Gastric Distress - How to avoid it.
Endurance athletes regularly suffer from GI distress during endurance events. (1) This article will discuss the nutritional causes and focus on strategies to help mitigate these.
GI distress is a highly individualised problem that many endurance athletes face when training and racing. (2) To maintain high levels of performance during endurance events, especially those of longer duration and higher intensity there is generally a need for significant volumes of fuel in the form of carbohydrate (CHO) and fluid. (3, 4) These requirements are in many instances the very cause of GI distress. Nutritional factors that promote GI distress are usually resultant from strategies aimed at providing the necessary CHO and fluid to ensure a high level of performance. By implementing these strategies athletes can ingest large highly concentrated volumes of CHO and inappropriate quantities of fluid which can slow Gastric Emptying (GE) and ultimately lead to GI distress. (5) Symptoms can be alleviated by executing specific individualised nutrition and hydration strategies. (6) including improved utilisation of lipids (fat) meaning less need for large quantities of CHO to maintain performance reducing the chance of slowed GE, residual CHO in the gut and the symptoms of GI distress related to this. (8) As with many other nutritional issues, individual trialling is the best way to identify effective solutions. (7)
GI distress is common in endurance athletes as they strive to maintain energy balance and hydration status to perform at their peak during training and racing. (8) At worst it could mean not completing an event but more often leads to a sub optimal performance. The causes are multi factorial and can be broadly summarised as; physiological, a reduction in the blood flow to the gut, mechanical, movement of internal organs and nutritional, made up of a number of factors. (2, 7) Symptoms are grouped into upper abdominal; reflux/heartburn, belching, stomach pain/cramps, vomiting, nausea and lower abdominal; intestinal/lower abdominal cramps, flatulence, urge to defecate, diarrhoea and intestinal bleeding. (2) This article will focus on the nutritional causes of GI distress and strategies that can help reduce the likelihood of suffering.
As with day to day nutrition one glove does not fit all in endurance sports. Experimenting to find the best nutritional strategy for an individual is key. Trialling different fuels and fluids at event intensity and duration is the best approach to understand an individuals most effective nutritional strategy. (7)
Slowed GE has been linked to GI distress. (7) It is one of the major causes and various factors can contribute. Consumption of hypertonic beverages should be avoided. (9) This is because the higher concentrations of CHO slow GE, lead to residual contents in the gut and cause symptoms of GI distress. (10) Hypertonic beverages can also reduce fluid intake leading to dehydration. (9, 11) Dehydration in excess of ~4% of body weight can lead to slowed GE. (12-14) A solution is the use of isotonic carbohydrate and electrolyte containing beverages which have been shown to support more rapid and prolonged GE. (15) Ensuring adequate hydration early in events is also key in avoiding dehydration and its side effects. (14) Because of the amount of fuel required to maintain peak performance in endurance events it is important to maintain a constant supply of CHO to the working muscles. Due to this many athletes ingest quantities and concentrations above their upper limits of processing ability. Oxidation rates of CHO fuels utilising multiple transporters are greater than those using single transporters so are preferential when building strategies for CHO ingestion. (16, 17) By taking this approach oxidation efficiency and rates of GE are improved reducing the chances of slowed GE and residual CHO in the gut, a key causation of GI distress. (6, 18)
A steady supply of both fluid and CHO are keys to maintaining optimal performance in endurance events. (19) To enable best possible performance athletes should ingest levels relevant to sustained performance for themselves. Absorption is dependant on maximal rates of GE being achieved and maintained. It has been shown that maintaining a proper balance of fluid, sodium and potassium plays a role in optimal GE in an individual. (9, 20, 21) To identify an appropriate hydration strategy and supplementation levels of sodium and potassium individuals should experiment in various conditions to understand fluid and minerals lost through sweat and therefore replacement requirements. By implementing the correct replacement strategy GE will be maintained helping to avoid potential GI distress. (8)
If an athlete could utilise lipids (fat) as a fuel source at higher intensities during endurance events it stands to reason that they would be less reliant on CHO. By building metabolic flexibility athletes could up regulate their fat metabolism during exercise thus sparing CHO. This would mean less need for large quantities of CHO to maintain performance reducing the chance of slowed GE, residual CHO in the gut and the symptoms of GI distress related to this. (8)
To some extent the gut is a trainable organ so training it to process higher concentrations and larger volumes of CHO and fluid during endurance events could be beneficial in reducing the instances of GI distress. (22, 23) By experimenting with specific volumes of CHO and fluid required during longer training sessions this adaptation could be achieved and ultimately help mitigate the possibility of GI distress. (23)
GI distress is common in athletes who compete in and train for endurance events. A number of the causal factors can be attributed to nutritional strategies put inplace in an effortt to supply the required levels of CHO and fluid to maintain peak performance throughout an event. By individual trialling athletes can identify nutritional practices and strategies to help mitigate the possibility of suffering.
