Running and Gastrointestinal Discomfort: Causes and Cures

by Kris Osterberg, M.S., R.D. Senior Scientist, Gatorade Sports Science Institute Many athletes have experienced symptoms of gastrointestinal (GI) discomfort. Though not the topic most people (i.e. non-runners) want to discuss at the dinner table, GI discomfort is an issue that repeatedly comes up (pardon the pun) among all endurance athletes, but runners in particular. GI discomfort may be as benign as burping or may be as show-stopping as diarrhea, but wherever you fall on the spectrum, it’s possible to reduce your risk of GI discomfort in training and racing. GI discomfort generally falls into two categories; problems from the stomach up (e.g. heartburn, burping) or, problems from the small intestine down (e.g. runner’s trots). There are medical conditions such as gastric esophageal reflux disease (GERD), colitis, and irritable bowel syndrome that cause some of these problems. These conditions are beyond the scope of this article and will not be addressed. For otherwise healthy runners who have not been diagnosed with a medical condition of the stomach or small bowel, there are principles that govern the function of these organs. If these principles are understood and adhered to, your GI tract will function smoothly. Symptoms originating from the stomach are generally related to gastric emptying (foods or fluids leaving the stomach), while issues that occur in the small intestine are related to intestinal absorption (foods or fluids absorbed into the bloodstream from the small intestine).

FACTORS THAT CONTROL GASTRIC EMPTYING:

First, let’s take a closer look at how your stomach functions. The maximal capacity of the average stomach is about 1-1.5 liters. Your stomach serves primarily as a holding tank for foods and fluids. In a healthy stomach, nothing is absorbed other than small amounts of alcohol. Some digestion of fats and proteins occurs in order to prepare the food to enter your small intestine. When the small intestine is ready to accept food from the stomach, the pyloric sphincter relaxes and allows a small amount of food to enter. So how does this relate to GI discomfort? When it comes to gastric emptying, faster is better. Slow gastric emptying causes food or fluids to slosh around in your stomach. This can cause any number of problems including sidestitches, stomach cramps, or the sensation of being bloated. Gastric emptying rate or the speed at which any food or fluid leaves the stomach is dependent upon two primary factors: energy content and volume. For example, let’s say you stop by the local coffee shop with a friend on your way to work. Your friend orders a small chocolate frappuccino with an extra shot of whipped cream. Because you’re a health-conscious runner, you order a small unsweetened green tea with an extra shot of wheatgrass. Your choice has very few calories (energy) while your friend’s choice has quite a few. Because of the calorie difference (the volume is irrelevant because both drinks were the same size) your green tea will likely empty from your stomach within 30-60 minutes while your friend will probably still be holding on to some of his beverage a few hours later. Gastric emptying rate is also influenced by the volume in your stomach. You may have heard that it’s better to chug than to sip. That’s true because when you eat or drink a large amount, your stomach must stretch to accommodate the volume. The stomach contents exert pressure which helps increase the rate at which the contents will empty from your stomach. For example, if you were to guzzle one quart

of water, the rate at which the first half of that water will exit your stomach will be greater because of the larger volume and greater pressure than the rate at which the second half will empty. Again, faster is better.

GASTRIC EMPTYING RATE AND EXERCISE:
Gastric emptying rate is not substantially affected at intensities lower than 70-75% of maximal effort or VO2MAX. That’s good news for most of your runs in which hydration is an important factor, such as during half or full marathons or long training runs. Your choice of food and fluid is an important consideration to help prevent GI discomfort during these longer efforts; for that reason, we’ll explore how these principles relate to your training. First, let’s backtrack a bit and talk about why fluid and carbohydrate are important while you exercise. Your body requires fluid to replace sweat losses and help maintain blood volume while carbohydrates fuel your muscles and brain during exercise. Carbohydrate is your muscles’ preferred fuel during moderate- to high-intensity exercise and is stored in two locations in your body in the form of glycogen: your liver, which helps control blood sugar (glucose) levels between meals, and your muscles. The carbohydrate that is stored in muscles is only used during exercise; an athlete can store 300-400 grams of carbohydrate in the muscles if they are eating a high carbohydrate diet. This is enough energy to fuel 90-100 minutes of moderate- to high-intensity exercise. If no carbohydrate is ingested during exercise to supplement the carbohydrate stored in the body, the muscles will be forced to rely on fat for fuel. Fat is plentiful even in the leanest athlete, but is broken down slowly and requires so much oxygen to convert it into fuel, that running speed must drastically decrease if fat becomes the predominant fuel. Running low on carbohydrate during a race is what runners know as ‘hitting-the-wall’ or ‘bonking’ because the switch to

