Gluten-related conditions vs. gluten sensationalism …low FODMAPs to Dana Lis PhD, RD, IOC Dipl Sport Nutrition, CSSD Post Doctoral Researcher Neurobiology, Physiology & Behavior, UC Davis treat GI syndrome www.summitsportsnutrition.com
When LPS increased ↑Inflammation ↑ HR ↑ Pyrogen (fever) ↑ Cortisol ↑ Body temperature ↓Heat tolerance
GI health a major concern • 30-90% of athletes report GI symptoms (nausea, loose stool vomiting, bloating) • Detrimental to performance/impaired quality of life • One of the most diagnosed illnesses at major international sporting events
Causes of Mechanical Physiological GI • Jostling during running • Reduced blood Syndrome • Bike position flow in Athletes • Swallowing air during • Stress hormones • Heat swimming Nutritional • High fat, protein • CHO source, amounts, FODMAPs • Gluten /wheat/wheat constituents? • Fiber • Dairy (lactose?) • Energy balance, hydration Adapted from www.mysportscience.com Adapted from www.mysportscience.com de Oliveira, E.P. and Burini, R.C. The impact of physical exercise on the gastrointestinal tract. Current Opinion in Clinical Nutrition and Metabolic Care, 2009.
n GFD>50=GFD more than 50% of the time n GFD<50=GFD less than 50% of the time 41% of nonceliac athletes eat gluten-free at least 50% of the time � �
So … we testing a gluten-free diet 7 day GCD or 7 day GCD or 10 day washout GFD GFD 350 325 Work (kJ)/15-min 300 275 250 225 200 175 5 4 3 2 1 0 GCD GFD
Gastrointestinal Symptoms GCD GCD Perceived well-being : DALDA GFD GFD scores of “worse than normal” between the GCD (26±19) and GFD (27±18) were not different (p=0.26). P>0.15 No significant differences in GI symptom rating during exercise or daily, or other symptoms, between a GCD and GFD
Intestinal Permeability and Inflammation IL-1 β , IL-8, IL-10, IL-15, TNF- α (all p>0.05) P>0.05 No significant difference in intestinal injury or systemic inflammation between a GCD and GFD
potential negative effects potential positive effects DIETARY ADEQUACY food availability unnecessary food conscientious eating balanced eating restriction energy/nutrient intake fruit, vegetable and risk ED, isolation gluten-free whole grains FODMAP intake WELLBEING PERFORMANCE intestinal permeability beneficial microbiota GI distress UCP-1 adiposity oxygen consumption inflammation adiposity COMPETITIVE PERFORMANCE performance performance via GI distress suboptimal fueling or belief effect confounding factors Figure 1. Schematic overview of the potential negative or positive effects/interactions of gluten in athletic performance or health performance. ED=eating disorder, UCP-1=uncoupling protein, GI=gastrointestinal, FODMAP=Fermentable oligosaccharides, disaccharides, monosaccharides and polyols
FODMAPs
Athletes avoid high FODMAP foods to reduce GI Symptoms 55% eliminated at least 1 high FODMAP food (n=501 of 910) 83% reported symptom improvement
Case Study: Utilizing a Low FODMAP Diet to Combat Exercise-Induced GI Symptoms Habitual Daily GI Low FODMAP Daily GI Habitual Exercise GI Low FODMAP Exercise GI
Daily GI Symptom Scores 82% had a smaller AUC for b a 100 120 HFOD Incremental AUC for Daily GI Symptoms daily GI symptoms LFOD 110 80 * (n=11, *p<0.05) Incremental AUC for GI Symptoms over 6-days 100 60 90 40 • Flatulence 80 20 • Urge to defecate 70 0 • Loose stool HFOD LFOD 60 • Diarrhea 50 40 50% experienced GI 30 symptoms during 20 prescribed running 10 0 1 2 3 4 5 6 7 8 9 10 11 c 20 Participant 19
Typical race feed station
High FODMAP foods in an athletes diet High fructose Apples, cherries, watermelon, dates, honey High fructans Wheat-based breads, bread products, some energy bars Galactooligosaccharides (GOS) Beets, some energy bars High Lactose Milk, some yogurt, some cheese High polyols Protein bars, cherry juice, sugar free gum
Clinical take- away’s • No evidence that GF is beneficial or Practical take- away’s harmful for nonceliac athletes. • Better diagnostics for NCGS may • Potential belief effect in the benefits improve GFD prescription. (erogenic?) of gluten-free. • Healthy athletes with GI symptoms • FODMAP reduction may be a novel and may benefit from FODMAP efficacious strategy to reduce GI restriction around/during strenuous symptoms in heathy athletes with exercise exercise-associated GI syndrome. • Low FODMAP predicted to be the next gluten-free market boom. • Proper education is key.