Notable non nutritional causes of GI distress include;
• Events longer in duration and higher in intensity lead to reduced splanchnic blood flow. This means the gut receives reduced amounts of blood which adversely impacts GE and can cause GI distress. (24)
• Training or racing in hotter environments causes blood flow to be directed away from the gut to aid in body temperature regulation. This in turn leads to slowed GE which is a key cause of GI distress. (12)
• A history of gastrointestinal issues such as irriatable bowed syndrome could indicate an individuals predisposition. (4)
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) used by those with a history of GI issues can induce GI distress during endurance events and should be avoided. (7, 9)
1. Rehrer NJ, Brouns F, Beckers EJ, Frey WO, Villiger B, Riddoch CJ, et al. Physiological changes and gastro-intestinal symptoms as a result of ultra-endurance running. Eur J Appl Physiol Occup Physiol. 1992;64(1):1-8.
2. Oliveira E, Jeukendrup A. Nutritional recommendations to avoid gastrointestinal complaints during exercise. Sports Sci Exch. 2013;26(114):1-4.
3. Jeukendrup AE, Jentjens RLPG, Moseley L. Nutritional Considerations in Triathlon. Sports Medicine. 2005;35(2):163-81.
4. Pfeiffer B, Cotterill A, Grathwohl D, Stellingwerff T, Jeukendrup AE. The effect of carbohydrate gels on gastrointestinal tolerance during a 16-km run. Int J Sport Nutr Exerc Metab. 2009;19(5):485-503.
5. Holmes N. Fluid requirements of endurance athletes. Dostupno na: https://www researchgate net/publication/268415268_fluid_requirements_of_endurance_athl etes[Preuzeto 285 2016]. 2008.
6. Jeukendrup AE. Carbohydrate and exercise performance: the role of multiple transportable carbohydrates. Curr Opin Clin Nutr Metab Care. 2010;13(4):452-7.
7. de Oliveira EP, Burini RC, Jeukendrup A. Gastrointestinal complaints during exercise: prevalence, etiology, and nutritional recommendations. Sports Med. 2014;44 Suppl 1:S79-85.
8. Laursen PB, Rhodes EC. Factors affecting performance in an ultraendurance triathlon. Sports Med. 2001;31(3):195-209.
9. Brouns F, Beckers E. Is the Gut an Athletic Organ? Sports Medicine. 1993;15(4):242-57.
10. Pfeiffer B, Stellingwerff T, Hodgson AB, Randell R, Pottgen K, Res P, et al. Nutritional intake and gastrointestinal problems during competitive endurance events. Med Sci Sports Exerc. 2012;44(2):344-51.
11. Rehrer NJ, van Kemenade M, Meester W, Brouns F, Saris WH. Gastrointestinal complaints in relation to dietary intake in triathletes. Int J Sport Nutr. 1992;2(1):48-59.
12. Neufer PD, Young AJ, Sawka MN. Gastric emptying during exercise: effects of heat stress and hypohydration. Eur J Appl Physiol Occup Physiol. 1989;58(4):433-9.
13. Rehrer NJ, Janssen GM, Brouns F, Saris WH. Fluid intake and gastrointestinal problems in runners competing in a 25-km race and a marathon. Int J Sports Med. 1989;10 Suppl 1:S22-5.
14. Rehrer NJ, Beckers EJ, Brouns F, ten Hoor F, Saris WH. Effects of dehydration on gastric emptying and gastrointestinal distress while running. Med Sci Sports Exerc. 1990;22(6):790-5.
15. Rehrer N, Brouns F, Beckers E, Ten Hoor F, Saris W. Gastric emptying with repeated drinking during running and bicycling. International journal of sports medicine. 1990;11(03):238-43.
16. Wallis GA, Rowlands DS, Shaw C, Jentjens RL, Jeukendrup AE. Oxidation of combined ingestion of maltodextrins and fructose during exercise. Med Sci Sports Exerc. 2005;37(3):426-32.
17. Jeukendrup AE, Moseley L, Mainwaring GI, Samuels S, Perry S, Mann CH. Exogenous carbohydrate oxidation during ultraendurance exercise. J Appl Physiol (1985). 2006;100(4):1134-41.
18. de Oliveira EP, Burini RC. Carbohydrate-dependent, exercise-induced gastrointestinal distress. Nutrients. 2014;6(10):4191-9.
19. Jeukendrup AE. Nutrition for endurance sports: marathon, triathlon, and road cycling. J Sports Sci. 2011;29 Suppl 1:S91-9.
20. Hunt J, Pathak J. The osmotic effects of some simple molecules and ions on gastric emptying. The Journal of physiology. 1960;154(2):254.
21. Rehrer NJ, Beckers EJ, Brouns F, Saris WH, Ten Hoor F. Effects of electrolytes in carbohydrate beverages on gastric emptying and secretion. Med Sci Sports Exerc. 1993;25(1):42-51.
22. ter Steege RW, Van der Palen J, Kolkman JJ. Prevalence of gastrointestinal complaints in runners competing in a long-distance run: an internet-based observational study in 1281 subjects. Scand J Gastroenterol. 2008;43(12):1477-82.
23. Cox GR, Clark SA, Cox AJ, Halson SL, Hargreaves M, Hawley JA, et al. Daily training with high carbohydrate availability increases exogenous carbohydrate oxidation during endurance cycling. J Appl Physiol (1985). 2010;109(1):126-34.
24. ter Steege RW, Kolkman JJ. Review article: the pathophysiology and management of gastrointestinal symptoms during physical exercise, and the role of splanchnic blood flow. Aliment Pharmacol Ther. 2012;35(5):516-28.