance nutritionist, as long as you make well-weight decisions on it. What I think is that we can do a much better job if we want to improve sports nutrition and how it lands in real life and how we influence our athletes if we work together in a better way. And that means that we need to share. And that I think that the performance nutritionist really needs to evolve more to a manager's less educator. And not only the athletes, but also their colleagues on the team. And why? Because the strength and conditioning coach, the athletic trainers, they see them every day. The sports dietitian is often not there always. That's possible. But you need the others. 

And therefore, you need to have communication and a strategy together how you get to the direction that you want to go. And it's the same for supplementation then. The example that you gave about the massage therapist saying this. The other saying that. That's what you don't want to have obviously. 

And then going back to the bottles. We know that probably one out of five supplements is containing substances that are not on the label. It doesn't necessarily mean that that is a doping or a banned substance that is in that supplement. 

But if you ask athletes, and we have been asking that for years now, if they like the idea that supplements can contain something else than is on the label. Almost 100%, it's between 98% and 100% of the populations that we ask, they think that that's unacceptable, right? 

In the end, to be honest, the contrast is so nice that you – So, they find it acceptable to have something that is on the label. On the other hand, if you ask them about if you take a supplement and you're not getting tested positive, is that a problem? Can you use the supplement then? I think there's a contrast there. Because there are many athletes that say, "If I'm not testing positive, then I can take it," which is a totally different ball game, I think.

[00:38:30] LB: Yeah. No. Look, there was so much you said there was just wonderful sort of layers of gems that – I mean, look, in terms of how one sort of manages or injects a sports nutrition strategy into a team environment is – Yeah, I mean, it will vary considerably from team to team, country to country and so on. But the fact is, is that almost all of them have a smaller budget for the nutritionist than they might have, unfortunately, for other members of the sports science and medicine delivery. 

I know my own personal approach to this, which is entirely because of how I've set up the IOPN, is that when I go in as a team nutritionist or as a consultant, is I will also upskill members of the staff. Now, I've done that for quite a few years. And as I talk now, I've got several French rugby, and football teams, and a British Olympic squad that have done the same thing. I can only be there periodically. But three or four members of the sports science medicine team are being upskilled as specialists and sports nutrition. Are they the only sports nutritionist in the squad? No. Because they're being strength conditioning coach. They're being a sports scientist. 

But what I tend to find is that they all sing from the same hymn sheet at this point. I mean, it is that general messaging. The management, if you like, of that strategy that is so important. It is definitely more than a one-man, one-woman job. But it's like when you started the podcast, you had mentioned sort of the 20 odd years of your sort of career at this point. I've been in the game for about 30 years, but I was a strength conditioning coach for 10 years. And then for the last 15, 20 years, has been more into nutrition. That's it though. That's as long as the history is. 

I think we probably just have to be a little bit more patient before we're really taken on board where the science, the evidence, the buy-in gets to a level where it is being prioritized. 

What I've noticed, since you're based in the US now, having spent some time in the US myself, we've got quite a few of our graduates are in US football, baseball, basketball teams, is it is actually being taken on with a lot more priority, I think, in the US. How are you seeing it from your side of things how sport and excise nutrition is being taken as a discipline stateside? How do you see it? 

[00:40:57] FW: I think it has been taken very seriously. For example, only until a couple of years ago, you were able to practice as a dietitian with a bachelor education. And it's now upscaled to that people also need to have a master's degree. And then to become a sports dietitian, a nutritionist, then you need to go through certain certifications. 

There is a variety of options there that involves, I think, 1500 hours of internship service hours, that kind of stuff. Yeah, it's taken I think very seriously. We have a large body of sports dietitians here in the country. And it is growing. And I think it started – and that's interesting. It started in 2014 what is called the down regulation of feeding on a collegiate level. Before that time, it was very, very limited what a sports dietitian could do, because it was not allowed to provide a lot of different foods. Probably it was a bagel with peanut butter or something like that and not much more. 

And sort of the idea was that they would limit the advantage of having programs with a lot of money versus programs with only limited amount of funds. And as such, they said, "Okay, then we just down regulate it, so nobody can do anything." 

When that was lifted, then nutrition in the US and especially at a collegiate level exploded. But still, there is a lot to do, because we have been looking into it. I think there's different type of colleges. College athletics takes a very big part of athletics in the US. That's the way you get towards potentially professional career or an elite career, because it starts during high school. And then you move up to college. 

And even if you don't make it to one of the big research university, you can go to junior college. That's the community colleges. Some of them have very successful and large programs with a lot of athletes. But in the end, if you look into those programs and the amount of sports dietitians that are affiliated with it, it's very low level. Almost to zero. 

Most of them have, for example, an athletic trainer. They have strength and conditioning coaches. But it sort of stops there. And as a result, you see some research data that when athletes have questions, they end up with the athletic trainer and the strength and conditioning coach. 

