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Compromised energy and nutritional intake of ultra-endurance runners during a multi-stage ultra-marathon conducted in a hot ambient environment

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Energy and macronutrient intake of ultra-endurance runners (UER n=74; control (CON) n=12) during a 5-days 225km multi-stage ultra-marathon (MSUM) in the heat (Tmax 32-40˚C), were determined through dietary recall interview and analysed by dietary analysis software. Body mass (BM) and urinary ketones were determined pre- and post-stage. Recovery, appetite and gastrointestinal symptoms were monitored daily. Pre-stage BM, total daily energy (overall mean: 3348kcal/day), protein (1.5g/kgBM/day), carbohydrate (7.5g/kgBM/day) and fat (1.4g/kgBM/day) intakes did not differ between stages in UER. CON presented a daily macronutrient profile closer to benchmark recommendations than UER. Carbohydrate intake pre-stage (102g), during running (24g/h) and immediately post-stage (1.7g/kgBM), and protein intake post-stage (0.3g/kgBM) did not differ between stages, and were below benchmark recommendations in the majority of UER. Post-stage urinary ketones increased in UER as competition progressed (Stage 1: 16% vs. Stage 5: 32%). Gastrointestinal distresses and appetite suppression were reported by 85% and 72% of UER, respectively, along the MSUM. Correlations between subjective symptomology, energy and carbohydrate intakes were observed in UER (P<0.05). Sub-optimal macronutrient profile, carbohydrate intake, and recovery nutrition throughout the MSUM suggests energy quantity and quality may be compromised in ultra-runners along competition; indicating that specialised nutritional education may be beneficial in this population.
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International Journal of Sport s Science 2013, 3(2): 51-62
DOI: 10.5923/j.sp ort s .20130302.03
Compromised Energy and Macronutrient Intake of
Ultra-endurance Runners During a Multi-stage
Ultra-marathon Conducted in a Hot Ambient
Environment
Ric ardo J. S. Costa1 ,2,* , Abigail J. M. Swanco tt2, Samantha Gill2, Joanne Hanke y2, Vo lke r Schee r3,
Andre w Murray4, Charles D. Thake2
1Department of Health Professions, Coventry University, Priory Street, Coventry, CV1 5FB, United Kingdom
2Sport & Exerc ise Science Ap p lied Research Group , Coventry University, Priory Street, Coventry, CV1 5FB, United Kingdom
3Sports Medicine Department, University of Heidelberg, Im Neunheimer Feld 710, 69120 Heidelberg, Germany
4Sports Scotland Institute of Sport, Airthrey Road, Stirling, FK9 5PH, United Kingdom
Abs t ra c t Energy and macronutrient intake of ultra-endurance runners (UER n=74; control (CON) n=12) during a
5-days 225km multi-stage ultra-marathon (MSUM ) in the heat (Tma x 32-40˚C), we re determined through dietary recall
interview and analysed by dietary analysis software. Body mass (BM) and urinary ketones were determined pre- and
post-stage. Recovery, appetite and gastrointestinal symptoms were mon itored daily. Pre-stage BM, total daily energy
(overall mean: 3348kcal/day), protein (1.5g/kgBM/day), ca rb ohydrate (7.5g/kgBM/day) and fat (1.4g/kgBM/day) intakes
did not differ between stages in UER. CON presented a daily macronutrient profile closer to benchmark recommendations
than UER. Carbohydrate intake pre-stage (102g), during running (24g/h) and immed iately post-stage (1.7g/ kg BM), a nd
protein intake post-stage (0.3g/kgBM) did not differ between stages, and were below benchmark recommendations in the
ma jority of UER. Post-stage urinary ketones increased in UER as competition progressed (Stage 1: 16% vs. Stage 5: 32%).
Gast ro intestina l dis tre s ses and appetite suppression were reported by 85% and 72% of UER, respectively, along the MSUM.
Corre lations between subjective symptomology, energy and carbohydrate intakes were observed in UER (P<0.05).
Sub-optima l macronutrient profile, carbohydrate intake, and recovery nutrition throughout the MSUM suggests energy
quantity and quality may be compromised in ultra-runners along competition; indicating that specialised nutritional
education may be beneficial in this population.
Ke ywo rds Heat, Running, Endurance, Gastrointestinal, Appetite, Carbohydrates
1. Introduction
Mult i-stage ultra-marathon (MSUM) events have
increased in popularity over the past decade, and are
predicted for future growth within recreational endurance
sports participation; especially amongst endurance
enthusiasts that have successfully completed ma rathon and
triathlon events (www.racingtheplanet.com). MSUM events
are unique as they present additional challenges to
ultra -runners. Not only are participants required to perform
loaded (e.g. pack weight ranging from 5 to 15 kg) prolonged
strenuous exercise, and sleep rough (e.g. outdoors, tents,
and/or sports halls), on consecutive days (commonly ranging
* Corresponding author:
aa6914@coventry.ac.uk (Ricardo J.S. Costa)
Published online at http://journal.sapub.org/sports
Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved
fro m 5 to 8 days); but are also required to carry, prepare, and
consume sufficient foods and fluids to maintain optimal
exercise performance throughout competition. Associations
between sub-optimal nutritional status and decrements in
exercise performance have previously been well established,
highlighting the importance of consistently meeting
nutritional requirements on consecutive days of
ultra -marathon competition[1]; especially during periods of
greater endogenous energy solicitation[2,3].
Nutrit ional recommendations aimed at preventing fatigue,
and subsequently attenuating decrements in endurance
exercise performance have previously been developed to
guide dietary strategies and aid endurance athletes meet their
nutritional needs. For consecutive days of prolonged
endurance exercise, achieving energy balance is
recommended, alongside the provision of sufficient
carbohydrate (CHO) to meet exercise load demands (up to
10 gCHO/ kgBodyMass(BM)/day), and consumption of
52 Ricardo J.S. Costa et a l.: Compromised Ener gy and Macronutrient Intake of Ultra-endurance Runners During
a M ulti-stage Ultra-marathon Conducted in a Hot Ambient Environment
sufficient protein (PRO) to meet daily nitrogen balance (1.2
to 1.4 gPRO/kgBM/day)[1,4,5]. With regards to s pecific
macronutrient intake and timing, >200 g of carbohydrate up
to 2 h before prolonged strenuous exercise is recommended
for consumption[6,7], and is thought to be particularly
beneficial if carbohydrate intake during recovery fa ils to
fully restore muscle glycogen storage, and additionally
provides exogenous carbohydrate during the initial phase of
exercise[8]. The consumption of 30 to 60 gCHO/h, in an
individualised tolerable form, is recommended for endurance
exercise lasting ≥2 h, with the aim of maintaining blood
glucose concentration and sparing muscle glycogen stores;
contributing towards the maintenance of exercise workload
[9,10]. Immed iately post-exercise the consumption of 1.0 to
1.5 gCHO/kgBM is recommended to assist muscle glycogen
resynthesis, with some addit ional protein (up to 0.5
gPRO /kg BM ) to aid repair and healing of exercise-induced
tissue damage[5,11]. Moreover, carbohydrate and protein
immed iately a fter prolonged strenuous exercise has been
shown to attenuate the exercise-induced depression in innate
immune responses (e.g. neutrophil degranulation)[12 ,13]
involved in tissue repair, wound healing, and prevention of
illness/infection that commonly accompanies endurance
exercise[14].
Anecdotal evidence suggests ultra-runners may not be
following these recommendations during MSUM
competition set in hot ambient conditions (2009 Al Andalus
Ultimate Trail, Loja, Spain). This may be due to the lack of
nutritional education, ultra-endurance sports cultural trends,
development of unintentional symptoms (e.g. exercise and
environmentally induced appetite suppression, taste fatigue ,
nausea, involuntary vomiting and other gastrointestinal
d is tre ss es ), and/or practical real-life factors (e.g. lack of food
preparation facilities, equipment, location, time and/or
motivation), associated with limiting total food and fluid
intake during consecutive days of competition in extreme
environmental conditions[15-18]. Interestingly, some
observational evidence suggests faster ultra-runners
generally tolerate greater food and fluid ingestion during
ultra -marathon events compared with slower runners[19-21].
Moreover, the multitude of stressors including: strenuous
exercise, phases of food and fluid rationing (acute
under-nutrition and hypohydration), sleep disturbances,
environmental extremes, accu mulated fatigue and minor
tissue injurie s (e.g. blisters, abrasions, sunburn) that
accompanies MSUM, individually and in combination have
the potential to substantially increase nutritional
requirements and/or exacerbate factors that would limit
overall food and fluid ingestion[3,16,2 2,23].
Considering that most of the nutritional recommendations
for endurance exercise are derived from controlled
laboratory settings and generally amongs t highly tra ined elite
athletes; the majority o f the ultra-marathon competit ive
population are recreational amateurs. To date,
comprehensive research on the dietary practices of
recreational ultra-runners during one-stage and multi-sta ge
ultra -marathon running events is absent. It is therefore
plausible that current recommendations for endurance
exercise may need adjusting to cater for the unintentional
symptomology, real-life practical ba rriers, and s pecific race
characteris tics (e.g. deg ree of s elf suffic iency, environmental
conditions and/or course topography) experienced by
ultra -marathon competitors. With this in mind, the aims of
the current observational study were to assess the adequacy
of energy and macronutrient intake of ultra-runners during a
semi self-sufficient MSUM conducted in a hot ambient
environment.
