DIRETRIZES DE PRÁTICA CLÍNICA PARA NUTRIÇÃO ESPORTIVA: ASSOCIAÇÃO BRASILEIRA DE NUTRIÇÃO ESPORTIVA

Quaresma, Marcus V.L. dos Santos; Trindade, Michele Caroline de Costa; Oliveira, Erick P. de; Dátillo, Murilo; Pimentel, Gustavo Duarte; Barros, Andrea Regina Zaccaro de; Barrella, Ana Beatriz; Mendes, Renata Rebello; Campanholi, Raphael Alves; Alvarenga, Mariana Lindenberg; Braggion, Glaucia Figueiredo; Longo, Sueli; Santos, Karin Graziele Marin dos; Melo, Camila Maria de; Gonçalves, Livia de Souza; Juzwiak, Claudia Ridel; Joaquim, Daniel Paduan; Gonçalves, Daniela Caetano; Marins, João Carlos Bouzas; Buzzachera, Cosme Franklim; Carvalho, Arthur; Souza, Helton de Sá; Costa, Roberto Fernandes da; Pinheiro, Marcia Nacif; Chináglia, Claudio Filgueiras Pinto; Stancanelli, Mirtes; Lazarim, Fernanda Lorenzi; Marchiori, Vanderli; Silva, Eduardo Augusto dos Reis e; Niehues, Lili Purim; Marques, Camila Guazzelli; Nakamoto, Fernanda Patti; Mello, Marco Túlio de; Artioli, Guilherme Giannini; Saunders, Bryan; Rogero, Marcelo Macedo; Burini, Roberto Carlos; Ribeiro, Sandra Maria Lima; Santos, Tânia Rodrigues dos

doi:10.4025/jphyseduc.v36i1.3605

Tabla de contenido Anterior Actual Siguiente

Tabla de contenido

Document • J. Phys. Educ. 36 • 2025 • https://doi.org/10.4025/jphyseduc.v36i1.3605 linkcopiar

DIRETRIZES DE PRÁTICA CLÍNICA PARA NUTRIÇÃO ESPORTIVA: ASSOCIAÇÃO BRASILEIRA DE NUTRIÇÃO ESPORTIVA

Autoria SCIMAGO INSTITUTIONS RANKINGS

Considerando o crescimento da nutrição esportiva no mundo e no Brasil, nosso objetivo foi elaborar uma diretriz de prática clínica sobre nutrição e exercício físico para otimizar as práticas baseadas em evidências. Trata-se de uma diretriz de prática clínica elaborada com base nas recomendações propostas pelo sistema GRADE. A busca foi padronizada considerando atletas adultos como população e o desempenho físico como desfecho de interesse. Esta diretriz recomenda que o consumo de carboidratos seja ajustado de acordo com a demanda energética, respeitando a quantidade total e os ajustes feitos antes, durante e após o exercício físico quando necessários. Além disso, o consumo de proteínas e lipídios deve ser adequado para desfechos como força, massa muscular e perfil inflamatório, respectivamente. A diretriz também recomenda o monitoramento e a correção de deficiências de micronutrientes ao longo do tempo. Os suplementos ergogênicos (p. ex., cafeína, creatina, beta-alanina, bicarbonato de sódio e nitrato) são recomendados em casos específicos, sendo fundamental avaliar as características do atleta e do esporte praticado. Contudo, a diretriz não recomenda o uso de suplementos alimentares com descrições incertas dos compostos, principalmente pelo risco de doping. Finalmente, esta diretriz recomenda que, para atletas com necessidades especiais, a avaliação nutricional seja feita respeitando as particularidades dessa população.

