conditions vs. gluten sensationalism low FODMAPs to Dana Lis PhD, - - PowerPoint PPT Presentation

Gluten-related conditions vs. gluten sensationalism …low FODMAPs to treat GI syndrome

Dana Lis PhD, RD, IOC Dipl Sport Nutrition, CSSD Post Doctoral Researcher Neurobiology, Physiology & Behavior, UC Davis www.summitsportsnutrition.com

When LPS increased ↑Inflammation ↑ HR ↑ Pyrogen (fever) ↑ Cortisol ↑ Body temperature ↓Heat tolerance

• 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

GI health a major concern

Mechanical

• Jostling during running
• Bike position
• Swallowing air during

swimming Physiological

• Reduced blood

flow

• Stress hormones
• Heat

Nutritional

• High fat, protein
• CHO source,

amounts, FODMAPs

• Gluten/wheat/wheat

constituents?

• Fiber
• Dairy (lactose?)
• Energy balance,

hydration Causes of GI Syndrome in Athletes

• nGFD>50=GFD more than 50% of the time

nGFD<50=GFD less than 50% of the time

41% of nonceliac athletes eat gluten-free at least 50% of the time

7 day GCD or GFD 10 day washout 7 day GCD or GFD

So…we testing a gluten-free diet

GCD GFD 1 2 3 4 5 175 200 225 250 275 300 325 350 Work (kJ)/15-min

GCD GFD

No significant differences in GI symptom rating during exercise or daily, or other symptoms, between a GCD and GFD

P>0.15

Gastrointestinal Symptoms

GCD GFD

Perceived well-being: DALDA scores of “worse than normal” between the GCD (26±19) and GFD (27±18) were not different (p=0.26).

Intestinal Permeability and Inflammation

No significant difference in intestinal injury or systemic inflammation between a GCD and GFD

P>0.05 IL-1β, IL-8, IL-10, IL-15, TNF-α (all p>0.05)

potential positive effects

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

conscientious eating balanced eating fruit, vegetable and gluten-free whole grains food availability unnecessary food restriction energy/nutrient intake risk ED, isolation FODMAP intake DIETARY ADEQUACY GI distress adiposity inflammation intestinal permeability beneficial microbiota UCP-1 oxygen consumption adiposity WELLBEING PERFORMANCE performance GI distress belief effect COMPETITIVE PERFORMANCE performance via suboptimal fueling or confounding factors potential negative effects

FODMAPs

83% reported symptom improvement 55% eliminated at least 1 high FODMAP food (n=501 of 910)

Athletes avoid high FODMAP foods to reduce GI Symptoms

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

1 2 3 4 5 6 7 8 9 10 11 10 20 30 40 50 60 70 80 90 100 110 120 Participant Incremental AUC for GI Symptoms over 6-days

HFOD LFOD 20 40 60 80 100

*

Incremental AUC for Daily GI Symptoms

19 20

HFOD LFOD a b c

82% had a smaller AUC for daily GI symptoms (n=11, *p<0.05)

• Flatulence
• Urge to defecate
• Loose stool
• Diarrhea

50% experienced GI symptoms during prescribed running

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

harmful for nonceliac athletes.

• Better diagnostics for NCGS may

improve GFD prescription.

• Healthy athletes with GI symptoms

may benefit from FODMAP restriction around/during strenuous exercise

• Potential belief effect in the benefits

(erogenic?) of gluten-free.

• FODMAP reduction may be a novel and

efficacious strategy to reduce GI symptoms in heathy athletes with exercise-associated GI syndrome.

• Low FODMAP predicted to be the next

gluten-free market boom.

• Proper education is key.

Practical take-away’s

GI issues occurring regularly and not exercise-associated Follow appropriate medical workup

• Clinical diagnosis of medical condition such

as CD, IBD, NCGS, FGID Seek medical diagnosis for possible medical condition such as FGID, food intolerance / allergy, CD, IBD and NCGS with the aim to correct GI symptoms

Sport Nutritionist’s Intervention Matrix for Treatment of Exercise-Associated GI Symptoms with FODMAP Focus

• Train fluid and CHO intake, practice and adapt/individualize fuelling strategies , optimize

• Consider and manipulate fiber, protein, fat intake leading into and during exercise
• Experiment and practice with CHO blends (fructose:glucose)
• Determine individual food trigger(s) and determine if “real” or “perceived” trigger

• Consider non-dietary trigger(s): mechanical impact, physiological stress, environmental

• Personality traits, life stress and coping mechanisms

Low FODMAP diet will be used infrequently (a few times per race season)

• If there is no risk of long-term nutritional inadequacy, then likely okay to adhere to a strict low FODMAP diet

for 3-days prior to strenuous exercise or race

• Nutrition plan individualised to minimise risk of suboptimal nutrient intake

Low FODMAP diet will be used frequently (more than once per month)

• A dietary elimination and reintroduction to determine specific FODMAP food triggers
• Nutrition plan to support minimal unnecessary food restriction

Medical diagnosis excluded. Confirmed exercise-associated GI symptoms Typical high FODMAP pre- or during exercise foods or fuels to avoid

• Fructans/GOS: Wheat, rye or barley based bread, bagels, pasta, cereals, garlic, onion, cashew, pistachio, baked beans, legumes
• Excess fructose: Apple, pears, watermelon, dried fruit, honey
• Lactose: Cow’s milk, yogurt, cream, ice cream
• Polyols: Apricots, peaches, plums, prunes, chewing gum
• Sports foods such as sports drinks, gels, bars and protein/recovery drinks containing excess fructose, dried fruit, dates, FOS or

inulin, polyols such as sorbitol, mannitol Low FODMAP alternatives

• Gluten-free or low FODMAP breads, pasta, bagels, cereals, garlic infused oil, almonds, peanuts, walnuts, ½ cup canned

drained lentils, ¼ cup canned drained chickpeas

• Excess fructose: 1/3 sugar ripe banana, rockmelon, honeydew, orange, pineapple , blueberries, maple
• Lactose: Lactose-free milk/yogurt, hard cheese, cottage cheese, sorbet
• Polyols: Raspberries, strawberries, kiwi fruit
• Sports foods with glucose, maltodextrin, maple syrup, sweetener instead of polyols

Athlete with persistent exercise and / or daily GI distress

Continue to refine nutrition strategy

Athlete has desire to follow a GFD

• Determine athlete rationale (e.g. potential risk for restrictive or disordered eating

practices)

• Present evidence-based dietary advice
• Allow athlete to make informed decision
• Provide individualized nutrition support to potential risk of nutritional inadequacy,

psychosocial stress or food security

• Investigate FODMAPs as potential main dietary trigger(s)

• https://www.monashfodmap.com

Acknowledgements

References

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