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Copyright © 2017 American College of Sports Medicine
Low FODMAP:
A Preliminary Strategy to Reduce Gastrointestinal Distress in Athletes
Dana M. Lis1, Trent Stellingwerff1,2, Cecilia M. Kitic1, James W. Fell1, and Kiran D.K. Ahuja1
1Sport Performance Optimisation Research Team, School of Health Sciences University
of Tasmania, Launceston, Tasmania, Australia; 2Canadian Sports Institute – Pacific,
Victoria, British Columbia, Canada
Accepted for Publication: 31 August 2017
ACCEPTED
d o
nal Distress in Athletnal Distress in Athlet
, James W, James W
.
F
e
ll1
, and Kirand Ki
Team, School of Health Seam, School of Health
ustralia;ustralia;
22
Canadian SportsCanadian Sport
tish Columbia, Canadah Columbia,
Accepted for Publicad for Publica
Low FODMAP: A Preliminary Strategy to Reduce Gastrointestinal Distress
in Athletes
Dana M. Lis1, Trent Stellingwerff1,2, Cecilia M. Kitic1,
James W. Fell1, and Kiran D.K. Ahuja1
1 Sport Performance Optimisation Research Team, School of Health Sciences
University of Tasmania, Launceston, Tasmania, Australia; 2Canadian Sports Institute – Pacific,
Victoria, British Columbia, Canada
Address for correspondence and reprint requests:
Dana Lis
School of Health Sciences
University of Tasmania
Locked Bag 1322
Launceston, Tasmania, Australia 7250
Email: Dana.Lis@utas.edu.au
The King and Amy O’Malley Trust provided scholarship support. The results of this study are
presented clearly, honestly, and without fabrication, falsification, or inappropriate data
manipulation. The results of the present study do not constitute endorsement by ACSM. This
study was supported in part by the Canadian Sport Institute Pacific. No conflict of interest is
present.
Medicine & Science in Sports & Exercise, Publish Ahead of Print
DOI: 10.1249/MSS.0000000000001419
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Health SciencesHealth Sciences
lia;lia;
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rint requests:rint requests:
nia
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n, Tasmania, Australia 72mania, Australi
ail: Dana.Lis@utas.edu.au
: Dana.Lis@utas.edu.au
g and Amand A
Abstract
Introduction: Gastrointestinal (GI) distress in endurance athletes is prevalent and detrimental to
performance. Adverse GI symptomatology can be analogous with irritable bowel syndrome,
where fermentable oligosaccharide, disaccharide, monosaccharide and polyols (FODMAP)
reduction has demonstrated efficacy. This study investigated the effects of low FODMAP
(LFOD) diet on GI distress parameters in runners with a history of non-clinical exercise-
associated GI symptoms. Methods: Eleven recreationally competitive runners (5 males, 6
females; 5km personal best 23:00±4:02 min:sec) participated in the study. Runners were
allocated to a randomized 6-day LFOD or high FODMAP (HFOD) diet separated by a 1-day
wash-out in a controlled, single-blinded cross-over study. In each period participants completed
two strenuous running sessions consisting of 5x1000m and a 7km threshold run. GI symptoms
(during-exercise and daily) and the Daily Analysis of Life Demand for Athletes (DALDA)
questionnaires were completed. Area under the curve (AUC) was calculated for daily GI
symptoms across each dietary period and analysis was conducted using multilevel mixed-effects
linear regression for comparison between the two diets. Results: A significantly smaller AUC
for daily GI symptoms.6-days-1 during the LFOD compared to HFOD (mean difference -13.4,
95% CI [-22, -4.60], P=0.003) was observed. The daily GI symptoms that were significantly
lower during LFOD were flatulence (P<0.001), urge to defecate (P=0.04), loose stool (P=0.03)
and diarrhea (P=0.004). No significant differences in during exercise symptoms or DALDA
responses were observed between diets (p>0.05). Conclusion: Preliminary findings suggest that
short-term FODMAP reduction may be a beneficial intervention to minimize daily GI symptoms
in runners with exercise-related GI distress.
Key words: gastrointestinal distress, exercise, diet, short-chain carbohydrates, athlete, runner’s
trots
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clinical e
clinical e
e runners (5 males,
runners (5 male
n the study. Runners w
n the study. Runners
HFOD) diet separated bHFOD) diet separated b
y. In each period participy. In each period particip
000m and 00m a
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Analysis of Life DemanAnalysis of Life Deman
under the curve (AUCunder the curv
riod and analysis was cond and analysis was con
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diarrhea (P=0.004).
iarrhea (P=0.004).
No No
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were observedwere observe
rm FODMAFOD
Introduction
Optimal athletic performance can be directly compromised by gastrointestinal (GI) dysfunction
(1). High rates of GI distress are reported to occur in 30-50% of endurance athletes (2, 3).
Although most symptoms occurring are mild to moderate, severe symptoms may impair training
capacity and performance (2). During strenuous exercise GI symptoms are triggered in part by
significant splanchnic hypoperfusion, as blood is shunted away from the GI tract towards the
working muscles, which instigates acute enterocyte injury, increased intestinal permeability and
altered motility (4). Symptoms associated with exercise-induced GI distress are numerous, but
many are analogous with clinical indications associated with irritable bowel syndrome (IBS) (5,
4). In particular, lower abdominal symptoms such as diarrhea, bloating, abdominal pain and
flatulence share remarkable similarities in both conditions. Interestingly, fermentable
oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) restriction has been
emerging as an efficacious treatment for IBS symptoms (6, 7, 5, 8). Therefore, it is plausible that
FODMAP manipulation may also positively affect exercise-associated GI symptoms (9, 10).
