Athlete Case Study – FODMAP Diet
\24-year old female international multi-event athlete who had received nutrition support to assist with an exceptionally heavy training and competition schedule. She was also a full-time student and living away from home so food prep and timing where a difficulty especially on a number of days of the week where the athlete has three disciplines to train for in conjunction with her studies.
Given her multisport training schedule, another big challenge for the athlete and the practitioner was fuelling and the volume of food required to do this often proved a difficult. In an effort to give pragmatic solutions, the athlete had decided to use a number of nutritional supplements along with normal foodstuffs specifically on these ‘time poor’ days. This also allowed some competition prep as these heavy training days mimicked competition days and trialling of fuelling strategies would have been a priority. As the relationship developed between the practitioner and the athlete, it was then did the athlete reveal that there were occasional gastro-intestinal symptoms of bloating and pain. She was quite vague about severity of the symptoms initially and on further questioning it appeared that they didn’t appear to follow any specific pattern and actually she would have periods of time (months) where she had no symptoms at all.
She did feel that competition was potentially an issue. A further number of months passed and fuelling training became the most significant issue as the athlete was presenting with biochemical changes which would indicate RED-s. Changes in circulating and storage iron levels, abnormalities in white cell measures and lipid profiles and reporting fatigue. Requests were made by the wider service support team to look at the training schedule as it was felt that the athlete would be unable to sustain performance especially with some major qualification events on the horizon.
At one of these events, the athlete suffered with extreme pain and her gastrointestinal symptoms caused major performance problems. Following this event, a major review of practices was undertaken. In-depth dietary assessment of symptoms highlighted that in recent times one specific day in the week (triple training day) she seemed to follow a similar pattern to competition and it was on this day that the athlete relied on a number of nutritional supplements due to lack of time. Gels, bars and shakes along-side normal foods got her through exceptionally busy days and a similar pattern of intakes were seen at competition where time was short and access to suitable foodstuffs could be problematic.
From calculations, it was identified that the fructose and sorbitol content of the supplements that she was using was exceptionally high. This was not immediately evident from the labels and further information was sought from the supplement companies. Alternative suggestions were made and a specific plan for triple training and competition days was prepared. Symptoms resolved almost immediately, which from a practitioner experience is very unusual in any intervention. Subsequent interventions in this area with other athletes have shown that you can get significant changes in a very short time frame if the athlete responds.
Key learning points
Athletes rarely have just one issue and often in the complexity of other issues other problems especially gastrointestinal issues can get lost. Now as part of initial assessment, all athletes are asked about gut health. The aim of this is to educate athletes that even though gut issues may not currently be a problem, issues can arise as competition and training intensities increase. This also helps to normalise a topic area, which some athletes find uncomfortable to discuss.
There are different subtypes of IBS and it is important to establish the symptoms the athlete has in order to target the treatment.
Prior to going down the FODMAP route which some athletes can find tricky to follow and difficult to apply especially when travelling first lie dietary advice should be given to modify the diet (especially around fibre) and avoidance of potential triggers and ensuring balance if a specific food group is a trigger.
Gluten free does not automatically mean low FODMAP. Quite often, many of the gluten free bars and snacks can be a significant source of the other triggers. They often contain significant amounts of dried fruit and probably polyols in large amounts. Food labels will provide information relating to this but quite often further detail may need to be sought from manufacturers.
The “load” of FODMAP rich foods is an important factor. The athlete in the case report did not have issues with all FODMAPS and the biggest problem was with fructose. However, on occasion we would include gluten free pasta into her diet based on the “load or quantity” of pasta that she needed to consume.
Ask athletes have they changed their diet significantly recently especially if symptoms are relatively new. The phenomenon of “clean eating” is certainly linked to increases in FODMAPS. Although perceived as healthier for certain individuals the overall increase in the amounts of them can have a real impact on their gut health and does not suit them.
For some athletes the gut issues only arise around training and competition. Carefully planning the intakes and types of carbohydrates at these times can be a simple way of managing symptoms.
There is some evidence that probiotics can help with IBS symptoms, but this may vary depending on which probiotic preparation is used. Our advice is to try one management strategy at a time. Commence a low FODMAP diet first and if you have not achieved good symptom control with the athlete after 2-6 weeks on the diet, then look at other management strategies, including the possibility of introducing probiotics.
Author
Dr Sharon Madigan
Dr Madigan is Head of Performance Nutrition at Sport Ireland Institute. She delivers service to a range of sports and is responsible for coordinating nutrition support services. She has supported Team Ireland through the last 3 Olympic Games.
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References
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