It's certainly not that they will get the questions, and I think it's part of their profile. And what we really need to make sure in the future is that we do a better job in aligning those professions and what we feel that is important related to supplements. And supplement safety is one part of it. But also, the efficacy that we align with those supplements. 

I think a large difference that I have noticed is that if you are with the division one university program, an athletic division or athletic program can then have probably between 300 and 900 athletes. And then often, what you see is that there's one or two dietitians. One or two dietitians are overseeing 300 to 600 athletes. And sometimes even more athletes. 

The reason why they can do it is that there is a lot of funds most of the time for feeding. So, meal planning. And that's a huge difference with Europe, I think. I'm not sure about the other continents. But I know based on my experience with Europe, the UK, there's much more focus on the one-on-one guidance that you give. That's more being able to coach the athletes, that the athlete can really make the right choice. And you see in the US that there's much more focus on organizing the setting around the athlete. There are fuel stations. There are meal opportunities. There is shake or feeding opportunities after practice. 

In that way, they're sort of complementing the diet of the athletes and modifying the situation. And one of the interesting foundings that we found based on a data collection of one of my PhD students [inaudible 00:45:21]. I worked on that together with [inaudible 00:45:23] as well. She is now a dietitian I think at Michigan University in the sports dietitian. And we published a paper, and I think we published two, right? 

But we looked into how financials secure the athletes felt. And what we saw was that, on a division one level at our own university, because they are having those many meal opportunities and fueling opportunities, that they can spend the money that they have. They can keep some in pocket and then they can make it through the week. 

If you then go to junior college, where all those opportunities are not available, most of time they have the same type of budget. But then they need to pay for the whole week themselves. And therefore, they feel much more insecure. There is food insecurity in financial insecurity all out through the Western country as the US is. And obviously, that's not optimal if you want to focus on a good basic diet.

[00:46:27] LB: Yeah, it's an interesting set of challenges that we have as a performance nutritionist, sports nutrition, sports dietitian. There are so many different environments you can find yourself in. And of course, we might be talking about, as we often do on this podcast, about the elite level, world cups and pro teams. But you have to get there first. And that involves a bit of a career journey, doesn't it? Where you will navigate all sorts of challenges and environments where you – yes, ultimately, you might be lucky to be a full-time employed nutritionist or dietitian working with just a men's team or women's team. That's a luxurious place to be, particularly if the budget is fairly generous. 

Whereas like you say, you can find yourself in the polar opposite end of the spectrum. But it's about being able to, I guess, interpret where your sort of quickest wins are going to be? What are the low-hanging fruits, so to speak? And it's about impact, isn't it, at the end, Flores? I think that's what we're trying to do, is have as much impact as possible, which is why this conversation is interesting about the perception of, "Who is the expert?" "Where do you get this information from?" "Who do you go to?" is something that the practitioner has to play a role in positioning themselves as the beacon of light, the lighthouse of information. Otherwise, they get sort of ignored, overseen. 

Just going back to your research that you did on prescribing supplements to Olympic and non-Olympic athletes. In terms of the health professionals themselves, did anything come from that on how they themselves perceived what should be recommended? Shouldn't be recommended? Any barriers to advising or prescribing? Was there anything through the lens of the practitioner that you were able to learn?

[00:48:18] FW: We looked into, for example, their perception of that third-party tested system that we have in place in the Netherlands as well. And you see just that the familiarity of the sports dietitian group was much higher than that of the other professionals with that specific system. That all already suggests that if you want athletes to make the right choice and use this type of third-party testing situation, it starts probably with pointing them in the right way. 

In this case, likely, the athletes is a little bit better off consulting the sports dietitian than another professional, because it's more likely that the sports dietitian will know. And then one of the things that we found is if we split the data for sports health professionals working with Olympic athletes versus non-Olympic athletes, and then you see that those professionals working with Olympic athletes score higher at that point, which is a good thing. And probably, it has something to do that those teams are more organized. So, the team around the athletes. The team around the team. 

But probably, also, that they are influenced by each other, right? So, there is a sports dietitian on staff. And that there's just more awareness. At the same time, it is also more highlighted at that level, because when you're an Olympic athlete or you're in a national team with the potential of going to the Olympics, then there's just more focus on the topic as well. 

It is especially – and that's interesting, because you say, "Where do you come from?" You always start at the bottom, right? You need to climb up the ladder. There's a little bit more risk of making the wrong choice when you're not on that level yet. That's something to consider. 

I think we definitely need to make sure that when we educate trainers, that we educate coaches in sports nutrition and the safety aspect of dietary supplements is really something that should be part of the curriculum. And I think if you compare the compliance of using that specific knowledge about third-party testing and its importance, then you can almost overlay the data from the sports dietitian towards the athletes. And you see sort of that in the end if we talk about a compliance, a maximal compliance that I found in in Olympic athletes of 80%, the sports dietitians say that they adhere to it for 92%. 