Palavras-chave:
Ciências da Nutrição Esportiva; Exercício Físico; Guia de Prática Clínica

Potential consequences for performance (Aerobic and anaerobic)	Potential consequences for health - Damages/changes in
Reduced endurance performance	Menstrual function
Increased risk of injury	Bone health
Reduced muscle strength	Endocrine function
Reduced glycogen levels	Metabolic function
Reduced Coordination	Hematological Function
Reduced concentration	Psychological/mental function
Reduced judgment capacity	Cardiovascular function
Reduced adaptive response to training	Gastrointestinal function
Increased irritability	Immune function
Increase in depression	Growth and development

Green
Severity/risk	Clinical criteria	Treatment	Recommendation for training and competitions
None or very low	0 primary indicators; ≤ 1 secondary indicators	No need	No limitations to train or compete
Yellow
Light	0 primary indicator and ≥ 2 secondary indicators	Regular monitoring at regular intervals	No limitations to train or compete
	1 primary indicator and ≤ 2 secondary indicators
	2 primary indicators and ≤ 1 secondary indicator
Orange
Moderate to high	1 primary indicator and ≥ 3 secondary indicators	Treatment, monthly monitoring	Some aspects of training and competitions may be modified
	2 primary indicators and ≥ 2 secondary indicators
	3 primary indicators and ≤ 1 secondary indicator
Red
Very high/Extreme	3 primary indicators and ≥ 2 secondary indicators or ≥ 4 primary indicators	Immediate treatment (hospitalization) required for daily monitoring up to monthly intervals depending on severity	Significant changes in training and competitions are necessary and, in most cases, interruption of training and/or competitions is necessary.

Severe primary indicators (Count as 2 primary criteria)
Primary amenorrhea (females: primary amenorrhea is indicated when there has been failure of menstruation by age 15 years in the presence of normal secondary sexual development (two standard deviations [SD] above the mean of 13 years), or within 5 years of breast development if this occurs before 10 years); or prolonged secondary amenorrhea (absence of 12 or more consecutive menstrual cycles) due to functional hypothalamic amenorrhea
Clinically low free or total testosterone (men: below reference values)
Primary indicators
Secondary amenorrhea (women: absence of 3 to 11 consecutive menstrual cycles) caused by functional hypothalamic amenorrhea
Subclinically low total or free testosterone (men: within the lowest 25% (quartile) of the reference range)
Subclinical or clinically low total or free T3 (within or below the lowest 25% (quartile) of the reference range)
History of ≥ 1 high-risk bone stress injury (femoral neck, sacrum, pelvis) or ≥ 2 low-risk bone stress injuries (all other bone stress injury locations) in the past 2 years or absence of ≥ 6 months of training due to bone stress injuries in the past 2 years
Premenopausal women and men <50 years of age: bone mineral density Z-score* <−1 at the lumbar spine, total hip, or femoral neck or a decrease in bone mineral density Z-score on previous testing.
Children/adolescents: Bone mineral density Z-score* <− 1 at the lumbar spine or whole body (except head) or a decrease in bone mineral density Z-score from previous testing (may occur due to bone loss or inadequate bone accrual)
A negative deviation from a pediatric or adolescent athlete's previous growth trajectory (height and/or body mass)
An elevated global EDE-Q score (>2.30 in women; >1.68 in men) and/or clinically diagnosed DSM-5-defined eating disorder (only one primary indicator for one or both outcomes)
Secondary indicators
Oligomenorrhea caused by functional hypothalamic amenorrhea (>35 days between periods for a maximum of 8 periods/year)
History of 1 low-risk bone stress injury (see definition of high versus low risk above) in the previous 2 years and absence of <6 months of training due to bone stress injuries in the previous 2 years