2. Me thods
2.1 . Setting, P artici pants, and Experimental Design
The study was conducted during the 2010 and 2011 Al
Andalus Ultimate Trail, held during the second week of July,
in the region of Lo ja, Spa in. The MSUM was conducted over
five stages (5-days) totalling a distance of 225 km (Table 1),
which was performed on a variety of terrains; predominantly
off-road tra ils and paths, but also included steep and narrow
mountain pass es and occasional road. Sleeping arrangements
fro m Stages 1 to 5 included a combination of outdoor tent
and village sports hall accommodation.
After ethical approval from the Coventry University
Ethics Committee that conforms with the 2008 Helsinki
declaration for human research ethics, a convenience
sampling observational cohort was studied, whereby 74 out
of 134 u ltra-endurance runners entered into the MSUM
competition volunteered to participate in the study (mean:
UER (M ale n= 46, Fema le n= 28): age 41±8 years, height
169± 14 cm, BM 70±11 kg, body fat mass 17±5%).
Additionally, 12 age and anthropometrically matched
individuals who accompanied the UER a long the MSUM
course, but did not compete (absence of exercise stress),
volunteered to participate in the study as part of the control
group (CO N (M ale n= 5, Female n = 7): age 35±13 years,
height 167±9 c m, BM 70±16 kg, body fat mass 21±6%), for
comparison only. For the purpose of data analysis,
participants were divided into two groups. A slow group
(SR), who completed the entire distance of the MSUM using
a mixture of walking and running (overall mean s peed <8
km/h); and a fast group (FR), who completed the majority of
the MSUM distance running (overall mean speed ≥8 km/h).
This criterion was predetermined, and participants were
grouped according to their overall race time, prio r to data
analysis .
Height was measured by a wall-mounted stadiometer.
Baseline BM was determined using calibrated e lectronic
scales (BF510, Omron Healthcare, Ukyo-ku, Kyoto, Japan)
placed on a hard levelled surface. Waist and hip
circumferences were measured using a standard clinical tape
measure by trained researchers. BM and circumference
measures were used in conducting multi-frequency
bioelectrical impedance analysis (Quadscan 4000, Bodystat,
Douglas, Isle of Man, UK), which was used to determine
body composition.
International Journal of Sport s Science 2013, 3(2): 51-62 53
The current MSUM was semi self-sufficient, whereby
participants (including CON) planned and provided their
own foods and fluids (except plain water) along the five days
of competition. Pa rticipants’ equipment and sustenance was
transported to each stage section by the race organisation.
Only p lain water was provided by the race organisers a d
libitum during the rest phase throughout competition.
Additionally, a id stations along the running phase of
competition were situated approximately 10 km apart, and
only provided plain water, fruit (oranges and watermelon),
and electrolyte supplementation (Elete e lectrolyte add-in,
Mineral Resources International, South Ogden, Utah, US).
UER and CON were advised to adhere to their programmed
habitual dietary practices throughout the entire duration of
the MSUM competition.
Each day, fo r five consecutive days, running stages
commenced at either 08:00 h or 09:00 h. All participants
consumed their breakfast 2 to 3 h before the start of each
stage. Within the hour before the start of each running stage,
pre-stage measurements were determined and samples
collected. Participants were required to provide a mid-flow
urine sample (2nd urine of the day upon waking) into 30 ml
universal tubes (HR 120-EC, A & D instruments, Tokyo,
Japan), before BM meas urements. Immed iately post-s t age
and before any foods or fluids could be consumed, BM was
measured. Participants were then asked to provide a
mid -flo w urine sample at their earliest convenience. For
consistency, the order of pre- and post-stage measurements
and sampling were identical for all stages. Additionally, a
final BM measurement was taken the morning following
completion of the overall MSUM. To monitor carbohydrate
adequacy[24], urine reagent strips (Multistix® 10SG
Ur ina lysis st rips, Siemans Healthcare Diagnos tic, NY, USA)
were used to identify urinary ketones (acetoacetic acid) fro m
pre- and post-stage urine samples .
At the end of each competition day (20:00 to 22:00 h) on
Stages 1 to 4, trained researchers conducted a standardis ed
structured interview (dietary recall interview technique), on
UER and CON, to ascertain total daily food and fluid
ingestion. Due to practical and participant factors, it was not
feasible to conduct the daily dietary assessment on Stage 5,
since MSUM completion occurred within the duration of
Stage 5, not completing a 24 h period. To avoid
inter-observer variations, each researcher conducted the
standardised structured interview on the same participant
throughout the entire MSUM. Participants were educated
and instructed to recall in detail all foods and fluids ingested
along the competition day, which included specified food
and beverage quantities (e.g. g, ml, litres, portions) and
qualities (e.g. type of foods-beverages, brands of
foods-beverages) inges ted for breakfast (pre-stage), during
the stage (during running), within the hour after stage
completion (post-stage), and fro m the hour post-s t ag e unt il
sleep. Relevant nutritional info rmation from all
food-beverage packages was recorded by researchers. The
addition of carbohydrate, protein, and/or mixed
macronutrient supplementations to foods and fluids was also
recorded and combined with daily macronutrient intake.
Additionally, gastrointestinal distress symptoms and
subjective appetite sensation during running and rest periods
were explored through a research generated symptomology
tool on Stages 1 to 4. Participants also completed a general
recovery log to determine subjective quality of recovery. The
recovery log included a Likert Scale (-3 to +3, with 0
indicating a neutral response) which included: perceived
recovery quality, anxiety levels, motivation, fatigue, and
muscle soreness.
2.2 . Die tary a n d D at a A nal ysi s
Total daily, pre-stage, during running, and post-s tag e
energy and macronutrient int akes were calculated through
Dietplan6 d ietary analysis software (v6.60, Forestfield
Software, Horsham, West Sussex, UK) by a trained dietetic
researcher. To improve the validity of the dietary analysis,
all the nutritional informat ion gathered from food-beverage
packages during the interview procedure was entered into the
dietary analysis software program. In addition, to improve
the reliability of the dietary analysis, all the completed
dietary interview logs were blindly analysed by a 2nd trained
dietetic researcher. The overall mean inter-observer
coefficiency of variation for energy and macronutrient
variables analysed was 1.3% and 2.3%, respectively. In
addition, estimated total daily energy expenditure was
calculated through predictive equations[1] and verified
through tri-a xia l accele rometry (SenseWear 7.0, BodyMedia
Inc., Pittsburgh, PA, USA) in a sub-sample of part icipants , as
previously used[25] to guide Sports Dietetic support during
MSUM competition.
Data is presented as mean value ± standard deviation (SD),
otherwise specified. Descriptive statistics were used to
explore urinary ketones, gastrointestinal symptomology, and
subjective appetite sensation. Considering the potential
influence of individual BM differences (especially in re lat ion
to gender and training status) on dietary intake variables,
data analysis was performed on total values and corrected for
BM, as previously reported[26]. A one-way ANOVA was
applied to determine differences in variables between stages;
whi le a two-way ANOVA was applied to determine
diffe rences between groups (UER vs. CO N, an d SR vs. F R),
and between pre- and post-stage values within stages (SPSS
v.17.0.2, Illinois, US). Assumptions of homogeneity were
checked, with adjustments to the degrees of freedom and
verification by non-parametric equivalents (Kruskal-Wal lis
and Friedman two-way, respectively) where appropriate.
Significant main effects were analysed using post hoc
Tukey’s HSD test. Additionally, Spearman's correlation
coeffic ient was us ed to determine relationships between
variables. The acceptance level of significance was set at
P<0.05.
54 Ricardo J.S. Costa et a l.: Compromised Ener gy and Macronutrient Intake of Ultra-endurance Runners During
a M ulti-stage Ultra-marathon Conducted in a Hot Ambient Environment
Ta b l e 1 . St age t ime s an d a ver age sp eeds o f ultr a-en duran ce runn er s (UE R) pa rtici pating in a 225 km multi -sta ge ultra-marat hon (MSUM) com petit ion
con duct ed in a hot ambie nt env ironm ent
UER
Running time (h:min)
an d spee d (km/h)
SR
Running time (h:min)
an d spee d (km/h)
FR
Running time (h:min)
an d spee d (km/h)
Sta ge 1 : 37 km
503 to 1443 m A SL
Tmax : 32ºC; RHmax : 3 2%
4: 54±0:51
7.6
5: 29±0:35
6.8
4: 10±0:28
8.9
Sta ge 2 : 45 km
830 to 1338 m ASL
Tmax : 34ºC; RHmax : 3 3%
6: 37±1:20
6.8
7: 32±1:06
6.0
5: 38±0:46
8.0
Sta ge 3 : 40 km
689 to 1302 m ASL
Tmax : 38ºC; RHmax : 3 7%
4: 59±0:53
8.0
5: 37±0:39
7.1
4: 15±0:27
9.4
Sta ge 4 : 65 km
671 to 1152 m ASL
Tmax : 40ºC; RHmax : 3 3%
7: 51±1:25
8.3
8: 52±1:01
7.3
6: 48±0:54
9.6
Sta ge 5 : 38 km
473 to 1065 m ASL
T
max
: 40 ºC; RH
max
: 40 %
4: 16±1:05
8.9
4: 49±1:05
7.9
3: 35±0:35
10. 6
Tot al: 2 25 km 28:03±4:34
8.0
31:52±2:51
7.1
24:22±2:20
9.2
M ean ± SD: UER (n = 74); slow runners (SR: MSUM mean speed <8 km/h, n= 41 ); fast runne rs ( FR: MSUM m ean spee d 8 km/h, n= 33 ) . ASL
(above sea level), Tmax (m axima l am bient t emp erature), RH max ( max im a l r elat i ve h um idit y )
3. Res ults
No significant changes in pre- and post-stage BM were
observed throughout the MSUM in UER and CON.