Nutritionists and athletes employ various dietary strategies to reduce exercise-associated GI
distress, including limiting dietary fiber and lactose, eating low-residue foods around
competition, training the gut to tolerate larger carbohydrate loads or removing gluten (11, 12). A
gluten-free diet has become a popular regimen to supposedly alleviate exercise-associated in
non-celiac athletes (13) and IBS-related GI symptoms (14) although negligible peer-reviewed
evidence exists supporting these anecdotal claims (13). Conversely, data in non-athlete clinical
populations proposes that GI symptom improvement associated with gluten elimination may
actually be modulated by the subsequent reduction in FODMAP content that generally
accompanies a gluten-free diet, and not necessarily gluten elimination itself (3, 15). A low
FODMAP diet is predicted to be the next popular equivalent to the gluten-free diet (16).
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tract tow
tract tow
stinal permeability a
tinal permeability
GI distress are numerous,
I distress are numerous
irritable bowel syndromerritable bowel syndrome
diarrhea, bloating, abdomdiarrhea, bloating, abdo
both conditions. Intereoth conditions.
arides and polyols (FODMrides and polyols (FOD
r IBS symptoms r IBS symptoms
(6, 7, 5,
positively affectositively affe
exercisexercise
etes employ various dieemploy various die
ing limiting dietary fibng limiting dietary fib
n, training the gut to tolerining the gut to
n-free diet has become
-free diet has become
on
-ce
lia
c
athl
e
t
es
iac athletes
(13) (13)
ce exists supexists
FODMAPs are poorly absorbed short chain carbohydrates that have been shown to increase
osmotic load in the small intestine and colonic gas volume, which instigates adverse symptoms
in hypersensitive individuals (10). Examples of foods restricted with a low FODMAP diet
include: lactose-containing products such as cow’s milk, a range of fruit high in fructose, wheat-
based products, onions and garlic encompassing fructans and galactooligosaccharides, and fruits
with stones (pits) or confectionary with naturally occurring or added polyols. In Western diets up
to 40 g of undigested carbohydrates reach the colon daily (17) including an average of 1-10
g.day-1 of inulin and oligofructans (18). In sensitive individuals, FODMAPs can cause adverse
GI symptoms. FODMAPs are also important dietary constituents offering favorable prebiotic
effects such as acting as a substrate for beneficial microbial populations, increasing stool bulk,
enhancing micronutrient absorption and immune function (19), so unnecessary restriction is not
advocated. To date, studies suggest that healthy individuals without IBS would not benefit from
restricting FODMAP intake (9, 20) and a prolonged strict low FODMAP diet does not appear to
be a common practice amongst athletes (21). However, in athletes looking to reduce GI
symptoms self-reported data indicates that over half eliminate high FODMAP foods, without
necessarily realizing that these foods were considered part of the FODMAP family (21). Eighty-
six percent of these athletes report subsequent symptom improvement (21). Therefore, it is
plausible that the physiological mechanisms and symptoms associated with exercise-associated
GI injury increase sensitivity to all, or some FODMAPs, and it is relevant to consider if
symptoms could be reduced with FODMAP restriction in endurance athletes.
We have recently published a case study showing positive outcomes of a low FODMAP dietary
intervention in a multisport athlete (22). Based on these results, and encouraging clinical
research on low FODMAP diets (10), it is imperative that the manipulation of short-chain
carbohydrate be investigated as a novel tool for individualized dietary management aimed at
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Western
Western
ng an average of 1-
g an average of
ODMAPs can cause adv
ODMAPs can cause adv
uents offering favorable uents offering favorable
obial populations, increaobial populations, increa
function (19),unction (19),
so unneces so un
thy individuals without IBhy individuals without I
d a prolonged strict low Fa prolonged stri
t athletes (21)athletes (21)
.
HoweveHoweve
a indicatesa indicat
that over halhat over ha
hat these foods were conshese foods were con
hese athletes report subhese athletes report sub
hat the physiological mehe physiological
njury increase sensitivity
jury increase sensitivity
ymptoms could be redu
ms could be redu
attenuating GI distress in a group of healthy athletes. Hence, the purpose of this preliminary
study was to examine the effect of a low FODMAP vs a high FODMAP diet on symptoms of
self-reported GI distress and perceived wellbeing in clinically healthy recreationally competitive
runners with a history of GI symptoms. Our a priori hypothesis was that a short-term low
FODMAP diet would reduce the severity of GI symptoms appearing daily and during strenuous
running sessions.
Methods
Participants
Eleven recreational competitive runners (>25 km running per week) aged 18-50 years with self-
reported persistent exercise-associated GI symptoms were invited to participate in this study.
Inclusion criteria included: a minimum of three chronic exercise-associated GI symptoms (e.g.
nausea, bloating, diarrhea) with score greater than 4 (quite often) on the background GI
questionnaire (23), a habitual high FODMAP intake of ≥20 g FODMAP.day-1 (24) as assessed
with the Complete Nutrition Assessment Questionnaire (CNAQ; http://www.cnaq.com.au/) (25)
and the capacity to complete two consecutive days of prescribed strenuous running training
during the study. Exclusion criteria included: a history of food intolerance (e.g. diagnosed lactose
intolerance), known celiac disease or known familial history of celiac disease, clinically
diagnosed non-celiac gluten sensitivity or IBS, current adherence to any special diet, or any pre-
existing medical condition that could be affected by dietary intervention. The dietary
intervention periods were purposefully scheduled to avoid the potential influence of hormone
changes over the menstrual cycle for the female runners. Ethics approval was obtained from the
Tasmanian Health and Medical Human Research Ethics Committee (H0015151). All participants
provided signed informed consent.
