Gastrointestinal distress and endurance athletes: - PowerPoint Presentation

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Gastrointestinal distress and endurance athletes:What do carbohydrates have to do with it?

Renee

Korczak

Ph.D., RDN, CSSD, LD

Assistant Professor

Department of Clinical and Preventive

Nutrition Sciences

Email:

rk919@shp.rutgers.edu

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Disclosures

Consultant Registered Dietitian, Premier Nutrition, LLC

Remote faculty, Department of Food Science and Nutrition, University of Minnesota

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Objectives of Today’s Presentation

Define gastrointestinal distress (GI), causes of GI distress, and prevalence rates in endurance athletes

Detail GI physiology during exercise and adaptations that occur during high-intensity training

Describe the role of carbohydrates in endurance training as well as its relationship to GI distress

Describe current nutritional approaches to help manage GI distress

Explain practical techniques that can help prepare the gut for competition

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What is GI Distress?

AGA Governing Board Approves New Definition of Digestive Health. American Gastroenterological Association, 2013.

American Gastroenterological Association, 2013.

Multiple definitions exist in the scientific literature

“A GI problem that can impair performance and possibly prevent athletes from winning or finishing a race”

(de Oliveira EP and Burini RC, 2014)

“Exercise-induced and associated with lower abdominal symptoms such as diarrhea, bloating, abdominal pain, and flatulence”

(Lis, Stellingwerf, Kitic, Fell and Ahuja, 2017)

“A pervasive problem in ultra-distance runners including symptoms such as nausea, vomiting, abdominal cramping, and diarrhea-sometimes bloody

”

(Stuempfle, Hoffman and Hew-Butler, 2013)

Free images provided by unsplash.com and Creative Commons

Photo credit to

Waldemar

Brandt

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GI Distress is a Problem among Endurance Athletes, especially Runners

Stuempfle KJ, Hoffman MD, Hew-Butler T

. Int. J

Sp

Nutr Ex Metab. 2013; 23(2): 103-9.Lis D, et al. Med & Sci Sports Ex 2018; 50(1):116-123.Ten Haaf DS, et al. BMJ

2014;4(8): e005780.

Did you know?

37-47%

of runners participating in races between 67-161 km reported nausea, vomiting, cramping and diarrhea

A survey of marathon runners found that up to

26% reported diarrhea and up to 54%

reported fecal urgencyThe prevalence of exercise-induced GI symptoms in runners vary from 25-83%

during or after a run

Free images provided by unsplash.com

Photo credit to Ben Stern

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Proposed Framework for GI Distress

Spiegel BR et al.

Am J Gastroenterol

2011; 106(3): 380-5

.

*Permission obtained to use image from lead author. Free image provided by Creative Commons.

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GI Distress Profiles among Active Individuals Vary

Spiegel BR, et al.

Am J Gastroenterol

2011; 106(3): 380-5.

Patient 1

Patient 2

Patient 3

Patient 4

GI physical

symptoms

(pain, gas/bloating,

etc.)

GI cognitions

(loss of control, embarrassment, stigma)

GI emotions

(depression, anxiety, etc.)

*Permission obtained to use image from lead author

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Pre-existing GI ConditionsIrritable bowel syndromeTraveler’s diarrheaMalabsorption syndromes

Pancreatic disease

Perianal disease-fistulae, hemorrhoids

Medications

Inappropriate use of non-steroidal anti-inflammatory drugs (NSAIDs)

May contribute to GI bleedingMisuse has also been associated with gastritis and peptic ulcer diseaseHo, GW. Current Sports Med Reports

2009; 8(2): 85-91.

What Causes GI Distress?

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MechanicalJostling of intestinal organs due to continuous movementBruising of the stomach, abdomen or cecum

Posture in certain sports (ex: forward orientation of a cyclist

abdominal pressure)

Ischemic

Splanchnic vasoconstriction and hypovolemia

Ischemic colitisNutritionalDehydration/electrolyteType and amount of carbohydrate in the dietHypertonic sports drinks & gelsHigh-fiber/high-fat dietCaffeine

What Causes GI Distress?

(contd.)

O’Connor AM, et al.

Int

J Sports Med 1995; 16(5): 283-7.

De Oliveira EP, Burini RC. Nutrients 2014; 6(10): 4191-9.

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Other Factors that Contribute to the Occurrence of GI Symptoms

Type of exercise

Prevalence is higher during running vs. cycling

Peters HP, et al.