Although MSUM participation tended to gradually reduce
BM in U ER (pre - to post-MSUM: UER -1.1% vs. CON 0.3%;
SR -0. 9% vs. FR -1.2%) .
Average estimated total daily energy expenditure was
calculated to range between 3831 to 4999 kcal/day in UER.
Total daily energy intake did not vary significantly between
stages in UER, SR and FR (Table 2). Total daily energy
intake was greater in UER co mpared to CON on Stage 1 only;
while total daily energy intake was greater in FR co mpared
with SR on Stages 1, 3 and 4 (P<0.001). Although, when
corrected for BM, no significant difference in total daily
energy intake was observed between UER and CON (overall
mean : 49± 11 kca l/kg BM/ da y a nd 45±4 kcal/ kgBM /d ay ,
respectively), nor between SR and FR (47±11
kcal/kgBM/day and 52±10 kcal/kgBM/day, respectively).
Total daily carbohydrate intake did not significantly vary
between stages in UER, CON, SR and FR. However, a
higher total daily carbohydrate intake was observed in UER
compared to CON on Stage 1 only; while total daily
carbohydrate intake was greater in FR compared to SR on
Stages 3 and 4 (P<0.001; Table 2). Although when corrected
for BM, no significant difference in total carbohydrate intake
was observed between UER and CON (Figure 1A), nor
between SR and FR (Figure 1B). Total daily protein intake
did not significantly vary between stages in UER, CON, SR,
and FR. Whereas, a higher total daily protein intake was
observed in UER (50% ) compared to CON, and in FR (23%)
compared to SR, throughout the MSUM (P<0.001; Table 2).
When corrected for BM, a significant difference in total daily
protein intake was only observed between UER and CON on
Stages 1 and 3 (Figure 1A ). A lower total daily fat intake was
observed on Stage 3 compared with Stage 1 in UER only
(P=0.025; Table 2). No other significant differences we re
observed for total daily fat intake. Total daily alcohol intake
did not contribute significantly to overall energy intake in
UER (53 kcal/day) and CON (0 kcal/day), and did not
significantly differ between stages along the MSUM.
Total daily polysaccharide and oligo/di/monosaccharide
(accounting for 39% and 61% in UER, and 33% and 67% in
CON, of total daily carbohydrate intake, respectively), were
similar between stages for UER and CON. Total daily fibre
intake did not differ along the MSUM in UER (overall mean:
18±9 g/day), nor differ with CON (overall mean: 18±4
g/day). Tot al daily s aturated, monounsaturated (MUFA) and
polyunsaturated (PUFA) fat intakes accounted for 31%, 32%
and 35% in UER, and 23%, 45% and 27% in CON, of total
daily fat intake, respectively. Lo wer saturated fat intakes
were observed on Stage 3 (23 g/day) compared with Stage 1
(36 g/day) in UER (P<0.001). A higher total saturated fat
(29±13 g/day and 19±9 g/day, respectively) and n6 to n3
ratio (22:1±7: 1 an d 1 3:1±5 :1, respectively) were observed in
UER compared with CON along the MSUM (P<0.001).
No acetoacetic acid was identified in pre-stage urine
samples throughout the MSUM in UER and CON. However,
the presence of acetoacetic acid (range: 1.5 t o 8.0 mmo l/l) in
post-s tage u rin e s a mple s wa s ev id en t in 4 6% o f UER a t s o me
point along the MSUM. The numbers of UER presenting
post-stage urinary acetoacetic acid increased as the MSUM
progressed (Stage 1: 16%, Stage 2: 22%, Stage 3: 27%, Stage
4: 30%, Stage 5: 32%). A weak but significant Spearman’s
correlation was observed between total daily intakes of
energy (r= -0.444, n= 92 , P<0.001) and carbohydrate (r=
International Journal of Sport s Science 2013, 3(2): 51-62 55
-0.336, n= 9 2, P=0.001) with presence of urinary acetoacetic
acid in post-stage urine sa mples. No significant correlations
were observed between intakes of energy and carbohydrate
(total and correct for BM) pre-stage and during running with
presence of urinary acetoacetic acid in post-stage urine
s a mp le s.
Ta b l e 2 . Total daily en ergy and ma cron ut rient int ake (an d overa ll m acron ut rient ener gy dis tribut io n ( % )) of u lt ra -enduran ce r unne r s (UE R) part icipat in g in
a 225 km mult i-stage ult ra-marathon (MSUM) compet itio n con ducte d in a hot ambie nt env ironment
Stage 1
Stage 3
Ov er al l M ean
En ergy (k cal /day)
UER
CON
SR
FR
3445 ±929 bb
2491 ±338
3315 ±971
3626 ±850 c
3285 ±797
3021 ±256
3132 ±766
3493 ±809
3252 ±934
2886 ±399
3023 ±900
3601 ±896 c
3410 ±923
3016 ±456
3194 ±920
3710 ±826 c
3348 ±750 b
2858 ±159
3166 ±734
3608 ±701 c
Protein (g/da y)
UER
CON
SR
FR
110±39bb
54±8
1035
1145c
1033bb
77±28
93±26
1139c
1042bb
68±6
93±37
1145c
1039bb
81±27
91±33
126±39cc
1029 (13%)bb
70±14 (10%)
96±24 (12%)
1131 (13%)cc
Car bohy drate (g/day )
UER
CON
SR
FR
515±146b
4058
491±131
551±162
511±136
4837
483±113
552±156
529±149
469±47
494±139
581±151c
527±137
4845
496±126
572±142c
52116 (62%)
460±19 (67%)
49100 (62%)
56127 (63%)c
Fat (g/day)
UER
CON
SR
FR
1046
75±12
1052
106±38
93±37
85±10
92±42
80±37†
82±27
75±41
89±29
98±39
84±23
94±45
94±32 (25%)
82±13 (23%)
91±38 (26%)
98±21 (24%)
M ean ± SD: UER (n = 54); control (CON, n = 12); slow runners (SR; MSUM mean speed <8 km/h, n= 32); fast runners (FR; MSUM mean speed 8
km/h, n = 22). †† P <0.01 an d † P <0.05 v s. St age 1; bb P<0.01 and b P<0.05 vs. CON ; cc
P<0. 01 a nd c
P<0. 05 vs. SR
Fi gu re 1. T otal daily car bohydrat e (CH O) and prot ein (PRO ) intak e (corre cted for BM) of ult ra-endur anc e runners ( UER) p articipat in g in a 225 km
mul t i-st age ultr a-mar athon (MSUM ) competit ion conduc ted in a h ot ambi ent env ironm ent. M ean±SD : (A ) UER (■ , n = 5 4) an d cont ro l (CON ○, n= 12); (B)
slo w runn ers (SR ∆; M SUM mean speed <8 km/h, n = 32) , and fast r unner s (FR ◊; MSUM me an speed 8 km /h, n= 22). a
Benchmark recommendations[1,4];
b P <0 .05 vs. CO N
56 Ricardo J.S. Costa et a l.: Compromised Ener gy and Macronutrient Intake of Ultra-endurance Runners During
a M ulti-stage Ultra-marathon Conducted in a Hot Ambient Environment
Lowe r pre-stage energy and protein intakes were observed
on Stage 3 in UER (P=0.05 and P=0.018, respectively), and
on Stages 3 and 4 in SR (P=0.026 and P=0.014, respectively),
compared with Stage 1 (Table 3). Pre-stage carbohydrate
intakes were also observed to be lower on Stages 3 and 4 in
UER ( P=0.01), and on Stage 4 on ly in SR (P=0.015),
compared with Stage 1. In FR, no significant differences in
pre-stage energy and macronutrient intakes between stages
were observed. Additionally, no significant difference was
observed for pre-stage energy and macronutrient intakes
between SR and FR within stages.