Sport Nutritionist’s Intervention Matrix for Treatment of Exercise-Associated GI Symptoms with FODMAP Focus Athlete with persistent exercise and / or daily GI distress GI issues occurring regularly and not Yes exercise-associated Seek medical diagnosis for possible medical condition such as FGID, food intolerance / allergy, CD, IBD and NCGS with the aim to correct GI symptoms Follow appropriate medical workup • Clinical diagnosis of medical condition such as CD, IBD, NCGS, FGID Strategies to Investigate to Minimize for GI symptoms Yes Dietary factors Medical diagnosis excluded. Yes • Train fluid and CHO intake, practice and adapt/individualize fuelling strategies , optimize Athlete has desire to follow a GFD Confirmed exercise-associated GI nutrition symptoms • Determine athlete rationale (e.g. potential risk for restrictive or disordered eating • Consider and manipulate fiber, protein, fat intake leading into and during exercise practices) Experiment and practice with CHO blends (fructose:glucose) • • Present evidence-based dietary advice • Determine individual food trigger(s) and determine if “real” or “perceived” trigger Allow athlete to make informed decision • Non-dietary factors Symptoms do not resolve Investigate Provide individualized nutrition support to potential risk of nutritional inadequacy, • Consider non-dietary trigger(s): mechanical impact, physiological stress, environmental • FODMAPs psychosocial stress or food security conditions and travel FODMAP manipulation Personality traits, life stress and coping mechanisms • Symptoms resolve • Investigate FODMAPs as potential main dietary trigger(s) Trial a 3-day low FODMAP diet leading into strenuous training or race that usually triggers GI distress Continue to refine nutrition strategy Low FODMAP diet will be used infrequently (a few times per race season) Low FODMAP diet will be used frequently (more than once per month) • If there is no risk of long-term nutritional inadequacy, then likely okay to adhere to a strict low FODMAP diet A dietary elimination and reintroduction to determine specific FODMAP food triggers • for 3-days prior to strenuous exercise or race Nutrition plan to support minimal unnecessary food restriction • • Nutrition plan individualised to minimise risk of suboptimal nutrient intake Practical Application Low FODMAP alternatives Typical high FODMAP pre- or during exercise foods or fuels to avoid Gluten-free or low FODMAP breads, pasta, bagels, cereals, garlic infused oil, almonds, peanuts, walnuts, ½ cup canned • • Fructans/GOS: Wheat, rye or barley based bread, bagels, pasta, cereals, garlic, onion, cashew, pistachio, baked beans, legumes drained lentils, ¼ cup canned drained chickpeas Excess fructose: Apple, pears, watermelon, dried fruit, honey • • Excess fructose: 1/3 sugar ripe banana, rockmelon, honeydew, orange, pineapple , blueberries, maple Lactose: Cow’s milk, yogurt, cream, ice cream • • Lactose: Lactose-free milk/yogurt, hard cheese, cottage cheese, sorbet • Polyols: Apricots, peaches, plums, prunes, chewing gum • Polyols: Raspberries, strawberries, kiwi fruit • Sports foods such as sports drinks, gels, bars and protein/recovery drinks containing excess fructose, dried fruit, dates, FOS or Sports foods with glucose, maltodextrin, maple syrup, sweetener instead of polyols • inulin, polyols such as sorbitol, mannitol
• https://www.monashfodmap.com
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