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g per week) aged 18-50 g per week) aged 18-50
oms were invited to partms were invited t
hree chronic exercise-assree chronic exercise-ass
e greater than 4 (quite e greater than 4
h FODMAP intake of FODMAP intake of
≥≥
n Assessment Questionnan Assessment Questionna
omplete two consecutivlete two consecutiv
Exclusion criteria includExclusion criteria includ
), known celiac diseasnown celiac di
nosed non-celiac gluten se
osed non-celiac gluten se
xisting medical cond
medical cond
ntion periodon pe
Experimental Design
Utilizing a single-blind, cross-over design participants were randomized to receive either a high
FODMAP (HFOD) or a low FODMAP (LFOD) diet for 6-days, separated by a 1-day washout,
followed by the alternative diet (Figure 1). Randomization was generated using GraphPad
QuickCals software. Participants were informed that they would be assigned “Specific
Carbohydrate Diet A or B” for the first dietary period then the alternate diet for the subsequent
dietary period, with no specific reference to FODMAPs or gluten. Participants self-selected their
training schedule based on study guidelines (see details below). All training was replicated
during the subsequent dietary period. Participants were asked to record their daily exercise, food
intake and complete a post-exercise GI questionnaire, daily GI questionnaire and Daily Analysis
of Life Demands (DALDA) questionnaire each day throughout the two dietary periods.
Food Preparation & Provision
Participants were provided with pre-made frozen lunch and dinner meals (prepared, weighed and
frozen in a commercial kitchen; Matson’s Catering, Launceston, Australia), breakfast (cereals,
breads, milk, yoghurt) and snack foods (muesli bars, crackers). As the study participants were
blinded, all food was packaged in the same opaque containers and labeled according to each
dietary period (e.g. week-1 muesli bars, day-2 lunch). Alongside the controlled study food
provisions, the participants were able to self-select from a suggested list (of choose and avoid)
and supplement the study food with fresh fruits, vegetables and nuts with the stipulation that a
counterpart substitution be exchanged in the second dietary period. A registered dietitian (lead
researcher) provided dietary education to participants on nutrition intake recording and
appropriate food selections. LFOD and HFOD meals were established based on previous
research (20), Monash University’s low FODMAP diet resources
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or the sub
or the sub
pants self-selected th
ants self-selected
All training was replic
All training was replic
to record their daily exerto record their daily exer
aily GI questionnaire and ily GI questionnaire and
y throughout the two dietathroughout the two
with pre-made frozen lunwith pre-made frozen lun
al kitchen; Matstchen; Mats
on’s Caton’s Ca
ghurt) and snack foods (ghurt) and snack foods (
l food was packaged in d was packaged
ry period (e.g. week-1
y period (e.g. week-1
rovisions, the participa
ons, the participa
pplement themen
(http://www.med.monash.edu/cecs/gastro/fodmap/) and typical athlete diets (26). Recipes for
LFOD and HFOD were similar, but ingredients modified to alter the FODMAP content (Table
1). Meals were matched for content of total energy, protein, carbohydrate, fat and fiber; however,
resistant starch information was not available due to the absence of comprehensive resistant
starch food composition tables. Each meal was analyzed for FODMAP content using a
FODMAP specific database (Monash University, FoodWorks Professional 7, Xyris, Brisbane,
Australia) to ensure that LFOD meals contained less <0.5 g FODMAP.meal-1 (27). An example
of the study meals for each diet are provided in Table 1. The prototype study menu presented a
macronutrient profile containing carbohydrate 5-7 g.kg-1, protein 1.2-1.7 g.kg-1 and fat 0.8-1.2
g.kg-1 (26) (FoodWorks Professional 7, Xyris, Brisbane, Australia).
Exercise and Prescribed Running
Participants self-selected their training schedule based on study guidelines which indicated: day
1 and 2 to be light to moderate intensity training, day 3 to be rest or very light non-running
exercise (e.g. yoga, swimming). Day 4 and 5 were prescribed very intense running sessions and
day 6 was entirely self-selected exercise or rest. Day 4 (interval session) consisted of a 10 min
self-prescribed warm up with increasing intensity, 5 x 1000 m interval pace (100% of predicted
vV02max) with 3-min brisk walk or light jog between intervals followed by a 10-min self-selected
cool down. Day 5 (threshold session) consisted of a 7–10 min self-selected warm up with
increasing intensity, 7 km at threshold pace (~90% of predicted vV02max) followed by a 10-min
self-selected cool down. Prescribed running sessions were individually monitored using
participants’ personal Garmin GPS running watches (Forerunner® 735XT, 630XT, 235 or
910XT) and all training was replicated in the second intervention period. Interval and threshold
paces were individually prescribed based on calculations from a recent race performance using
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Xyris, B
Xyris, B
mealeal
-
1
-1
(27). An examp
(27). An exam
type study menu presente
type study menu presen
otein 1.2-1.7tein 1.2-1.7
g.k
g g.k
-
1
and fand f
Australia). Austral
ining schedule based on ing schedule based on
derate intensity training, erate intensity training,
wimming). Day 4 and 5 wming). Day 4 and 5 w
ely self-selected exercise ly self-selected exercise
ibed warm up with increawarm up with in
max
max
)
)
with 3-min brisk walwith 3-min brisk wal
ool down. Day 5 (thr
wn. Day 5 (thr
ing intensityinten
VDOT (velocity at vV02max) tables (28). Running sessions were completed on flat terrain, at the
same time of day (±30 min) over the period of data collection (December 2015 to February
2016).