Am J Gastro

1999; 94(6): 1570-81.

Duration of exercise

Longer the duration, higher the prevalence

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GI Physiology During Exercise

Blood flow shifts

away

from the GI tract towards the active muscles and lungs

Decreased gut blood flow relaxes gut tone and may increase the passage of colonic contents into the rectum

Gastric emptying rate is reduced

Mental stresses of competition + vigorous exercise reduce splanchnic blood flow by

50-80%

A

75%

reduction in blood flow with long duration activity causes portions of the intestine to lose functional integrity and increase membrane permeability

Increased permeability initiates inflammatory events that alter gut structure and function, may result in bloody stool

Brouns F, Beckers E.

Sports Med

1993; 15(4): 242-57.

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Clark and Match.

J Intl. Soc. of Sports Nut

. 2016;13:43.

GI Physiology During Exercise,

contd

.

The redistribution of blood flow away from the intestines + thermal damage to the intestinal mucosa can cause intestinal barrier disruption followed by an inflammatory response

Increased production of pro-inflammatory cytokines and intestinal permeability is made worse by reactive oxygen species (ROS) and altered gut-microbiota composition (

dysbiosis

)

GI tract responds to stress by releasing hormones such as GABA, NPY and dopamine; these can all cause GI disturbances and an increase in unpleasant GI symptoms

*Permission obtained to use image from lead author

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Common GI Symptoms Experienced by Endurance Athletes

Peters HP, et al.

Am J Gastro

1999; 94(6): 1570-81.

Upper GI Symptoms

NauseaVomitingBelching

Heartburn

Chest pain

Lower GI Symptoms

Bloating

Cramps

Gas

DiarrheaRectal bleedingConstipation

Symptoms can adversely impact performance and the health of athlete

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Overview of Current Methods to Assess GI Complaints Among Athletes

Peters HP, et al.

Am J Gastro

1999; 94(6): 1570-81.

*Permission obtained to use image from lead author

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Peters HP, et al.

Am J Gastro

1999; 94(6): 1570-81.

Overview of Current Methods to Assess GI Complaints Among Athletes,

contd.

*Permission obtained to use image from lead author

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Peters HP, et al.

Am J Gastro

1999; 94(6): 1570-81.

Overview of Current Methods to Assess GI Complaints Among Athletes,

contd.

*Permission obtained to use image from lead author

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Carbohydrates, Exercise and GI Distress

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Role of Carbohydrates for Sports PerformanceProvides a key fuel for the brain and central nervous system

Substrate for muscular work

Provides a greater yield of ATP over other macronutrients

When carbohydrate availability is high, sustained or intermittent high-intensity exercise is enhanced

Position of the Academy of Nutrition and Dietetics, Dietitians of Canada and ACSM: Nutrition and Athletic Performance 2016; 116(3): 501-528.

Free image provided by Creative Commons

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Summary of Guidelines for Carbohydrate Intake

Type of Exercise

Timing

Carbohydrate Targets

During brief exercise

<45 minutes

Not needed

During sustained

high intensity exercise

45-75 minutes

Small amounts including mouth rinse

During endurance

exercise including stop and start sports1-2.5 hours30-60 g/hour

During ultra-endurance exercise

>2.5-3 hours

Up to 90 g/hour

Position of the Academy of Nutrition and Dietetics, Dietitians of Canada and ACSM: Nutrition and Athletic Performance 2016; 116(3): 501-528.

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Why are some Carbohydrates troublesome for GI Distress?Some carbohydrates are high in FODMAPs

FODMAPs are a group of short-chain carbohydrates that are rapidly malabsorbed in the small intestine and increase colonic fluid and gas

A diet rich in FODMAP containing foods may trigger or amplify unpleasant GI symptoms including bloating, flatulence, abdominal pain, loose stool or diarrhea

F

ermentable

Oligosaccharides

D

isaccharides

M

onosaccharides

AndPolyols

Lis D, et al. Intl J Sports Nut and Ex Metab 2016; 26: 481-487.

Some High

FODMAP Containing Foods

Cow’s milk

Ice cream/yogurt

Wheat

Apples

Ripe

bananas

Pear

Black beans

Kidney/lima beans

Cashews

Fruit juices

Artichokes/onions

Asparagus/mushrooms

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High FODMAP Foods and Alternatives

High polyols-sorbitol

Brown sugar, maple syrup, stevia

High lactose-regular cow’s milk, yogurt, soft cheese

Lactose-free milk and yogurt, hard cheese

High fructan galacto-oligosaccharides-dates, honey, wheat-based breads and barsDried kiwi, maple syrup, wheat-free barsHigh fructose-apples, watermelon, cherriesBlueberries, pineapple, honeydew lemon

Low FODMAP: A novel tool to prevent GI problems- https://www.mysportscience.com/single-post/2017/09/22/Low-FODMAP-A-novel-tool-prevent-GI-problems

. Accessed April 23, 2020

.