Ta b l e 3 . Pre-st a ge tot al ene rgy an d ma cron ut rient (and overall macronutrient en ergy distribut ion ( %)) of ult ra-enduranc e runn ers (UER) part icipating in a
225 km m ult i-st age ultra-marath on (M SUM) comp etition conducted in a hot am bient enviro nment
Stage 1
Stage 2
Stage 3
Stage 4
En ergy (k cal)
UER
SR
FR
77266
77282
75246
664±239
660±231
671±254
64203†
64185†
64230
64256
59242†
71269
680±166
664±166
696±169
Protein (g)
UER
SR
FR
27±14
28±14
25±15
22±10
22±10
23±11
20±8††
20±8†
20±8
22±11
20±10†
24±11
23±8 (14%)
22±7 (13%)
23±9 (13%)
Car bohy drate (g)
UER
SR
FR
117±39
117±40
117±40
99±34
98±37
1030
96±37†
95±36
99±39
94±42†
86±40†
106±4 4
1028 (60%)
99±28 (60%)
1028 (61%)
Fat (g)
UER
SR
FR
22±16
22±17
22±15
20±12
20±12
19±13
20±11
20±11
19±11
20±12
19±12
22±13
20±9 (26%)
20±9 (27%)
M ean ± SD: U ER (n= 54); slow runners (SR; MSUM mean speed <8 km/h, n = 32) ; fast r un ner s (FR; MSUM m ean sp eed 8 km/h,
n = 22). †† P<0. 01 an d
P<0.05 vs. St age 1
International Journal of Sport s Science 2013, 3(2): 51-62 57
Fi gu re 2. Tot al car bohy drate intak e (A), car bohy drate int ake co rrected for BM (B), and rate of carboh ydrat e intak e (C) dur ing run n ing, of ult ra-en dur ance
run ner s (UER) part icipat ing in a 225 km m ulti-sta ge ultra -marath on (M SUM) compet ition conducted i n a hot ambie nt env ironm ent. Mean±SD: U E R (■ , n=
54), slow runners (SR; MSUM mean speed <8 km/h, n= 32), and f ast runners (F R ◊; MSUM me an spe ed 8 km /h, n= 22) . a Ben chmark
r eco m m en dat io n s[1,5]. P <0 .05 vs. St age 4; cc P <0 .01 and c P <0 .05 vs. SR
Total carbohydrate intake during running was lower on Stages 1 to 3 in UER compared with Stage 4 (P=0.009), and lower
on Stage 1 only compared with Stage 4 in FR (P=0.019; Figure 2A). When corrected for BM, carbohydrate intake during
running was lower on Stages 1 to 3 in UER (P< 0.001) an d SR (P=0.007) compared with Stage 4, and lower on Stage 1 only
compared with Stage 4 in FR (P=0.05; Figure 2B). No difference in carbohydrate intake during running (total and corrected
for BM) was observed between SR and FR within stages. A significant difference was however observed between SR and FR
within stages when represented as rate of carbohydrate ingestion during running (P<0.001); whereby carbohydrate intake per
hour of running was consistently greater in FR (33%) throughout the MSUM compared with SR (Figure 2C).
Total energy, protein, and fat intake immediately post-stage did not vary between stages for UER, SR and FR (Table 4).
Whereas, total carbohydrate intake immediately after stage comp letion appeared to be generally higher in FR than SR
(P=0.038). When corrected for BM (Figure 3), energy (UER: 9.3 kcal/kgBM), protein (UER: 0.3 g/kgBM), carbohydrate
(UER: 1.6 g/kgBM), and fat (UER: 0.2 g/kg BM) intakes immediately post-stage did not differ between stages for UER, SR
and FR; nor between SR and FR within stages.
Ta b l e 4 . P o st -st age total ener gy and macronutrient (an d m acro n ut rient energy distribut ion (%)) of ultr a-en duranc e runn er s (UE R) part icipat ing i n a 225 km
mul t i-st age ult ra-mar athon (MSUM) co mpet ition conducted in a hot ambient environment
Stage 1
Stage 2
Stage 3
Stage 4
Ov er al l M ean
En ergy (k cal)
UER
SR
FR
611±338
538±299
716±362
591±266
588±279
606±249
577±271
581±281
556±262
623±256
633±276
595±228
600±202
584±185
618±226
Protein (gday )
UER
SR
FR
17±17
17±16
18±18
15±13
16±14
14±12
14±13
14±13
13±13
14±12
14±11
14±13
15±10 (10%)
15±9 (10%)
15±11 (10%)
Car bohy drate (g)
UER
SR
FR
111±55
95±47
134±58
1052
1060
115±37
110±52
111±56
108±48
1045
1047
110±42
109±36 (73%)
104±35 (71%)
117±37 (76%)c
Fat (g)
UER
SR
FR
11±1
10±10
12±11
11±10
12±11
10±9
9±9
9±9
8±8
15±13
17±15
11±8
12±8 (17%)
12±9 (19%)
10±7 (14%)
Mean±S D: UER (n= 54); slow runners (SR; MSUM mean speed <8 km/h, n = 32); fast runners (FR; MSUM mean speed 8 km/h, n= 22). c
P<0. 05 vs. SR
58 Ricardo J.S. Costa et a l.: Compromised Ener gy and Macronutrient Intake of Ultra-endurance Runners During
a M ulti-stage Ultra-marathon Conducted in a Hot Ambient Environment
Fi gu re 3. Ca rbohy drat e (A) and protein (B) intake (correcte d for BM) immediat ely post-sta ge of ult ra-endur ance runn ers (UE R) part icipat in g in a 225 km
mul t i-st age ult ra-mar athon (MSUM) co mpet ition conducted in a hot ambient env ironme nt. Mean±SD: U ER (■, n = 54), slow r unne rs (SR ∆; MSUM mean
speed <8 km /h, n = 32), and fast runners (FR ; MSUM mean speed 8 km/h, n= 22 ). a
Ben chm a rk r ecommendat ion s[1,5,11]. No s ign if ic ant dif f er enc es
between st ages, and between groups within stages
Gastrointestinal distress was a common feature, with 85%
of UER presenting at least one severe gastrointestinal
symptom along the MSUM, with rates of gastrointestinal
distress being higher in SR (92%) than FR (76%) throughout
competition. These included: nausea, gastrointestinal pain,
vomiting, indigestion, and irritable bowel symptoms. No
gastrointestinal symptoms were reported by CON
throughout the MSUM. Weak but significant correlations
between episodes of sev e re gastrointestinal distress, total
daily en ergy (r= -0.277, n= 54, P=0.05) and carbohydrate (r=
-0.348, n= 54, P=0.013) intakes were observed in UER.
Occurrence of appetite suppression was reported by 72%
of UER along the course of the MSUM, with suppressed
appetite constantly reported throughout the MSUM, but
improved as stages progressed (Stage 1: 46%, Stage 2: 41%,
Stage 3: 33%, Stage 4: 33%). Greater reports of suppressed
appetite were observed in SR (78%) than FR (64%).
Moreover, weak but significant correlat ions were observed
between total daily energy (r= 0. 342, n= 54, P=0.011) and
carbohydrate (r= 0.337, n= 54, P=0.013) intake with appetite
in UER.
Similarly, weak but significant correlations were observed
between total daily energy (r= 0.44 7, n= 5 4, P<0.001) and
carbohydrate (r= 0.376, n= 54, P= 0. 005) int akes wit h
perceived recovery quality during the rest period between
stages in UER. While, weak but significant correlations were
also observed between total post-stage energy (r= 0.456 , n=
54, P<0.001) and carbohydrate (r = 0.4 29, n= 54, P<0. 001)
intakes with perceived recovery quality during the rest
period between stages in UER.
4. Discussion
The current study was the first to comprehensively assess
energy and macronutrient intake of ultra-runners during a
MSUM conducted in hot ambient conditions. The results
indicate that the majority of ultra -runners were not able to
consistently meet estimated energy requirements along
competition; possibly due to gastrointestinal distress,
reduced appetite, and/or barriers to food/fluid preparation
and consumption. Attempts to achieve energy balance,
favoured the ingestion of fat dense foods, which was at the
expense of carbohydrate energy substrate, with all
ultra -runners failing to meet benchmark recommendations
for carbohydrate intake on consecutive days of prolonged
strenuous exercise[1,4,5]. Overall observations actually
indicate that CON consumed a more appropriate
macronutrient profile, for coping with exercis e -stress on
consecutive days compared with UER. Results also indicate
International Journal of Sport s Science 2013, 3(2): 51-62 59
all ultra -runners failed to meet benchmark recommendations
for carbohydrate intake during running and presented
incomp lete post-exe rcis e recovery nutrition[1,5, 11]. Of the
total number of runners participating in the 2010 and 2011 Al
Andalus Ultimate Tra il, 55% volunteered to participate in
the study. The strength of this sample size potentially gives a
valid and reliable representation of current dietary habits of
ultra -runners during MSUM conducted in hot ambient
conditions.
According to ACSM guide lines[1] and tri-axial
accelerometry verification[25], estimated lower and upper
limits for daily energy expenditure during MSUM were
calculated in UER to range between 3831 to 4999 kcal/day,
respectively; while average energy intake for UER was 3348
kcal/day, indicating a negative energy status. Changes in
resting BM have previously been used as a subjective tool in
asses sing energy balance, subsequently indicating changes in
nutritional status[27]. Observed pre-stage BM values suggest
energy needs for the majority of ultra-runners along the
MSUM were generally met. However, using resting BM
change as an indicator of energy balance throughout MSUM
set in hot ambient conditions may be misleading; since
progressive increases in resting total body water (Stage 1 to
Stage 5 1.9 litres, supported by 20.4% increase in resting
plasma vo lume fro m Stage 1 to Stage 5)[28], likely induced
by heat acclimatisation[29, 30], were obs erved as
competition progressed. These progressive increases in body
water likely contributed towards maintenance of pre-s t ag e
BM throughout MSUM, masking any negative energy
balance induced by competition. It would be advised to
consider measurements of body water when using BM to
assess energy balance along MSUM in the heat.