Gastrointestinal Symptom Monitoring
During-exercise GI questionnaires and daily GI questionnaires were used to assess the
occurrence and severity of upper and lower abdominal symptoms determined using a 10-point
scale ranging from 0 “no problem at all” to 9 ‘‘the worst it has ever been” (23). Section 1 of the
questionnaire addresses upper abdominal symptoms: reflux, heartburn, burping, bloating,
stomach pain/cramps, vomiting and nausea. Section 2 addresses lower abdominal symptoms:
flatulence, urge to defecate, left abdominal pain (side stitch), right abdominal pain (side stitch),
loose stool, diarrhea and intestinal bleeding (23). Diarrhea criteria was defined as an increase in
the number of bowel movements per day compared with the participants usual bowel habit.
Participants completed the during-exercise GI questionnaire immediately following their training
session and the daily GI questionnaire at the end of each day at the same time. GI symptom
scores were tabulated for each day and exercise session (23). Mean scores for daily GI
symptoms, during-exercise GI symptoms, and incremental area under the curve (AUC) for daily
GI symptoms across all 6-days of each dietary period were compared between the diets.
Perceptual Wellbeing Monitoring
Participants completed the DALDA questionnaire at the end of each day. This questionnaire is
used to assess general stress levels (Part A) and to determine stress-reaction symptoms (Part B)
using a rating scheme of “worse than normal,” “normal,” or “better than normal” for variables.
Scores were tabulated and the “worse than normal” and “better than normal” scores compared
between the two dietary periods.
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ed to ass
d to as
mined using a 10-po
ined using a 10-p
r beenbeen
”
”
(23). Section 1 of
). Section 1 o
ux, heartburn, burping, ux, heartburn, burping,
addresses lower abdomiaddresses lower abdom
side stitch), right abdomiide stitch), right ab
(23). Diarrhea criteria wa23). Diarrhea criteria wa
day compared with the day compared w
-exercisexercise
GI questionnairGI questionnair
uestionnaire at the end ouestionnaire at the end o
d for each day and exr each day and ex
ng-exercise GI symptomsg-exercise GI symptoms
ms across all 6-daysross all 6-days
of
o
ea
erceptual Wellbeing M
ual Wellbeing M
pants complts co
Statistical Analysis
All GI symptoms and DALDA scores and dietary variables were treated as continuous data (29)
and compared between the two diets using multilevel mixed-effects repeated measure linear
regression adjusted for order and period effects (Stata 13.0, StataCorp LP, College Station, TX).
Regression residuals were tested for assumptions of linear regression (heteroscedasticity,
skewness, kurtosis or linearity). Where regression residuals did not meet the assumptions of
linear regression the analyses were repeated with multilevel mixed-effects ordered logistic
regression. For consistency, all comparison results are presented as mean difference (95%
Confidence Interval). For each dietary intake variable, the mean±SD was calculated and
compared between the diets using mixed-effects ordered logistic regression. P values (P<0.05)
are from the relevant analyses (linear regression or ordered logistics regression in case of
violation of linear regression assumptions). Incremental AUC, above zero, for daily GI
symptoms was calculated from total daily GI symptom scores over each 6-day diet (GraphPad
Prism, version 6.0, San Diego, CA) and compared between the two diets.
Results
Participants details and compliance
Dietary intake (Table 2), GI symptom assessment (Figure 2) and DALDA results were available
for 11 of 12 participants (5 males, 6 females, 41±10 years, weight 69.0±12.0 kg, height
171.1±10.0 cm, 5 km personal best 23:00±04:02 min:sec). One participant was removed due to
incomplete data. Background GI symptoms, primarily boating, flatulence, urge to defecate and
loose stool were predominant and were reported to occur quite often to always (score of ≥4 to
9). Total habitual daily FODMAP intake was 43.8±16.9 g FODMAPs.day-1. The prescribed
running sessions were completed as assigned, and exercise volume matched in each period
(HFOD total exercise volume 50:12:43 hh:min:sec, 0:56:51±0:25:33 daily mean±SD; LFOD
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e assump
e assump
ffects ordered logis
fects ordered log
d as mean difference (9
d as mean difference (
he meane mean
±±
SD was calcuSD was calcu
d logistic regression. d logistic regression.
P vP
n or ordered logistics ren or ordered logis
).).
II
nc
r
e
m
e
ntal
ncrementa
AUC
,
aily GI aily GI
s
ymptom
mptom
scores
A)
and compared betweenand compared between
ails and complianceails and compliance
ake (Table 2), GI symptoTable 2), GI sym
1 of 12 participants (5
1 of 12 participants (5
71.1±10.0 cm, 5 km pe
0.0 cm, 5 km p
lete data. Be dat
50:36:42, 0:57:18±0:23:55) with no significant differences in temperature (16.2±5.2 vs
15.7±4.9°C) or humidity (64.0±14.9 vs 55.3±19.6%) for the LFOD or HFOD dietary periods,
respectively.