Elevated total cholesterol or LDL cholesterol (above the reference value)
Clinically diagnosed depression and/or anxiety (only a secondary indicator for one or both outcomes)
Potential indicators (unscored, emerging) †
Subclinically or clinically low IGF-1 (within or below the lowest 25% (quartile) of the reference value)
Clinically low blood glucose (below reference value)
Clinically low blood insulin (below reference value)
Chronic or sudden decline in indicators of iron status (e.g., ferritin, iron, transferrin) and/or hemoglobin
Lack of ovulation (via urinary ovulation detection)
Elevated morning resting or 24-hour urine cortisol (above reference range or significant change for an individual)
Urinary incontinence (women)
Gastrointestinal or hepatic dysfunction/adverse gastrointestinal symptoms at rest and during exercise
Reduced or low RMR < 30 kcal/kg FFM/day or measured (indirect calorimetry)/predicted (predictive equation) RMR ratio < 0.90
Reduced or low libido/sexual desire (especially in men) and decreased morning erections
Symptomatic orthostatic hypotension
Bradycardia (HR < 40 beats per min in adult athletes; HR < 50 beats per min in adolescent athletes)
Low systolic or diastolic BP (<90/60 mmHg)
Sleep disorders
Psychological symptoms (e.g., increased stress, anxiety, mood swings, body dissatisfaction, and/or body dysmorphia)
Exercise dependence/addiction
Low BMI
Legend: EDE-Q: Eating Disorder Examination Questionnaire; DSM-5: Diagnostic and Statistical Manual of Mental Disorders; LDL-c: Low-density lipoprotein cholesterol; IGF-1: Insulin-like growth factor; FFM: Fat-free mass; RMR: Resting metabolic rate; HR: Heart rate; BP: Blood pressure. Each indicator above requires consideration of a non-LEA-mediated differential diagnosis. All indicators apply to both women and men unless otherwise noted. Menstrual cycle status and endogenous sex hormone levels cannot be accurately assessed in athletes taking medications that alter sex hormones (e.g., hormonal contraceptives), and indicators of thyroid hormone status cannot be accurately assessed in athletes taking thyroid medications. All laboratory values should be interpreted according to age- and sex-appropriate, laboratory-specific reference values. Most RED data and associated thresholds were established in premenopausal/andropausal adults, unless otherwise indicated. Note: This tool should not be used in isolation or solely for diagnosis, as each indicator requires clinical consideration of a non-LEA-mediated differential diagnosis. Furthermore, the tool is less reliable in situations where it is impossible to assess all indicators (e.g., menstrual cycle status in women using hormonal contraception). This tool is not a substitute for professional clinical diagnosis, counseling, and/or treatment by a team led by physicians with expertise in health and RED performance. Adolescent refers to <18 years of age. *Bone mineral density assessed by DXA at ≤6 months. In some situations, the use of a Z-score from another skeletal site may be warranted (e.g., distal 1/3 of the radius when other sites cannot be measured or including proximal femoral measurements in some older adolescents (>15 years) for whom longitudinal BMD monitoring into adulthood is indicated). A true decrease in BMD (identified in previous testing) is ideally assessed by comparison with the individual facility’s DXA LSC based on the facility’s calculated coefficient of variation (%CV). As established by the International Society for Clinical Densitometry, at a minimum, the difference should be 5.3%, 5.0%, and 6.9% for spine, hip, and femoral neck to detect a clinical change. †Potential predictors are intentionally vague in quantification, pending further research to more precisely quantify parameters and cutoffs.