Primarily due to food and fluid choices, and secondary to
practical real-life factors a nd exe rcise-heat stress
symptomology, all UER were not able to consistently meet
benchmark recommendations for total daily carbohydrate
intake (≥10 g/kgBM/day), previously suggested to support
the replenishment of muscle glycogen stores during
consecutive days of prolonged strenuous exe rcise[1,4-7]. If
carbohydrate needs for exercise loads are not met, the
predominance of fat as an energy substrate will beco me
apparent through the production of ketones. Monitoring o f
urinary ketones at rest and after running may provide a useful
non-invasive method to assess whether sufficient dietary
carbohydrates are being consumed along MSUM[2 4].
Acetoacetic acid was identified in urine samples in UER
throughout competition, but not in CON; and prevalence
increasing as competit ion progressed. This provides some
evidence of sub-optimal carbohydrate status in UER along
the MSUM. Moreover, confounding factors known to
increase urinary acetoacetic acid (e.g. severe dehydration,
acute illness, high protein diet, and/or Diabetes
M ell itu s )[2 8, 31 ] were not observed. These findings are not
surprising taking into account that total daily carbohydrate
intakes in UER (total running stress load over five days:
28: 03±4: 34 h:min) did not significantly differ from CON (no
running stress load) from Stage 2 onwards.
Carbohydrate consumption pre-exercise is thought to be
particularly beneficial if carbohydrate intake during recovery
fails to fully restore muscle glycogen storage, and
additionally provides the working muscles with exogenous
carbohydrate during the initial phase of exercise[8,9]. A n
overall average of 102 g of carbohydrates from awakening
until race start (approximately 2 h) was observed in UER,
with no participant achieving ≥200 g of carbohydrates during
this period; despite 200 to 300 g o f carbohydrate in a
non-bulky form, up to 2 h before prolonged strenuous
exercise, being recommended for consumption[6,7].
Predominant food-beverage types selected for consumption
during this time period inc luded: freeze-dried/dehydrated
expedition meals (e.g. porridge), instant porridge, breakfast
cereals, dried fruit and nuts , cereal bars, and fruit juices.
During the running phase of the MSUM, UER only
managed to consume an overall average of 24 g CHO/h , far
below the lower limit benchmark recommendations (30 to 60
gCHO/h)[1,5]; despite all UER reported carrying sufficient
carbohydrate rich foods-beverages (e.g. isotonic drink
powders, carbohydrate gels, energy bars, cereal bars, jelly
sweets, dried fruit, soft drinks, and fruit juices) during each
stage to meet recommendations. Moreover, FR were able to
consistently consume higher rates of carbohydrate during
running than SR; possibly since FR presenting less severe
gastrointestinal distress and greater appetites along the
MSUM. These results are similar to those observed during an
Olymp ic course triathlon event and mountain marathon,
whereby carbohydrate intake during competition also failed
to meet benchmark recommendations in the majority of the
studied population[19, 26]. Nevertheless, appetite
suppression, nausea, vomiting, and other gastrointestinal
distresses are likely factors that prevented ultra-run ners fro m
consuming optimal quantities of carbohydrates during
running, irrespective of carbohydrate type and/or running
speed. Exercise-heat stress inducing splanchnic
hypoperfusion, splanchnic ischemia, running impact on the
gastrointestinal and splanchnic areas, potential increased gut
permeability and subsequent endotoxin leakage, and/or an
increased pro-inflammatory profile are a ll likely factors to
explain the high rates of gastrointestinal distress and appetite
suppression reported in both SR and FR along the
MSUM [16-18,24,32-36]. Tailoring and interlin king train ing,
heat acclimat isation, and dietary strategies to individual
tolerance and symptomology may support ultra-runners in
increasing their ability to consume mo re carbohydrates
during exercise-heat stress[30,3 7]. Additionally, training the
gastrointestinal tract to cope with food-drink ingestion
during exercise-heat stress may also potentially increase the
ability of ultra-runners to consume more carbohydrates
during running throughout MSUM competition.
Previous reviews, base on laboratory controlled studies,
have suggested the consumption of carbohydrate (1.0 to 1.5
gCHO/kg BM) and protein (up to 0.5 gPRO/kg BM)
immediately after prolonged strenuous exercise improves
muscle glycogen replenishment, and provides a nutrient base
for tissue repair and healing during the recovery period[5,11] .
60 Ricardo J.S. Costa et a l.: Compromised Ener gy and Macronutrient Intake of Ultra-endurance Runners During
a M ulti-stage Ultra-marathon Conducted in a Hot Ambient Environment
The overall average carbohydrate and protein intake in UER
immed iately post-stage was 1.7 gCHO/kgBM and 0.3
gPRO/kgBM, respectively. Predo minant food-beverage
types selected for consumption during this time period
included: soft drinks, fruit juices, fresh fru it (wa te rmelon ,
oranges, and apples), salted crisps, salted pretzels, and cold
meats. Moreover, <10% of UER reported consuming a
formulated recovery drink during this time period, which
provided sufficient carbohydrate and protein (variety of
forms: whey, casein, skimmed milk powder, and soya) to
meet benchmark recommendations. Although carbohydrate
consumption was generally sufficient, ultra-runners would
benefit fro m developing strategies that increases protein
intake during this period (especially high biological value
(HBV) protein that contains a reasonable leucine dose: cold
meats, fish and seafood, eggs, milk and cheese, soya, pulses,
and nuts). The consumption of HBV protein immed iately
after exe rcise, co-ingested with carbohydrate, has been
lin ked with an increased amino acid blood pool and insulin
response; subsequently suppressed muscle proteolytic
activity, enhanced net amino acid muscle uptake, enhanced
net intramuscular protein synthesis, and reductions in
perceived muscle soreness after a period o f res t[38-41];
responses which are likely to be advantageous to
ultra -runners competing on consecutive days. In addition,
carbohydrate and protein ingestion immediately after
prolonged strenuous exercise appears to prevent the decline
in neutrophil function (an important mechanis m in tissue
repair and healing) often observed after endurance
exercise[12,13]. From a practical v iew point, race organisers
simply providing a carbohydrate-protein enriched beverage
(e.g. enriched milkshake or equivalent)[42-44 ] immed iately
after stage completion at the recovery feeding tent may be a
positive initiative to improve overall general recovery of
MSUM competitors, rather than just supplying plain water,
soft drinks, and fruit juices.
Overall total daily protein intake of UER was above
benchmark recommendations[1,4, 45]. Even though overall
total daily fat intake was generally within recommendations
[4,6,7], fat quality appears unbalanced, with high intakes of
saturated fat, and a n6 to n3 ratio of 22:1 being consumed by
UER. Interestingly, on this occasion, CON presented a more
appropriate fat profile compared with UER. The lack of
nutritional education and ultra-endurance sports cultural
trends encouraged UER, but not CON, to consume
free ze-dried/dehydrated expedition meals (average of two
meals per day; approximately 80 0 kcal/ mea l) , whic h
contains predominantly fat based ingredients (~53% average
fat energy contribution), with accompanying low levels of
carbohydrates (average~38% carbohydrate energy
contribution). Taking into account the multiple stressors
associated with MSUM, which have been associated with
exacerbated pro-inflammatory cytokine responses[46,4 7],
with or without clinical manifestation[24,48, 49]; it would be
favourable for ultra-runners during competition to select and
consume foods that predominate wit h M UFA (e .g . o liv e o ils )
and marine based PUFA n3 (e.g. tinned oily fish), both of
which have been reported to present anti-inflammatory
properties[51, 52] .
5. Conclusions
Current food and fluid intakes of ultra-runners during a
MSUM conducted in a hot ambient environment may not be
sufficient to meet total energy requirements during
consecutive days of competition; possibly due to a
combination of exercise-heat stress induced gastrointestinal
d is tress, suppressed appetite, and/or barriers to food/fluid
preparation and consumption. Unbalanced total daily
macronutrient intakes, primarily led by sub-optimal
carbohydrate intake and food choices rich in unfavourable
fats were observed consistently throughout the MSUM.
Additionally, the amount of total daily energy and
carbohydrate ingested (and post-stage energy and
carbohydrate ingested) appears to contributed towards the
degree of perceived recovery quality in-between stages. Th e
findings from the current study indicate that nutritional
education by qualified sport and exercise nutritional
professionals (e.g. Sports Dietitians, Registered Sport &
Exe rc is e Nut ritio nists ) focused at recreational ultra-runners
is warranted.
Reflecting on results of the current study, nutritional
education may include developing dietary strategies and
promoting dietary changes aimed at: increasing total daily
carbohydrate intake through meals, snacks, carbohydrate
rich fluids, and carbohydrate supplementation (if required);
introduce individualised tolerable carbohydrate intakes
before, during, and after each stage completion; provide a
diverse selection of HBV protein rich foods to meet daily
nitrogen needs and supporting tissue repair and healing after
running; introduce anti-inflammatory fats within dietary
regimes throughout competition; modifying eating
behaviours during periods of food-fluid d isint eres t,
suppressed appetite, and gastrointestinal distress. A
follow-up study should be conducted to evaluate the
outcomes of such nutritional education on dietary practices
of u ltra-runners in proceeding MSUM events.