All participants consumed the prescribed diets and dietary intake was analyzed from food intake
records for HFOD and LFOD. The composition of the diets is shown in Table 2. The two test
diets were similarly matched for total energy, carbohydrate, and fiber. Protein and fat were
statistically different between the diets (P=0.03 and P=0.003, respectively). These differences are
of negligible clinical significance given the 5 g protein and 7 g fat daily variances. As designed,
FODMAP intake differed significantly between the two diets being 41.4±7.9 g.day-1 HFOD and
8.1±3.5 g.day-1 LFOD (P<0.0001).
Gastrointestinal Symptoms: Daily and During Exercise
Daily GI symptoms scores were collected each day of the study and tabulated. Individual AUC
responses show that 82.0% (9 of 11) of participants had a smaller AUC for daily GI symptom
scores.6-days-1 during the LFOD compared to HFOD (mean difference -13.4, 95% CI [-22, -
4.60], P=0.003; Figure 2a). The group AUC (Figure 2b) was lower in LFOD (31.4±24.6;
mean±SD) compared to HFOD (44.6±33.6). Specific daily GI symptoms that were reduced
during LFOD included: flatulence (mean difference -1.12 95% CI [-1.55, -0.75], P<0.001), urge
to defecate (mean difference -0.41, 95% CI [-0.81, -0.02], P=0.04), loose stool (mean difference
-0.38, 95% CI [-0.73, -0.04], P=0.03) and diarrhea (mean difference -0.45, 95% CI [-0.75, -0.14],
P=0.004). The mean GI symptoms scores for day 1 to 6 were higher during HFOD compared to
LFOD (mean difference -2.45, 95% CI [-4.21, -0.69], P=0.006; Figure 2c). No order or period
effects were observed for total daily GI symptoms, during-exercise GI symptoms on any of
analyzed variables except for loose stool (mean difference -0.35, 95% CI [-0.79, -0.01], P=0.03).
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e 2. The
e 2. The
. Protein and fat we
Protein and fat w
tively). These differences
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g fat daily variances. As g fat daily variances. As
diets being 41.4±7.9 g.ddiets being 41.4±7.9 g.d
During Exercise During Exercise
collected each day of thellected each day of the
(9 of 11) (9 of 11
of participantsf participants
the
L
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FigFig
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mean differmean differ
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0.7
During-exercise GI symptoms scores for the HFOD and LFOD dietary periods for day 4 and day
5, when prescribed strenuous running sessions, were compared. Half of the participants rated GI
symptoms during the prescribed running sessions to be moderate to severe (≥3). Burping was the
one symptom that was significantly higher (mean difference 0.30, 95% CI [0.01, 0.58], P=0.04)
during LFOD compared to HFOD. No significant differences in any other GI symptoms were
found during the prescribed running sessions between HFOD and LFOD.
Perceptual Wellbeing
Overall wellbeing was measured using DALDA and the worse and better than normal scores
were compared for each dietary period, as well as the scores on the prescribed training days (day
4 and 5). Total worse than normal scores for stress (part A) and stress response (part B)
combined were not different (mean difference -0.45, 95% CI [-1.30, 0.40], P=0.30) during
HFOD (3.71±3.18) compared to LFOD (3.30±3.31). Similarly, total better than normal scores for
the HFOD (2.59±2.80) and LFOD (2.97±3.66) were not significantly different across each
dietary period (mean difference 0.43, 95% CI [-0.52, 1.37], P=0.38). Total worse than normal
scores on day 4 or day 5 were not different (mean difference -0.82, 95% CI [-2.26, 0.63], P=0.30;
mean difference -0.91, 95% CI [-2.35, 0.53], P=0.25, respectively). Total better than normal
scores on day 4 or day 5 were not different (mean difference 0.5, 95% CI [-1.11, 2.11], P=0.55;
mean difference 1.23, 95% CI [-0.39, 2.84], P=0.10, respectively). No order or period effects
were observed for DALDA scores.
Discussion
Dietary intake, and its interactions with strenuous exercise, are of particular importance to
athletes as resulting GI distress is a common problem potentially impairing training capacity and
performance (12). This is the first study to examine the effects of a short-term low FODMAP
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rse and better than normrse and better than norm
ores on the prescribed traores on the prescribed tra
stress (part A) and strestress (part A) and
nce -0.45, 95% CI [-1.nce -0.45, 95% CI [-1.
(3.30(3.30
±
3.31
)
.
±3.31).
Similarly, Sim
to
OD (2.97D (2.97
±
3
.
6
6±3.66
)
were nowere n
ence 0.4ence 0.4
33
, 95% CI [-0.55% CI [-0.5
5 were not different (meere not different (me
-0.-0.
9
1
91
, 95% CI [-2.35, 95% CI [-2.35
,,
day 4 or day 5 were not dor day 5 were n
n difference 1.23, 95% C
difference 1.23, 95% C
ere
observed for DALD
served for DAL
diet on GI symptoms and perceptual wellbeing in athletes with a history of exercise-associated
GI distress. The aim of this preliminary study was to investigate if self-reported and case-study
outcomes, demonstrating beneficial effects of FODMAP reduction on exercise-associated GI
symptoms (22, 21), could be substantiated in a larger cohort. Results from this preliminary study
indicate that a low FODMAP diet had a positive effect on daily GI symptoms in 82% of
participants.