Technique	Measure/Estimate	Advantages	Disadvantages
Anthropometry	Anthropometric measurements for estimating fat mass and lean mass	Low cost, relatively simple and portable	Skinfold caliper opening limit Need for validated equations for the subject or group to be assessed
Skinfold Thickness		Low cost, relatively simple and portable
BIA or BIS	Measurement of ACT for estimation of fat-free mass Measurement of intracellular and extracellular water	Relatively low cost, non-invasive, fast and portable	Need for prior preparation of those being evaluated Need for validated equations for the subject or group to be evaluated, which are not available in most equipment
Ultrasound (portable)	Measurement of the thickness of subcutaneous adipose tissue and muscle tissue	Relatively low cost, non-invasive, fast and portable	Need for validated equations for the subject or group to be evaluated, which are not available in the equipment
Ultrasound (portable)	Estimation of fat mass	Relatively low cost, non-invasive, fast and portable
Three-dimensional photonic scanner	Measurement of total and regional volumes	Non-invasive, highly accurate anthropometric measurements and body volumes	High cost
	Estimation of fat mass		Not portable
			Few devices available in Brazil

System	Marker	Sample	Confusers	Reference values	Interpretation for high levels	Reproducibility
SkM	CK	Serum, plasma or capillary (earlobe or finger)	Myocardial damage, glutamine intake and circadian rhythm	F: 30 to 135 UL;	High mechanical or metabolic load	Good reproducibility (ICC = 0.9)
				M: 55 to 170 UL;
				Athlete Reference Ranges
				F: 47 to 513 UL
				M: 82 to 1083 UL
SkM	Myo-globin	Serum, plasma or capillary (earlobe or finger)	Myocardial damage, glutamine ingestion, kidney disease	M: <85 ng/mL	High mechanical or metabolic load	Good reproducibility (ICC: 0.75)
SkM	Lactate	Capillary (earlobe or finger), whole blood or plasma	Carbohydrates, collection site, protocol	0.3 to 1.5 mmol/L	High mechanical or metabolic load (high glycolytic flux)	Good reproducibility (ICC: 0.75 - 0.99)
Immune	Leuko-cytes	Whole blood	Inflammatory conditions (e.g., infections, chronic inflammation, injuries)	4 to 11 10⁹ L	Infections and inflammation	Moderate reproducibility (ICC: 0.51 - 0.74)
Metabo-lism	Urea	Serum, plasma or capillary (earlobe or finger)	Protein and fluid intake, sweat, plasma volume and lean mass	F: 4 to 6 mmol/L	Protein catabolism	N/A
				M: 5 to 7 mmol/L
				Blood nitrogen: 8 to 26 mg/dL
Inflamma-tion	CRP	Capillary (finger), serum, whole blood or plasma	Inflammatory conditions, acute and chronic diseases, and diet	< 10 mg/dL	Inflammation induced by exercise, infections or non-infectious diseases	Moderate reproducibility (ICC: 0.71)