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Diagnosing GI Issues in Athletes

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Case Scenario

A 36-yr.old male comes to your office 1 day after finishing a marathon. He reports no issues during the race and no issues immediately after the race. During the evening however, he noted one episode of bloody stool. He noted no other pain or blood stool.

No prior GI history

No use of medications including NSAIDs

One episode of stool was mixed with bright red blood streaks

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Diagnosing GI Issues in Athletes

Exclude other causes of GI issues (ex: IBS/IBD, GI cancer, Diverticular disease, Infectious diarrhea, etc.)

Those with pre-existing GI conditions may worsen with intense exercise

Thorough history and physical examination must be done

Labs and testing where appropriate (Food allergy intolerance workup, stool studies, colonoscopy for older athlete, etc.)

Ask about the onset, amount, duration, frequency color and consistency of bowel movements

Thoroughly investigate overall nutrition and supplement use

Ask about any changes in training

Come up with a nutrition plan!

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Treatment

Need a diagnosis

Modify training plan

If no bleeding, initially reduce training for 1-2 weeks and then observe for resolution of symptoms

Build recovery days into plan

Train with a high carbohydrate diet that minimizes high FODMAP containing foods if troublesomeConsume carbohydrates during exercise to help train the gut, improves absorption and oxidation of carbohydrate

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Overview of Approaches to HelpManagE GI Distress

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Approaches to Help Manage GI Distress-

Use of Multiple CHO Transporters

De Oliveira EP and Burini RC.

Nutrients

2014; 6(10): 4191-9.

Glucose transport across the brush border occurs by sodium-dependent glucose transporter (SGLT1)

Fructose is absorbed by GLUT5

Recommend consumption of multiple transporters of carb (glucose + fructose)

Increases gastric emptying and enhances fluid delivery while minimizing GI symptoms

Still NO consensus of ideal glucose: fructose ratio to prevent GI problems

*Permission obtained to use image from lead author

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Carbohydrate Mouth Rinse

Approaches to Help Manage GI Distress,

contd.

De Oliveira EP and Burini RC.

Nutrients

2014; 6(10): 4191-9.

:

*Permission obtained to use image from lead author

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Approaches to Help Manage GI Distress,

contd.

Enteric Coated Peppermint Oil Capsules

*Active ingredient L-menthol

Benefits

Normalizes orocecal transit time

Scientific evidence supports use of peppermint oil to treat IBS

ACG calculated a

50%

probability of improving symptoms of IBS

Chey WD.

Gastroenterol Hepatol

2017; 13(2 S1): 1-16.

Free images provided by Creative Commons

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Approaches to Help Manage GI Distress, contd.

Cash BD, et al.

Dig Dis

Sci

2016; 61(2): 560-571.*Permission obtained to use image from lead author

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Low FODMAP as a Preliminary Strategy to Reduce GI Distress in Athletes

High FODMAP Diet=

41.4 g

total

Low FODMAP Diet= 8.1 g total

Lis DM, et al.

Med & Sci in Sports Exercise

2018

; 50(1):116-123.

*Permission obtained to use image from lead author

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Low FODMAP as a Preliminary Strategy to Reduce GI Distress in Athletes, contd.

Lis DM, et al.

Med & Sci in Sports Exercise

2018

; 50(1):116-123.

ResultsSmaller AUC for daily GI symptoms 6 days during the LFOD vs. HFOD, p=0.003.

Flatulence, urge to defecate, loose stool and diarrhea were the daily GI symptoms that were lower during the LFOD, p<0.05 for all.

Short-term FODMAP reduction may be beneficial to minimize daily GI symptoms in runners with distress.

*Permission obtained to use image from lead author

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Results of a Low FODMAP Diet in Patients with Diarrhea Predominant IBS (IBS-D)

Chey WD

Gastroenterol Hepatol

2017; 13(2 S1): 1-16.

Eswaran SL et al.

Am J Gastroenterol

2016; 111(12): 1824-1832

.

*Permission obtained to use image from lead author

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Fiber and GI Distress

Clark and Match.