Effect of low FODMAPs on daily GI symptoms
In participants with persistent exercise-associated GI symptoms, 9 of the 11 reported a reduction
in daily GI symptoms on a short-term low FODMAP diet (Figure 2). To date, low FODMAP diet
research has predominantly focused on clinical populations, specifically individuals with IBS.
Discernible symptomatic improvements in approximately 70% of IBS patients encourage the use
of this diet as first line treatment (10). A limited number of investigations have included healthy
controls (9, 30, 20) and results suggest that although healthy individuals demonstrate functional
changes with FODMAP ingestion, GI symptoms remain very minor or non-existent (30, 20).
Low level GI symptoms likely have a negligible impact on athletic performance, but more
moderate to severe symptoms may be detrimental (1). Although healthy populations, including
healthy athletes, would be assumed to not benefit from FODMAP reduction with reduced GI
symptoms, it is interesting to consider if the unique physiological, mechanical and nutritional
stress encountered by endurance athletes could increase susceptibility to any dietary triggers,
such as FODMAPs, for some of these athletes. GI symptoms are largely variable but our
preliminary data suggests that a short-term low FODMAP diet may be efficacious in the
management of daily GI symptoms (Figure 2); particularly lower abdominal GI symptoms, in
healthy athletes. Although changes in GI symptoms during exercise were not found, the ability to
reduce daily GI symptoms would be very advantageous in extended events like the Tour de
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ms, 9 of the 11 reported a ms, 9 of the 11 reported a
(Figure (Figur
2
)
.
To date, lowo date, low
opulations, specifically iopulations, specific
pproximately 70% of IBSproximately 70% of IBS
A limited number of inveA limited numbe
uggest that although healtgest that although heal
gestion,gestion,
GI symptoms re GI symptoms re
oms likely have a negliglikely have a negli
ere symptoms may be deere symptoms may be de
hletes, would be assumed, would be assu
ptoms,
oms,
it is interesting to it is interesting to
ress encountered by e
ncountered by e
s FODMAPODM
France, rigorous training camps or multi-event athletics, which feature sequential days of
intensive and extensive exercise.
Effect of low FODMAPS on exercise specific GI symptoms
GI symptoms during prescribed running sessions were similar for the HFOD and LFOD dietary
periods. In race conditions four to 32% of athletes report GI distress and some symptoms are so
severe that withdrawal from competition results (23). Numerous factors exacerbate GI symptoms
during exercise including dietary intake/timing, mechanical impact and physiological stress.
Significantly greater GI issues are reported during prolonged events (e.g. Ironman), as compared
to relatively shorter events, such as the marathon (23). Ingestion of carbohydrates as consumed
in endurance sport, particularly solutions with a high osmolality, are associated with the
development of GI symptoms during exercise (31). Exercise duration in the current study did not
warrant carbohydrate ingestion, however it is interesting to consider if ingestion of short-chain
carbohydrates during exercise or pre-existing FODMAPs in the GI tract would have additive
osmotic actions and consequent symptoms (2). It is possible that the chosen exercise duration
(45-60 min.day-1), coupled with no CHO ingestion during exercise, curtailed any measurable
difference in during exercise GI symptoms between the diets. Timing of FODMAP intake may
also influencing symptoms. In the present study runners replicated their usual dietary patterns
(e.g. timing) before exercise, which was fundamental in this research design to avoid altering
habitual food intake timing and adding a confounding variable to the primary measure. Although
this study did not investigate mechanistic hypotheses it may also be conceivable that GI
symptoms during exercise could be exacerbated with the presence of short-chain carbohydrates
in the gut or during exercise FODMAP ingestion. In overall GI symptom reduction, our
preliminary findings support further research of the hypothesis that FODMAP reduction would
positively affect the severity or occurrence of exercise-associated GI symptoms.
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symptom
symptom
xacerbate GI symptom
acerbate GI sympt
act and physiological str
ct and physiological st
events (e.g. Ironman), as vents (e.g. Ironman), as
Ingestion of carbohydratengestion of carbohydrat
a high osmolality, are a high osmolality
e (31). Exercise duration (31). Exercise duration
er it is interesting to coner it is interestin
pre-existing FODMAPspre-existing FODMAPs
quent symptoms (2). It isuent symptoms (2). It is
upled with no CHO ingd with no CHO ing
ring exercise GI symptoming exercise GI symptom
ncing symptoms. In the symptoms. In
timing) before exercise,
iming) before exercise,
abitual food intake timi
l food intake tim
udy did nodid
Effects of altering FODMAPS on perceptual wellbeing
Extreme and persistently high chronic training loads are associated with greater psychosomatic
stress. Psychological wellbeing, personality traits and psychosocial factors, such as stress, also
have the potential to influence perceptions of GI symptom presence and severity (32). The
reverse may also occur, in that GI symptoms caused by exercise may be reflected by reductions
in overall perceptual wellbeing. In the current study DALDA evaluation was conducted
alongside each dietary intervention with the aim to capture the relationship between perceptual
wellbeing and GI symptoms influenced by diet and exercise stress. In athletes, the multifactorial
nature of GI distress is well known and the influence of psychological wellbeing or stress on
alterations of the autonomic nervous system has been recognized (33, 34). These changes in
homeostatic balance have been characterized by slowing of gastric emptying, increased distal
colonic motility and acceleration of intestinal transit, further contributing to adverse GI
symptoms (35). In the present study, it is possible that DALDA was not a sensitive enough tool
to detect any FODMAP related changes. A more chronic fatigue state over several days/weeks or
longer is likely required to capture changes in DALDA responses (36).