Carbohydrate recommendation	Information about physical exercise	Observations, effects and references
3-5 g/kg/day	Low intensity exercises	Adequate recovery of muscle glycogen over time, respecting the volume and intensity of physical exercise. Consider demands related to changes in body composition and health status. Finally, respect sociocultural aspects to choose the best carbohydrate food source for each individual⁵⁵^,¹²⁴^,¹³².
5-7 g/kg/day	Moderate intensity exercise (~ 1 h/day)
6-10 g/kg/day	Endurance Exercises (~ 1 - 3h per day) - moderate to high intensity
8-12 g/kg/day	High training duration > 4-5 h per day - moderate to high intensity
Moments close to physical exercise
Carbohydrate loading	8-12 g/kg/day 24 - 48 before the competition	Consider gastrointestinal tolerance when increasing carbohydrate intake (e.g., the day before a race) because it may be an unusual amount for the athlete.
		Consider the relevance of this recommendation, which will probably be higher in long-duration exercise (> 90 min).
		Clinical studies evaluating this type of strategy are scarce; its use is based on the concept that increasing glycogen stores before a competition is essential for physical exercise that may be limited by muscle glycogen.
Before physical exercise	1 - 4 g/kg of body mass, 1 - 4 h before starting physical exercise	Endurance physical exercise
	Evaluate practical aspects and potential gastrointestinal issues	ES: 0.2; 95% CI: 0 - 0.30
		Short-term physical exercise (< 60 min)
		ES: 0.0; 95% CI: -0.3 - 0.2
		Long-term physical exercise (≥ 60 min)
		ES: 0.3; 95% CI: 0.1 - 0.5
		Strength physical exercise
		Mean ES: 0.61; 95% CI: 0.11 - 1.11
		Subgroup analysis
		> 45 min ES: 1.02; 95% CI: 0.07 - 1.97
		< 45 min ES: 0.23; 95% CI: -0.21 - 0.67
		Fasting > 8 h ES: 0.39; 95% CI: 0.06 - 0.72
		Fasting < 8 h ES: 0.76; 95% CI: -0.19 - 1.71
Effect of carbohydrate type before physical exercise	Slow glycemic response vs. fast glycemic response	Time trial exercises
		ES: -0.18; 95% CI: -0.58 - 0.22 (no effect)
		Submaximal exercises + time trial tests
		ES: -0.17; 95% CI: -0.55 - 0.22 (no effect)
		Exercises until voluntary exhaustion
		ES: -0.36; 95% CI: -0.93 - 0.22 (no effect)
During physical exercise
Mouthwash		Mean power: ES: 0.25; 95% CI: 0.04-0.46
		Physical exercise time: ES: -0.13; 95% CI: -0.36-0.10
		Maltodextrin: ES: 0.15; 95% CI: 0.04-0.27
		10 s rinsing: ES: 0.22; 95% CI: 0.05-0.39
Consumption during physical exercise	Considering all volumes (time) of physical exercise.	Mean ES 0.43; 95% CI: 0.35-0.51¹⁵²
		ES cycling: 0.47; 95% CI: 0.38 - 0.57
		ES running: 0.35; 95% CI: 0.17 - 0.52
		The effect of carbohydrate intake during physical exercise is positive and may vary between different types of sports and by level of physical fitness; however, it remains stable regardless of age or biological sex.
During physical exercise (varying volumes of physical exercise)	< 1 h	ES: 0,19; 95% IC: -0,16 - 0,55
	< 1 h	Non-significant effect for short workouts, regardless of intensity.
	1 - 2h	ES: 0.41; 95% CI: 0.27 - 0.55
	2 - 4 h	ES: 0.51; 95% CI: 0.40 - 0.62
High amounts of carbohydrates during physical exercise	80 - 100 g/h	ES: 0.82; 95% CI: 0.31 - 1.34
High amounts of carbohydrates during physical exercise	> 100 g/h	ES: 0.17; 95% CI: -0.23 - 0.57
After physical exercise	Time to next exercise session < 8h	Carbohydrate consumption should occur immediately after the end of physical exercise to optimize the recovery of glycogen stores.
		1.0 -1.2 g/kg/h (23.5 mmol/kg/h; 95% CI: 19 - 27.9 mmol/kg/h)
		More frequent consumption can optimize glycogen recovery.
	Between 0 - 4 h	Carbohydrate amounts between 1 and 1.2 g/kg/h, ingested in a fractional manner, contribute to the rapid recovery of muscle glycogen. Working with beverages that offer glucose polymers with a rapid glycemic response and meals that are easy to empty can facilitate the total intake of carbohydrates and, consequently, glycogen recovery.
	For muscle glycogen recovery in 24h	To recover muscle glycogen in 24 h, the energy demand imposed by physical exercise must be considered, as well as the intensity that regulates glycogen depletion and glucose oxidation.
		Moderate-intensity exercise: 5 to 7 g/kg/24h
		High-intensity exercise: 6 to 10 g/kg/24h
		Extreme-intensity exercise: 8 to 12 g/kg/24h
		During longer recovery periods (> 6 h), when the athlete is able to ingest energy and carbohydrates adequately, the food organization must be conducted in partnership with the athlete, with the aim of facilitating carbohydrate ingestion. Furthermore, in these circumstances, there is no relevance in the fractionation or the form of presentation (liquid or solid) as long as the total amount is reached.
	Combine proteins and carbohydrates after physical exercise to recover muscle glycogen.	Adding protein to a carbohydrate-containing drink/meal does not optimize muscle glycogenesis (ES: 0.4; 95% CI: -2.7-3.4), unless carbohydrate intake is below the recommendation (<0.8 or between 0.8 and 0.9 g/kg); in this case, adding protein (0.3 to 0.4 g/kg) may promote positive effects on glycogenesis.
		It is a common practice (culturally) to ingest different macronutrients throughout meals, especially after physical exercise. However, attention should be paid when the athlete mistakenly gives preference to protein over carbohydrates, which may result in inadequate recovery of muscle glycogen.

location_on

Universidade Estadual de Maringá Avenida Colombo, 5790 - cep: 87020-900 - tel: 44 3011 4315 - Maringá - PR - Brazil
E-mail: revdef@uem.br

rss_feed Acompañe los números de esta revista en su lector de RSS

[TFN1] Source: Adapted from Mountjoy et al.⁴⁸^,⁴⁹