ACKNOWLEDGEMENTS
Firstly, the authors would like to thank all the
ultra -endurance runners that volunteered to participate in this
study. The authors acknowledge the Al Andalus Ultimate
Trai l (www.alandalus-ut.com) race directors Paul Bateson
and Barbara Price; and Team A xarsport SL: Michelle Cutler
and Eric Maroldo, for assisting and supporting various
aspects of this study. The authors also acknowledge Jane
Sheehy and Jagdeep Shergill from Coventry University for
their technical support along the course of the study
implementation; Lisa Hardy, Benjamin Lee, Ve ra
Ca mõ e s -Cos t a , Jessica Waterman, Emily Freeth, Edel
Barrett, Sla wo mir Marc zak, an d Encarna Valero-Burgos for
contributing towards various aspects of data and samp le
International Journal of Sport s Science 2013, 3(2): 51-62 61
co llection . The study was funded by Coventry University
Sport & Exe rcise Science Applied Research Group. All
authors declare no conflicts of interest.
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... Interestingly, low carbohydrate availability, independent of or in addition to LEA, is another risk factor in development of RED-S and related health and performance outcomes (37). It has been suggested that ultra-runners may fail to meet hourly carbohydrate intake guidelines during training and competition due to improper knowledge around fueling, higher reliance on fats as fuel, and gastrointestinal (GI) distress (7,36). Furthermore, a recent systematic review suggested that most runners did not meet the standard carbohydrate recommendations of 90 grams per hour for events lasting > 2.5 hours during single stage ultra-trail events (2,41). ...
... However, a large percentage of trail runners reported not meeting current fueling recommendations of 60 to 90 grams of carbohydrate per hour during training runs and competitions lasting longer than 2.5 hours (40). Similarly, other studies have suggested that most athletes racing ultramarathons in different environments failed to meet recommended levels of carbohydrate consumption during exercise (2,7). Stellingwerf (2016) followed (n = 3) runners over the course of year and several 100-mile races including the Western States 100-mile race, and found that these three veteran male runners implemented fueling strategies that met evidenced based guidelines for carbohydrate intake during exercise (36). ...
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Under fueling, disordered eating (DE), exercise dependence (EXD), and high training demands relative to energy intake may increase the risk of low energy availability (LEA) in endurance and ultra-endurance athletes. The purpose of this study was to evaluate the prevalence of LEA risk and relationship with risk of DE, EXD, and fueling habits during training and competition in endurance runners. Trail runners between the age of 18–40 (n = 1,899; males: n = 510, females: n = 1,445) completed a 45-question survey using Qualtrics that included training and racing characteristics, questions regarding carbohydrate intake during training and competition, the Low Energy Availability in Females Questionnaire (LEAF-Q), the Disordered Eating Screen for Athletes (DESA-6), and the Exercise Dependence Scale-21 (EDS-21). Among all runners, 43% of runners were at risk for LEA, 43% were at risk for DE, and 87.3% reported symptoms related to EXD. LEAF-Q scores were positively correlated with EDS-21 (r = 0.33, p < 0.001) and DESA-6 scores (r = 0.29, p < 0.001). From the population, 47.6% of athletes reported taking in less than the recommended carbohydrate guidelines during endurance events lasting > 2.5 hours. In females, athletes at risk for LEA appear less likely to fuel sufficiently than athletes not at risk for LEA (p < 0.001). Risk of LEA, DE, and EXD appears to be high in endurance runners. Furthermore, meeting carbohydrate recommendations during training and competition should be emphasized to avoid negative health outcomes associated with LEA in endurance runners.
... In addition, participants were also excluded if reporting adhering to macronutrient modification dietary practices (e.g., LCHF, ketogenic, and/or glycogen manipulation diets) within 1 month before the experimental protocol. All participants reported consuming a standard varied macronutrient diet on training and non-training days [mean ± SD (% energy contribution): 11.8 ± 2.8 MJ/day (149 ± 44 g/day protein (21 ± 6%), 403 ± 115 g/day carbohydrate (57 ± 16%), 68 ± 29 g/day fat (22 ± 9%), and 3.1 ± 0.9 L/day water)], which was confirmed by dietary assessment and analysis similar to previously reported procedures (Costa et al., 2013(Costa et al., , 2014. All participants reported having some exposure in consuming carbohydrate (i.e., solid, semi-solid, and/or fluid) during training and/or competition, but no participant reported being accustomed to consuming ≥90 g/h. ...
... The incremental test was deliberately undertaken 2 h postprandial (e.g., 2.9 ± 1.0 MJ, 29 ± 12 g protein, 97 ± 37 g carbohydrates, 18 ± 6 g fat, and 414 ± 235 ml water; Russo et al., 2021a) to reflect endurance athlete behavior before longer training sessions or competition (Costa et al., 2013(Costa et al., , 2014. Baseline stature and BM were measured, and body fat mass determined using multi-frequency bioelectrical impedance analysis (mBCA 515, Seca, Ecomed, Hamburg, Germany). ...
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Using metadata from previously published research, this investigation sought to explore: (1) whole-body total carbohydrate and fat oxidation rates of endurance (e.g., half and full marathon) and ultra-endurance runners during an incremental exercise test to volitional exhaustion and steady-state exercise while consuming a mixed macronutrient diet and consuming carbohydrate during steady-state running and (2) feeding tolerance and glucose availability while consuming different carbohydrate regimes during steady-state running. Competitively trained male endurance and ultra-endurance runners (n = 28) consuming a balanced macronutrient diet (57 ± 6% carbohydrate, 21 ± 16% protein, and 22 ± 9% fat) performed an incremental exercise test to exhaustion and one of three 3 h steady-state running protocols involving a carbohydrate feeding regime (76–90 g/h). Indirect calorimetry was used to determine maximum fat oxidation (MFO) in the incremental exercise and carbohydrate and fat oxidation rates during steady-state running. Gastrointestinal symptoms (GIS), breath hydrogen (H2), and blood glucose responses were measured throughout the steady-state running protocols. Despite high variability between participants, high rates of MFO [mean (range): 0.66 (0.22–1.89) g/min], Fatmax [63 (40–94) % V̇O2max], and Fatmin [94 (77–100) % V̇O2max] were observed in the majority of participants in response to the incremental exercise test to volitional exhaustion. Whole-body total fat oxidation rate was 0.8 ± 0.3 g/min at the end of steady-state exercise, with 43% of participants presenting rates of ≥1.0 g/min, despite the state of hyperglycemia above resting homeostatic range [mean (95%CI): 6.9 (6.7–7.2) mmol/L]. In response to the carbohydrate feeding interventions of 90 g/h 2:1 glucose–fructose formulation, 38% of participants showed breath H2 responses indicative of carbohydrate malabsorption. Greater gastrointestinal symptom severity and feeding intolerance was observed with higher carbohydrate intakes (90 vs. 76 g/h) during steady-state exercise and was greatest when high exercise intensity was performed (i.e., performance test). Endurance and ultra-endurance runners can attain relatively high rates of whole-body fat oxidation during exercise in a post-prandial state and with carbohydrate provisions during exercise, despite consuming a mixed macronutrient diet. Higher carbohydrate intake during exercise may lead to greater gastrointestinal symptom severity and feeding intolerance.
... Aside from maintaining a high circulating glucose availability for potential use in intramuscular glycolysis and oxidative phosphorylation, a greater reduction in markers of intestinal epithelial injury and small intestinal permeability was observed with glucose ingestion compared with water during 2 h of running [9]. Field studies of various endurance and ultra-endurance athletes such as long-distance runners, cyclists, and triathletes [10][11][12][13][14][15][16] have shown that these target intakes are challenging to achieve. This could be caused by appetite suppression, gastrointestinal discomfort, and exercise-associated gastrointestinal symptoms (Ex-GIS) onset; and individual feeding tolerance level during exercise, likely associated with exercise-induced gastrointestinal syndrome (EIGS) [17]. ...
Article
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Background Nutrition during exercise is vital in sustaining prolonged activity and enhancing athletic performance; however, exercise-induced gastrointestinal syndrome (EIGS) and exercise-associated gastrointestinal symptoms (Ex-GIS) are common issues among endurance athletes. Despite this, there has been no systematic assessment of existing trials that examine the impact of repetitive exposure of the gastrointestinal tract to nutrients before and/or during exercise on gastrointestinal integrity, function, and/or symptoms. Objective This systematic literature review aimed to identify and synthesize research that has investigated the impact of ‘gut-training’ or ‘feeding-challenge’ before and/or during exercise on markers of gastrointestinal integrity, function, and symptoms. Methods Five databases (Ovid MEDLINE, EMBASE, CINAHL Plus, Web of Science Core Collection, and SPORTDiscus) were searched for literature that focused on gut-training or feeding-challenge before and/or during exercise that included EIGS and Ex-GIS variables. Quality assessment was conducted in duplicate and independently using the Cochrane Collaboration’s risk-of-bias (RoB 2) tool. Results Overall, 304 studies were identified, and eight studies were included after screening. Gut-training or feeding-challenge interventions included provision of carbohydrates only (n = 7) in various forms (e.g., gels or liquid solutions) during cycling or running, or carbohydrate with protein (n = 1) during intermittent exercise, over a varied duration (4–28 days). Gut discomfort decreased by an average of 47% and 26% with a 2-week repetitive carbohydrate feeding protocol (n = 2) and through repeated fluid ingestion over five trials (n = 1), respectively. Repetitive carbohydrate feeding during exercise for 2 weeks resulted in the reduction of carbohydrate malabsorption by 45–54% (n = 2), but also led to no significant change (n = 1). The effect of gut-training and feeding-challenges on the incidence and severity of Ex-GIS were assessed using different tools (n = 6). Significant improvements in total, upper, and lower gastrointestinal symptoms were observed (n = 2), as well as unclear results (n = 4). No significant changes in gastric emptying rate (n = 2), or markers of intestinal injury and permeability were found (n = 3). Inconclusive results were found in studies that investigated plasma inflammatory cytokine concentration in response to exercise with increased carbohydrate feeding (n = 2). Conclusions Overall, gut-training or feeding-challenge around exercise may provide advantages in reducing gut discomfort, and potentially improve carbohydrate malabsorption and Ex-GIS, which may have exercise performance implications.