Reflections for future studies
Dietary control was achieved, however three reasons are suggested as to why no difference in GI
symptoms were observed during the prescribed strenuous running sessions. First, daily GI
symptoms on the LFOD diet were lower compared to HFOD. Lower pre-exercise symptomology
during the LFOD may have skewed perceptions of the during exercise GI symptoms toward
being more exaggerated (greater net difference) resulting in reporting of higher during exercise
symptom scores for LFOD. Secondly, although residual FODMAPs are suggested to transit
through the GI tract in less than 3-days (11) a longer period of LFOD may be necessary to
augment further symptom reduction. Changes in the gut microbiome occur over time as the
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n was co
was co
hip between perceptu
ip between percep
In athletes, the multifacto
In athletes, the multifact
ychological wellbeing or ychological wellbeing or
recognized (33, 34).recognized (33, 34).
Th Th
slowing of gastric emptylowing of gastric
tinal transit, further coinal transit, further co
is possible that DALDAis possible that D
hanges. A more chronic fanges. A more chronic f
apture changes in DALDapture changes in DALD
uture studies ture stud
ntrol was achieved, howewas achieved, h
ptoms were observed du
oms were observed du
ymptoms on the LFOD
ms on the LFOD
the LFOD e LFO
biomass evolves and it is possible that the full benefits of the diet are not realized until 7-days
(24) or a few weeks (10). Most importantly, exercise duration and climatic factors have been
correlated with GI distress (23). Longer running sessions may be required to distinguish
differences in GI symptoms between the diets. Although, the outdoor running climate throughout
the current study was moderate with nominal variance between intervention periods, differences
in climate and hydration status should be considered as influencers of GI symptoms. A greater
effect may be observed under more extreme exercise conditions and future research should
consider this element in the methodology.
FODMAP manipulation considerations for the practitioner
Our developing work proposes that FODMAP manipulation may be an innovative addition to the
sport nutrition practitioners’ toolbox for management of exercise-associated GI distress. Certain
considerations must be taken into account when trialing short-chain carbohydrate restriction with
athletes as dietary requirements are individual and unnecessary food restriction may compromise
optimal fueling (37). When appropriately planned, under the guidance of a dietetic professional,
a low FODMAP diet can be matched for energy, macronutrients and fiber (Table 2). Although
differences in protein and fat intake were statistically significant between LFOD and HFOD, 7
and 5 g, respectively, these findings are not clinically significant. As a source of high quality
protein, cow-based dairy is often consumed by athletes at or above the general population
recommendation of two to four servings per day. Coinciding high lactose intakes are likely
(Table 2) and should be investigated as a primary trigger for GI symptoms with appropriate high
protein substitutes made, such as lactose free milk if required. A low FODMAP diet should be
considered once typical GI symptom triggers have first been assessed, such as lactose (11, 12).
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D
ptoms
.
D
uture research sh
ner er
nipulation may be anipulation may be an
inno
nagement of exercise-assoagement of exercise-asso
unt when trialing short-chnt when trialing
re individual and unnecesindividual and unneces
appropriately planned,appropriately planned,
uu
can be matched for enerbe matched for ener
rotein and fat intake wereotein and fat intake were
espectively,tively
these findinge fin
in, cow-based d
n, cow-based d
air
y
airy
isis
ecommendation of two
mendation of two
2) and shouand s
Intakes of prebiotic fructooligosaccharides and galactooligosaccharides, found in high amounts
in wheat and legumes, are restricted with a low FODMAP diet, which is concerning. These
prebiotics stimulate healthy colonic Bifidobacterium. After 4-weeks of a restricted fermentable
carbohydrate diet Bifidobacteria populations were decreased in IBS patients (38). Immune health
may be compromised with lower Bifidobacterium count, which is an important consideration for
overall athlete immunity and health (39). In athletes, it is unclear if risk associated with
decreased healthy bacterial populations due to diet may be more or less apparent as exercise
further alters diet-microbe-host metabolic interactions and may support higher gut
microorganisms diversity (40). Exercise and an athletes’ diet could offer a protective element
against a decrease in healthy gut bacterial populations associated with FODMAP restriction.
Given the restrictive nature and novelty of this dietary approach a systematic and individualized
approach will be obligatory for successful and efficacious implementation of a low FODMAP
diet in an athletic setting.
Conclusions
Results from this study have shown that a short-term LFOD results in significantly lower daily
GI symptoms over the intervention period compared to a HFOD diet in athletes with a self-
reported history of persistent exercise-associated GI distress. Exercise-associated GI distress and
pathophysiology of IBS are multifactorial, but both conditions feature similar symptomatology.
Although, more work is needed to determine the effectiveness of a low FODMAP diet, our
preliminary findings suggest this dietary approach may be applicable beyond the clinical realm
and offer a novel strategy to reduce GI symptoms in some symptomatic but otherwise clinically
healthy athletes.
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associa
associa
ss apparent as apparent as
exerc
exe
may support higher
may support higher
couldcould
off
er a protec
offer a protec
tiviv
associated assoc
with FODMwith FODM
tary approach tary approach
aa
systematsys
nd efficacious implemennd efficacious implemen
y have shown that a shove shown that a sho
ver the intervention periver the intervention peri
story of persistent exerciof persistent ex
ophysiology of IBS are m
physiology of IBS are m
lthough, more work i
gh, more work i
nary findiny fin
Acknowledgments
The authors would like to thank Monash University, Department of Gastroenterology, for
assisting with FODMAP quantification. The King and Amy O’Malley Trust provided
scholarship support. Isabelle Goodwin and Sarah Weber assisted with data input and food
logistics. The results of this study are presented clearly, honestly, and without fabrication,
falsification, or inappropriate data manipulation. The results of the present study do not
constitute endorsement by ACSM.