predominantly fat metabolism limits the muscles ability to produce energy quickly. Therefore, it is crucial to have some sort of fluid and carbohydrate intake during training and races. And if your intake is not carefully planed, you could end up with GI discomfort! As mentioned above, the amount of energy (i.e., the number of calories) you choose to consume at any one time will impact the rate of gastric emptying. Research has shown that beverages that contain 1-6% carbohydrate (6 grams per 100 ml of water; 14 grams per 8-oz) empty from the stomach at the same rate as water. Water has no calories and empties from the stomach quickly but does not provide any fuel for the muscle. Beverages with carbohydrate concentrations greater than 6% impede gastric emptying. Again, the faster fluids leave your stomach, the less likely they are to cause problems such as sloshing and bloating. Fluids that remain in the stomach and intestine due to high caloric content are not readily available to provide hydration and fuel for the body and more likely to cause GI discomfort. From a practical standpoint, water and sports drinks with carbohydrate concentrations less than or equal to 14 grams per 8 oz fall into the 0-6% category. Other macronutrients (i.e., protein or fat) added to carbohydrate are additional calories and, unless the carbohydrate concentration is very low, will impede gastric emptying. Gels and sports bars are commonly consumed during training and racing. Care must be taken when using these products, however, because they contain a very concentrated form of carbohydrate. Gels and bars should be ingested judiciously by taking in only a portion at a time and in combination with water. Washing down a gel with a sports drink increases the carbohydrate content of both which can impede gastric emptying; so it is best to use water when consuming a gel or a bar. Again, from a practical standpoint, a gel packet that contains 25 grams of carbohydrate should be diluted with 14 oz of water to bring it down to the 6% carbohydrate level. Consuming half of the gel packet would bring your

recommended fluid intake to about 7oz of water, making fluid intake more manageable. Most energy bars contain about 45 grams of carbohydrate so a bar should be chased with 22 oz of water to dilute them. Eating a portion of the bar with 5-6 oz of water is a better alternative when it comes to your GI comfort. Another factor which impacts gastric emptying during exercise is hydration status. As an individual dehydrates, gastric emptying slows, increasing the risk of upper GI problems such as burping, sloshing, and bloating. Therefore, you’re much more likely to experience GI discomfort toward the end of a race than at the beginning. Replacing sweat losses early in a race will be beneficial later in the race not only because hydration helps maintain cardiovascular and thermoregulatory function, but also because any calories taken in toward the end of the race will be better tolerated.

INTESTINAL ABSORPTION:
Intestinal absorption is the final barrier fluids and nutrients face before entering the bloodstream. Like gastric emptying, the rate at which a fluid is absorbed is also dependent upon several factors. As previously stated, the carbohydrate concentration will determine, in part, the rate at which a fluid is absorbed - concentrations at or below 6% are absorbed at the same rate as plain water. Another important consideration is osmolality, which is just a fancy word referring to the number of particles in a solution. Inside the small intestine, water is attracted into areas of greater particle concentration. When you ingest a fluid that is near the osmolality of the blood (hypo- or isotonic), water will generally flow out of the small intestine and into the blood. When you ingest a beverage that has a significantly greater osmolality than the blood, water moves from the blood and into the small intestine. This is not what you want during exercise because water drawn into the small intestine usually results in runner’s trots (i.e. diarrhea). The good

news is you can prevent this from happening by regulating the osmolality of the liquids you intake. Many factors affect osmolality, including the amount as well as the type of carbohydrate ingested. The small intestine has transporters specific to carbohydrate type, primarily glucose and fructose. Glucose is actively transported while fructose is absorbed passively through a process called facilitated diffusion. When both sugars are present in a sports drink the body can activate multiple transporters, allowing a greater amount of carbohydrate and fluid into the blood which leads to greater fluid replacement (i.e. preventing dehydration) and providing fuel for the muscle. Maintaining hydration as well as optimizing carbohydrate delivery to the muscle will allow you to run faster for a longer period of time. If a beverage contains only one type of sugar, the transporters are quickly saturated and absorption slows, increasing your chance of GI discomfort. Fructose should not be confused with high fructose corn syrup (HFCS), however. HFCS is a combination of glucose and fructose and entirely appropriate for a sports drink formulation as long as the ratio of glucose to fructose is equal to or greater than one (i.e. glucose > fructose). Unfortunately, there is no easy way to determine the ratio of glucose to fructose in your drink as it will not be indicated on the label. However, you can contact the company that makes the product and they will provide you with that information.

INTESTINAL ABSORPTION, EXERCISE, AND CARBOHYDRATE OXIDATION:
Improving intestinal absorption of fluid and carbohydrate is not only an important consideration for hydration and reducing GI distress but also for the delivery of carbohydrate to the muscle for use as fuel. Researchers from the University of Birmingham in the UK have published several ground breaking

studies investigating the effects of ingesting different types of sugars on carbohydrate oxidation; the amount of carbohydrate being used by the body during exercise. They have found that when only one type of carbohydrate (e.g., glucose) was ingested during cycling, carbohydrate oxidation peaked at about 1 gram of carbohydrate per minute or 60 grams per hour. When subjects ingested a mixture of carbohydrate (e.g., glucose and fructose) while cycling, carbohydrate oxidation increased to 1.75 grams of carbohydrate per minute or a 50% increase over glucose alone. (For more info see Mueller’s article in 16.3 May/June 2007.) The practical implications of this study are clear in that a mixture of carbohydrate improves intestinal absorption and carbohydrate oxidation. However, the rate at which carbohydrate was ingested in this study (1.8 grams per minute) may have impacted gastric emptying in subjects exercising at a higher intensity. Nevertheless, improving absorption ultimately improves blood glucose levels and provides the muscle with fuel to continue to exercise at a high intensity. Whether a running neonate or veteran, we all have one thing in common: we would all like to feel good every time we run. Though many factors contribute to the quality and enjoyment of our runs, GI discomfort, is one that can be controlled once you know the principles at work. Train your GI system in the right way and you will be able to eliminate one “unknown” from your mental checklist.

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