... Participants reported to the laboratory at 0800h after consuming the standardised pre-trial low FODMAP meal (2.9 ± 0.7 MJ, 99 ± 28 g carbohydrate, 25 ± 6 g protein, 20 ± 5 g fat, 11 ± 4 g fibre, 1 ± 1 g total FODMAP), consumed at 0700h. The meal was consumed 2 h prior to the start of exercise, simulating real-life translational practice in the target population [47,48]. A dietary log containing the prescriptive diet determined ingestion compliance and food waste. ...
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The study aimed to investigate the impact of laboratory-controlled exertional and exertional-heat stress on concentrations of plasma endogenous endotoxin core antibody (EndoCAb). Forty-four (males n=26 and females n=18) endurance trained (V̇O2max 56.8min/kg/min) participants completed either: P1-2h high intensity interval running in 23°C ambient temperature (Tamb), P2-2h running at 60% V̇O2max in 35°C Tamb, or P3-3h running at 60% V̇O2max in 23°C Tamb. Blood samples were collected pre- and post-exercise to determine plasma IgM, IgA, and IgG concentrations. Overall resting pre-exercise levels for plasma Ig were 173MMU/ml, 37AMU/ml, and 79GMU/ml, respectively. Plasma IgM concentration did not substantially change pre- to post-exercise in all protocols, and the magnitude of pre- to post-exercise change for IgM was not different between protocols (p=0.135). Plasma IgA and IgG increased pre- to post-exercise in P2 only (p=0.017 and p=0.016, respectively), but remained within normative range (35-250MU/ml). P2 resulted in greater disturbances to plasma IgA (p=0.058) and IgG (p=0.037), compared with P1 and P3. No substantial differences in pre-exercise and exercise-associated change was observed for EndoCAb between biological sexes. Exertional and exertional-heat stress resulted in modest disturbances to systemic EndoCAb responses, suggesting EndoCAb biomarkers presents a low sensitivity response to controlled-laboratory experimental designs within exercise gastroenterology.
... Athletes reported to the laboratory 1 h before exercise commencement, after consuming their typical pre-event meal or snack 2 h beforehand. A dietary log (1-3 days) determined their nutritional intake, as per previously established dietary intake assessment and analysis procedures (Costa et al., 2013a(Costa et al., ,b, 2014b. Participants were asked to void before nude body mass measurement, provide a breath sample into a 250 mL breath collection bag (Wagner Analysen Technick, Bremen, Germany), and complete a mVAS GIS assessment tool , as a baseline measure. ...
Article
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This translational research case series describes the implementation of a gastrointestinal assessment protocol during exercise (GastroAxEx) to inform individualised therapeutic intervention of endurance athletes affected by exercise-induced gastrointestinal syndrome (EIGS) and associated gastrointestinal symptoms (GIS). A four-phase approach was applied. Phase 1: Clinical assessment and exploring background history of exercise-associated gastrointestinal symptoms. Phase 2: Individual tailored GastroAxEx laboratory simulation designed to mirror exercise stress, highlighted in phase 1, that promotes EIGS and GIS during exercise. Phase 3: Individually programmed therapeutic intervention, based on the outcomes of Phase 2. Phase 4: Monitoring and readjustment of intervention based on outcomes from field testing under training and race conditions. Nine endurance athletes presenting with EIGS, and two control athletes not presenting with EIGS, completed Phase 2. Two athletes experienced significant thermoregulatory strain (peak core temperature attained > 40°C) during the GastroAxEx. Plasma cortisol increased substantially pre- to post-exercise in n = 6/7 (Δ > 500 nmol/L). Plasma I-FABP concentration increased substantially pre- to post-exercise in n = 2/8 (Δ > 1,000 pg/ml). No substantial change was observed in pre- to post-exercise for systemic endotoxin and inflammatory profiles in all athletes. Breath H2 responses showed that orocecal transit time (OCTT) was delayed in n = 5/9 (90–150 min post-exercise) athletes, with the remaining athletes (n = 4/9) showing no H2 turning point by 180 min post-exercise. Severe GIS during exercise was experienced in n = 5/9 athletes, of which n = 2/9 had to dramatically reduce work output or cease exercise. Based on each athlete’s identified proposed causal factors of EIGS and GIS during exercise (i.e., n = 9/9 neuroendocrine-gastrointestinal pathway of EIGS), an individualised gastrointestinal therapeutic intervention was programmed and advised, adjusted from a standard EIGS prevention and management template that included established strategies with evidence of attenuating EIGS primary causal pathways, exacerbation factors, and GIS during exercise. All participants reported qualitative data on their progress, which included their previously presenting GIS during exercise, such as nausea and vomiting, either being eliminated or diminished resulting in work output improving (i.e., completing competition and/or not slowing down during training or competition as a result of GIS during exercise). These outcomes suggest GIS during exercise in endurance athletes are predominantly related to gastrointestinal functional and feeding tolerance issues, and not necessarily gastrointestinal integrity and/or systemic issues. GastroAxEx allows for informed identification of potential causal pathway(s) and exacerbation factor(s) of EIGS and GIS during exercise at an individual level, providing a valuable informed individualised therapeutic intervention approach.
... Participation in UER decreased significantly in 2020 due to the worldwide COVID-19 pandemic [4]. To date, research in UER has focused predominantly on acute injuries and medical problems, as well as physiological, biochemical, nutritional, performance, and training-related aspects [5][6][7][8][9][10][11]. More recently, researchers have inquired into the long-term effects of prolonged and strenuous exercise, particularly as UER is one of the most physiologically demanding sports that can potentially lead to long-term health related issues [12,13]. ...
Article
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It is well established that physical activity reduces all-cause mortality and can prolong life. Ultra-endurance running (UER) is an extreme sport that is becoming increasingly popular, and comprises running races above marathon distance, exceeding 6-hours, and/or running fixed distances on multiple days. Serious acute adverse events are rare but there is mounting evidence that UER may lead to long-term health problems. The purpose of this review is to present the current state of knowledge regarding the potential long-term health problems derived from UER, specifically potential maladaptation in key organ systems including cardiovascular, respiratory, musculoskeletal, renal, immunological, gastrointestinal, neurological, and integumentary systems. Special consideration is given to youth, masters, and female athletes, all of whom may be more susceptible to certain long-term health issues. We present directions for future research into the pathophysiological mechanisms that underpin athlete susceptibility to long-term issues. Although all body systems can be affected by UER, one of the clearest effects of endurance exercise is on the cardiovascular system, including right ventricular dysfunction and potential increased risk of arrhythmias and hypertension. There is also evidence that rare cases of acute renal injury in UER could lead to progressive renal scarring and chronic kidney disease. There are limited data specific to female athletes who may be at greater risk of certain UER-related health issues due to interactions between energy availability and sex-hormone concentrations. Indeed, failure to consider sex differences in the design of female specific UER training programs may have a negative impact on athlete longevity. It is hoped that this review will inform risk stratification and stimulate further research about UER and the implications for long-term health.
... Notwithstanding, reports on sex differences in GI distress during ultra-endurance exercise are sparse. This can be attributed to lower female participation numbers and/ or the failure of most studies to differentiate prevalence of GI distress by sex (e.g., [204,205]). In reports that do make such distinctions, the data are less equivocal than for marathon. ...
Article
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Ultra-endurance has been defined as any exercise bout that exceeds 6 h. A number of exceptional, record-breaking performances by female athletes in ultra-endurance sport has roused speculation that they might be predisposed to success in such events. Indeed, while the male-to-female performance gap in traditional endurance sport (e.g., marathon) remains at ~10%, the disparity in ultra-endurance competition has been reported as low as 4% despite the markedly lower number of female participants. Moreover, females generally outperform males in extreme-endurance swimming. The issue is complex, however, with many sports-specific considerations and caveats. This review summarizes the sex-based differences in physiological functions and draws attention to those which likely determine success in extreme exercise endeavors. The aim is to provide a balanced discussion of the female versus male predisposition to ultra-endurance sport. Herein, we discuss sex-based differences in muscle morphology and fatigability, respiratory-neuromechanical function, substrate utilization, oxygen utilization, gastrointestinal structure and function, and hormonal control. The literature indicates that while females exhibit numerous phenotypes that would be expected to confer an advantage in ultra-endurance competition (e.g., greater fatigue-resistance, greater substrate efficiency, and lower energetic requirements), they also exhibit several characteristics that unequivocally impinge on performance (e.g., lower O2-carrying capacity, increased prevalence of GI distress, and sex-hormone effects on cellular function/ injury risk). Crucially, the advantageous traits may only manifest as ergogenic in the extreme endurance events which, paradoxically, are the races that females less often contest. The title question should be revisited in the coming years when/if the number of female participants increases.