Funding
This study was supported in part by the Canadian Sport Institute Pacific. No conflict of interest is
present.
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nt study
nt study
ED
nstitute Pacific. No conflnstitute Pacific. No confl
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e in athletes: FODMA
in athletes: FODM
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ci Sports
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tial effects of FODM
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List of Figures
Figure 1 – Schematic showing participant selection and study design. LFOD=Low FODMAP
diet, HFOD=High FODMAP diet, GI=gastrointestinal, DALDA=Daily Analysis of Life
Demands for Athletes
Figure 2 – (a) Individual area under the curve (AUC) for daily gastrointestinal (GI) symptom
scores over 6 days for LFOD vs HFOD (n=11). (b) Mean group AUC during LFOD compared to
HFOD for daily GI symptom scores. (c) Mean total daily GI symptom scores for each day (day
1-6) of the dietary period for all participants (error bars represent standard deviations) on LFOD
and HFOD (p=0.006). * Denotes significance (P=0.003)
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ntestinal (GI) sympto
testinal (GI) symp
C during LFOD compare
C during LFOD compar
symptom scores for eachsymptom scores for each
represent standard deviatrepresent standard deviat
.003) 003)
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Table 1. Example of high and low FODMAP diets
a low FODMAP muesli made with rice crispies, corn flakes, quinoa flakes, shredded coconut,
and pumpkin seeds
b low FODMAP pesto pasta made with: cherry tomatoes, eggplant, garlic infused oil, pine nuts,
basil, parsley
c high FODMAP pesto pasta made with: cauliflower, asparagus, pistachios nuts, basil, parsley,
garlic
d low FODMAP vegetables included: small portion sweet potato, red bell pepper, spinach
e high FODMAP vegetables included: larger portion of sweet potato, beetroot, garlic, red onion
Meal
Low FODMAP diet
High FODMAP diet
Breakfast
low FODMAP muesli
a
lactose-free milk
blueberries
coffee/tea with lactose-free milk
muesli with dried fruit and nuts
milk
apple
coffee/tea with milk
Snack
corn Cruskits
lactose-free yogurt
grapes
rye Cruskits
yogurt
nectarine
Lunch
maple glazed salmon on quinoa/rice
pesto pastab
honey glazed salmon on durum wheat
pesto pastac
Snack
gluten-free biscuits
cheddar cheese
tomato, cucumber
wheat biscuits
cheddar cheese
snap peas, cucumber
Dinner
grilled chicken and vegetables on
quinoad
grilled chicken and vegetables on
couscouse
Snack
lactose-free yogurt
strawberries
coffee/tea with lactose-free milk
yogurt
cantaloupe
coffee/tea with milk
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made with rice crispies, code with rice crispies, co
s
ACC
pesto pasta made wit
AC
AC
FODMAP pesto
A
A
MAP
glazed salmon on durum wglazed salmon on durum w
sto pastato pasta
cc
wheat biscuits wheat b
c
heddar chee
s
e
cheddar che
snap peas, cucumsnap peas, cucu
es onon
grilled chickegr
couscous
th lactoseth lactose
-
f
ree milk
ree milk
yoguyo
CE
Table 2. Composition of dietary intake during the habitual and low FODMAP dietary periods
Dietary Component
HFOD
LFOD
P value
Total energy (kcal)
3181 ± 403
3198 ±429
0.724
Total carbohydrate (g)
323 ± 63
327 ± 67
0.569
Total protein (g)
158 ± 16
153 ± 20
0.030*
Fat (g)
130 ± 12
137 ± 15
0.003*
Fiber (g)
32 ± 5
30 ± 5
0.318
Total FODMAPs (g)
41.4 ± 7.9
8.1 ± 3.5
<0.0001*
Excess fructose (g)
1.9 ± 0.54
0.5 ± 0.4
<0.0001*
Lactose (g)
28.0 ± 8.6
0.9 ± 0.3
<0.0001*
Total oligosaccharides (g)
8.7 ± 1.9
5.5 ± 3.2
0.001*
Fructooligosaccarides (g)
7.3 ± 1.8
4.5 ± 2.7
<0.001*
Galactooligosaccarides (g)
1.4 ± 0.3
1.0 ± 0.5
0.006*
Total Polyols (g)
2.9 ± 0.9
1.3 ± 0.7
<0.0001*
Sorbitol (g)
1.8 ± 0.9
0.9 ± 0.4
0.001*
Mannitol (g)
1.1 ± 0.3
0.4 ± 0.5
<0.0001*
Energy, macronutrients and fiber were calculated using FoodWorks dietary software, which is
based on the Australian Food Composition tables. Total FODMAPs = excess fructose + lactose +
sorbitol + mannitol + fructans + galactooligosaccharides (GOS). Bold text indicates additive
constituents for total FODMAPs. Data is presented as group (n=11) mean ± standard deviation
(SD) for HFOD and LFOD. *Significance between HFOD and LFOD (P<0.05).
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<0.0<0.0
<0.000
<0.000
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000
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Total FODMotal FO
s + galactooligosaccharid+ galactooligosacchar
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