And if I compare individual supplement use and how they are advised, it almost seems that there's a sort of 10% loss in how athletes apply certain messages in real life. We just need to acknowledge too that it will take a lot of work to make sure that the message come through. I think we all played that game at parties that we were whispering in each other's ear. And then at the end, you know you start with a certain sentence or a word, and in the end, it became an elephant that was pink and it was shooting balloons out of the sky, something else. It was completely else. And it was actually about a pumpkin pie or something. That's what is happening here too, obviously. So, we really need to think about how do we get people compliant? 

Just take a little bit of an advantage to the future is, currently, we are looking into, again, questioning athletes about their supplement behavior. We would try to gain as much as possible information to better identify that specific group of athletes that is not compliant, so that we can, in the end, develop some form of a screening questionnaire or a screening tool, very short, very brief, so that we can already identify who might be at risk of not consistently purchasing third-party tested supplements. That may help to then focus on that specific group. 

I don't know what the solution is how we get those people there. But in the end, we know that out of all the positive doping situations in the US over the last couple of years, roughly 10% has been associated with contaminated supplements. You could say, "Okay, that's not really much." But it's still 10%. And it can happen to you. And I think we need to be aware that doping testing on itself is a very interesting topic and how it is organized. And that, often, panels are used so that it is not necessarily the whole population that is tested. The actual risk to get caught is relatively low. 

But at the end, if you perform well and you are tested during a championship, that's something that is not in your mind, right? You will be tested. And potentially, when you use the wrong supplement, you get a positive result. And then you are responsible for what you took.

[00:53:31] LB: Absolutely. Look, when you get into sports nutrition, sport and exercise science, one likes to get really into topics like protein, and carbohydrate, and energy availability and so on. But the reality is that it's these sorts of things that can really get you into trouble. We didn't talk about it so much. But the risk of taking supplements that, "Okay, they may not harm your health. It may not be a doping violation." But they may have a negative impact on performance or have a negative impact on another supplement that you're trying to take. It is unlikely that an individual is taking one supplement with only one ingredient. They're taking all sorts of things, aren't they? And it all gets really quite complicated, Flores. 

[00:54:18] LB: Most of the time, the athletes take multiple supplements, of course. And even though if I say only 10% has been of positive developing cases has been associated with. At the other end of the spectrum, we know that one out of five is containing substances that are not on the label, and potentially they can be harmful. That's sort of the spectrum that we have. 

I think it's even more interesting to apply in a slightly different way, is as sports nutritionists, as sports health professionals, we want that what we advise that people are compliant, right? It's almost like a model that shows how effective we are. And that's something that in nutrition we often lack that direct feedback for. That's probably what makes it so different. That's why that camera on the side of that diving board is so effective, because people make the jump. And when they come out of the water, they see their image and they see, "Okay, this is where my movement went wrong." And they can directly adjust. That's a limitation that we often have as sports nutritionist because we cannot always provide that direct feedback. In most cases, we can't. 

But by looking at the compliance of the use of certain supplements, third-party tested supplements, that will provide us also a direct insight in how effective we are in our communication. And if we can improve that, then we potentially can improve that effectiveness also in other areas of our job. 

From that perspective, it is bit much bigger than only the potential risk. Obviously, it is important that we erase that risk over time. But I think it can help as a model to see how effective we are as sports nutritionists as well. 

[00:56:13] LB: Well, on that note, Flores, that was a great way to end the conversation, I think. I mean, it's important that serious stuff. So much to get out of that conversation I had with you today. I really benefited. Thank you very much for your time today. 

[00:56:27] FW: You're welcome. 

[00:56:28] LB: I always end these things with just questioning how people can follow you and your work and keep tabs on what you're up to. What's the best ways of doing that? 

[00:56:36] FW: People can obviously Google my name, Flores Wardenaar and then look at the website of the College of Health Solutions. We have our own personal websites as part of the university. I think Google Scholar will do well to see what papers we published. 

I have an Instagram account. But to be honest, there's a person personal influx there too because I always like to post a picture about my family life. It's more the personal side of things of living in a different country. 

I recently eliminated my Twitter account, because I was not really using it. And then when they got a new director, I thought, "Okay, maybe it's time to send out that message." I'm not there anymore. People can always shoot me an email if they have questions.

[00:57:23] LB: Well, that's great. And very kind of you. I'll put all that stuff onto the show notes anyway. So, one way or the other, we can have Elon Musk send you some questions. 

[00:57:34] FW: It will be interesting, right? 

[00:57:34] LB: It will be. It will be. Well, look, thank you for your time. Thank you for listening. And thank you to the listeners for listening. And I look forward to bringing another episode of We Do Science back to you all very soon. Take care, everyone.

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