... The specific characteristics of this sport lead athlete to develop the so called "Fatigue induce by taste", due to a decrease of palatability towards certain food because of fatigue and duration of the race [103,104]. This leads the runner to eat different type of foods containing naturally sodium at the refreshment points, an unusual condition for shorter and higher intensity competitions [73,[105][106][107][108]. Despite Coyle [109] suggests an amount of 1 g/h of Na + to replenish losses, other authors [105,110] showed that the real assumption during endurance activity are lower. ...
Article
This review aims to investigate the physiological mechanisms that underlie the hydro-electrolyte balance of the human body and the most appropriate hydration modalities for individuals involved in physical and sports activities, with a focus on ultra-endurance events. The role of effective hydration in achieving optimal sports performance is also investigated. An adequate pre-hydration is essential to perform physical and sporting activity in a condition of eu-hydration and to mantain physiologic levels of plasma electrolyte. To achieve these goals, athletes need to consume adequate drinks together with consuming meals and fluids, in order to provide an adequate absorption of the ingested fluids and the expulsion of those in excess through diuresis. Therefore, there are important differences between individuals in terms of sweating rates, the amount of electrolytes loss and the specific request of the discipline practiced and the sporting event to pursue.
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A high-fat, low-carbohydrate, ketogenic diet has already appealed to athletes for a long time due to its purported ability to improve exercise performance and post-exercise recovery. The availability of ketone supplements has further sparked such interest. The review therefore focuses on the potential beneficial impact of exogenous and endogenous ketosis in the context of ultra-endurance exercise.
Article
The study aimed to determine the impact of exercise duration on gastrointestinal functional responses and gastrointestinal symptoms (GIS) in response to differing exercise durations. Endurance runners (n=16) completed three trials on separate occasions, randomised to 1 h (1-H), 2 h (2-H) and 3 h (3-H) of running at 60% V̇O 2max in temperate ambient temperature. Orocecal transit time (OCTT) was determined by lactulose challenge, with concomitant breath hydrogen (H 2 ) determination. Gastric slow wave activity was recorded using cutaneous electrogastrography (cEGG) pre and post exertion. GIS was determined using a modified visual analogue scale (mVAS). OCTT response was classified as very slow on all trials (~93-101 min) with no trial difference observed (P= 0.895). Bradygastria increased post-exercise on all trials (mean ± SD: 1-H: 10.9 ± 11.7%, 2-H: 6.2 ± 9.8% and 3-H: 13.2 ± 21.4%; P< 0.05). A reduction in the normal gastric slow wave activity (2-4 cycles/min) was observed post-exercise on 1-H only (-10.8 ± 17.6%; P= 0.039). GIS incidence and gut discomfort was higher on 2-H (81% and 12 counts) and 3-H (81% and 18 counts), compared to 1-H (69% and 6 counts) (P= 0.038 and P= 0.006, respectively). Severity of gut discomfort, total-GIS, upper-GIS, and lower-GIS increased during exercise on all trials (P< 0.05). Steady state exercise in temperate ambient conditions for 1 h, 2 h, and 3 h instigates perturbations in gastric slow wave activity compared to rest and hampers OCTT, potentially explaining the incidence and severity on exercise-associated GIS.
Article
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Carbohydrate ingestion can improve endurance capacity and performance. Since the 1980s, research has focused on optimizing the delivery strategies of these carbohydrates. The optimal dose of carbohydrate is still subject to debate, but recent evidence suggests that there may be a dose–response effect as long as the carbohydrate ingested is also oxidized and does not result in gastrointestinal distress. Oxidation rates of a single type of carbohydrate do not exceed 60 g·h−1. However, when multiple transportable carbohydrates are ingested (i.e. glucose and fructose), these oxidation rates can be increased significantly (up to 105 g·h−1). To achieve these high oxidation rates, carbohydrate needs to be ingested at high rates and this has often been associated with poor fluid delivery as well as gastrointestinal distress. However, it has been suggested that using multiple transportable carbohydrates may enhance fluid delivery compared with a single carbohydrate and may cause relatively little gastrointestinal distress. More research is needed to investigate the practical applications of some of the recent findings discussed in this review.
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Gastrointestinal tract (GIT) symptoms commonly affect endurance athletes. Although a number of risk factors for the development of GIT symptoms during exercise have been proposed, scientific evidence in support of these factors is limited. In this review article, the risk factors associated with the development of GIT symptoms during exercise will be critically reviewed. An extensive literature review was conducted using an evidence-based approach. Using selective keywords (gastrointestinal tract symptoms, exercise, risk factors, athletes, triathletes) a search was undertaken using the PubMed database to identify all research publications that relate to the development of GIT symptoms during exercise. There is strong evidence from a limited number of studies to support significant dehydration (body weight loss >4% during or after exercise) as a risk factor for GIT symptoms during exercise. However, more research studies are still needed to support this finding. There is some, but limited scientific evidence, to support the following as risk factors for GIT symptoms during exercise: female gender, younger age, high intensity exercise, vertical impact sport and medication use. Poor conditioning, dietary factors and previous abdominal surgery are risk factors for GIT symptoms that are not well supported and evidence is considered weak in these areas. Therefore, further research studies of greater power, such as case control and prospective cohort studies are needed in order to evaluate risk factors adequately. Subject selection needs to be random and subjects should not be self-selected. Data needs to be collected in an objective manner not relying on subject recall. Measurement parameters also need to be standardised. In conclusion, there is very little evidence-based research to support the majority of the currently suggested risk factors for GIT symptoms in endurance athletes and further research is essential.
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Heat acclimation induces adaptations that improve exercise tolerance in hot conditions. Here we report novel findings into the effects of ultra-marathon specific exercise load in increasing hot ambient conditions on indices of heat acclimation. Six male ultra-endurance runners completed a standard pre-acclimation protocol at 20°C ambient temperature (Tamb), followed by a heat acclimation protocol consisting of six 2 h running exercise-heat exposures (EH) at 60% O2max on a motorised treadmill in an environmental chamber. Three EH were performed at 30°C Tamb, followed by another three EH at 35°C Tamb. EH were separated by 48 h within Tamb and 72 h between Tamb. Nude body mass (NBM), blood and urine samples were collected pre-exercise; while NBM and urine were collected post-exercise. Rectal temperature (Tre), heart rate (HR), thermal comfort rating (TCR) and rating of perceived exertion were measured pre-exercise and monitored every 5 min during exercise. Water was provided ad libitum during exercise. Data were analysed using a repeated measures and one-way analysis of variance (ANOVA), with post hoc Tukey's HSD. Significance was accepted as P< 0.05. Overall mean Tre was significantly lower during 30°C EH3 and 35°C EH3 compared with their respective EH1 (−0.20 and−0.23°C, respectively; P
Article
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Abstract Background Anecdotal evidence suggests ultra-runners may not be consuming sufficient water through foods and fluids to maintenance euhydration, and present sub-optimal sodium intakes, throughout multi-stage ultra-marathon (MSUM) competitions in the heat. Subsequently, the aims were primarily to assess water and sodium intake habits of recreational ultra-runners during a five stage 225 km semi self-sufficient MSUM conducted in a hot ambient environment (Tmax range: 32°C to 40°C); simultaneously to monitor serum sodium concentration, and hydration status using multiple hydration assessment techniques. Methods Total daily, pre-stage, during running, and post-stage water and sodium ingestion of ultra-endurance runners (UER, n = 74) and control (CON, n = 12) through foods and fluids were recorded on Stages 1 to 4 by trained dietetic researchers using dietary recall interview technique, and analysed through dietary analysis software. Body mass (BM), hydration status, and serum sodium concentration were determined pre- and post-Stages 1 to 5. Results Water (overall mean (SD): total daily 7.7 (1.5) L/day, during running 732 (183) ml/h) and sodium (total daily 3.9 (1.3) g/day, during running 270 (151) mg/L) ingestion did not differ between stages in UER (p
Article
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Physical exercise places high demands on the adaptive capacity of the human body. Strenuous physical performance increases the blood supply to active muscles, cardiopulmonary system, and skin to meet the altered demands for oxygen and nutrients. The redistribution of blood flow, necessary for such an increased blood supply to the periphery, significantly reduces blood flow to the gut, leading to hypoperfusion and gastrointestinal (GI) compromise. A compromised GI system can have a negative impact on exercise performance and subsequent postexercise recovery due to abdominal distress and impairments in the uptake of fluid, electrolytes, and nutrients. In addition, strenuous physical exercise leads to loss of epithelial integrity, which may give rise to increased intestinal permeability with bacterial translocation and inflammation. Ultimately, these effects can deteriorate postexercise recovery and disrupt exercise training routine. This review provides an overview on the recent advances in our understanding of GI physiology and pathophysiology in relation to strenuous exercise. Various approaches to determine the impact of exercise on the individual athlete's GI tract are discussed. In addition, we elaborate on several promising components that could be exploited for preventive interventions.
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