J Intl. Soc. of Sports Nut

. 2016;13:43.

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Preparing the Gut for Competition

Tips for Preparing the Gut for Competition

1. Get fit and acclimatized

2. Stay hydrated & practice

your hydration strategy during training

3. Avoid

over-nutrition before and during exercise

4. Limit high-energy, hypertonic

foods and drinks (7-10% CHO)

5. Avoid

high-residue and high-fiber foods before exercise

6. Avoid the use of NSAIDs, alcohol,

caffeine, antibiotics, and supplements before and during exercise

7. Urinate and defecate prior to exercise

Ho G.

Curr. Sports Med. Rep

. 2009; 8(2): 85-91.

Murray R.

Curr. Sports Med. Rep

. 2006; 5: 161-164

.

Free image provided by Creative Commons

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FODMAP Resources for Healthcare ProfessionalsMONASH University Offers:

Information sheets for HCPs

FODMAP Diet Booklets

Recipes

Online training courses

Dietitian directory

www.monashfodmap.com

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Scientific Gaps

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Future Research Needs

Development of a

validated

and gender specific questionnaire or tool to assess common GI symptoms in athletes before, during and after training or participation in an athletic event

Development of a standard definition for GI distress that clearly identifies symptoms included in the definition

Standard definition should be widely adopted by the scientific community

Free image provided by Creative Commons

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Key Messages

GI distress is a multi-faceted problem that affects both male and female endurance athletes including runners, cyclists and triathletes

A standard definition for GI distress does not yet exist, however, the symptoms described in the literature are similar to symptoms associated with other GI conditions such as IBS

Nutritional approaches to manage symptoms of GI distress include the use of multiple carbohydrate transporters, low FODMAP diet, mouth rinses, peppermint oil, along with appropriate timing of fiber ingestion, but much more research is needed and aligned with dietetic professionals and the medical community

The gut should be properly prepared for competition to avoid GI distress and other GI problems

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References

Banfi

G. Pepsinogens and GI Symptoms in Mountain Marathon Runners

Int. J. Sports Med

. 1996; 17: 554-558.

Cash BD, et al. A novel delivery system of peppermint oil is an effective therapy for IBS symptoms Dig Dis Sci 2016; 61(2): 560-571.Chey WD. Symposium Report: An Evidence-Based Approach to IBS and CIC: Applying New Advances to Daily Practice Gastroenterol Hepatol 2017; 13 (S2): 1-16.

Clark A and Mach N. Exercise-induced stress behavior, gut-microbiota-brain axis and diet: a systematic review for athletes. J

. of the Intl. Society of Sports Nut.

2016; 13:43.

De Oliveira EP and Burini RC. Carbohydrate-Dependent, Exercise-Induced GI Distress

Nutrients 2014; 6: 4191-4199.Eswaran Sl, et al. A Randomized Controlled Trial Comparing the Low FODMAP Diet vs. Modified NICE Guidelines in US Adults with IBS-D. Am J Gastroenterol

2016; 111(12): 1824-1832.Ho G W.K. Lower GI Distress in Endurance Athletes Curr. Sports Med Rep. 2009; 8(2): 85-91.Lis DM, et al. Low FODMAP: A Preliminary Strategy to Reduce GI Distress in Athletes

Med. & Sci in Sports & Exercise 2017.

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References, contd.

Murray R. Training the Gut for Competition

Curr. Sports Med Rep.

2006; 5:161-164.

O’Connor A.M., et al. Circulating GI Hormone Changes in Marathon Running

Int. J. Sports Med. 1995; 16: 283-287.Peters H.P.F., et al. GI Symptoms in Long-Distance Runners, Cyclists and Triathletes: Prevalence, Medication and Etiology. The Am. J. Gastroenterolgy 1999.Position of the Academy of Nutrition and Dietetics, Dietitians of Canada and ACSM: Nutrition and Athletic Performance 2016; 116(3): 501-528.

Spiegel B, et al. Understanding gastrointestinal distress: A framework for clinical practice.

Am J Gastroenterol.

2011; 106(3): 380-385.

Stuempfle

KJ. Hoffman MD, Hew-Butler T. Association of GI Distress in Ultramarathoners with Race Diet. Int. J. of Sports Nutrition and Exercise Metabolism 2013; 23: 103-109.Ten Haaf D.S., et al. Nutritional indicators for GI Symptoms in Female Runners: the Marikenloop study.

BMJ Open 2014.

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