Gut Reactions

Gastrointestinal ailments can sideline any athlete anytime. Here are nutritional strategies that can ease suffering and get your athletes back in the game.

By Leslie Bonci

Leslie Bonci, MPH, RD, is Director of the Sports Medicine Nutrition Program at the University of Pittsburgh Medical Center Health System, and a consultant to the University of Pittsburgh Department of Athletics, the Pittsburgh Steelers, Pittsburgh Ballet Theater, and several Pittsburgh-area high schools.

Training & Conditioning, 11.8, November 2001,

A bout with nausea or diarrhea will blunt an athlete's urge to compete faster than an Olympic sprinter bursts out of the starting blocks. Yet, try as you might to keep your athletes in top shape, gastrointestinal problems can affect even the best athletes.

Sometimes, gastrointestinal problems are simply caused by eating something "bad." On other occasions, these maladies are the result of various gastrointestinal disorders. As an athletic trainer, you need to be familiar with the various types of gastrointestinal problems that can affect your athletes, and you should learn some of the nutrition solutions available for them.

This article will cover the nutritional and pharmacological management of the most typical digestive problems. These problems include food poisoning, nausea and vomiting, constipation, diarrhea, gas and bloating, heartburn, lactose intolerance, and irritable bowel syndrome (for irritable bowel syndrome, see Sidebar, "Managing IBS" at the end of this article).

Food poisoning can be especially problematic because it usually causes vomiting and diarrhea and can result in dehydration and electrolyte loss. For someone with food poisoning, competition is not an option.

In all but the most severe cases of food poisoning, the problem will usually run its course in less than a day. Your athletes will recover more quickly if they can slowly rehydrate and replenish lost electrolytes. Therefore, your affected athlete should sip fluids, such as sport drinks (preferably ones that contain electrolytes). Another option is to drink a pediatric electrolyte replacement solution designed for infants recovering from vomiting or diarrhea. Juices diluted with water are helpful and so are salty foods such as pretzels or salted crackers.

For nausea, it is important to recommend that affected athletes let their stomachs rest. A nauseous person may find normal food odors to be repulsive and it can even trigger vomiting. In many cases, athletes affected with nausea may feel better by staying away from food odors altogether.

The issue of a nauseous athlete finding food repulsive leads to a dilemma: even if an athlete is nauseated, he or she needs to consume some nutrition and enough fluids to prevent dehydration. Some foods can be helpful in alleviating the effects of nausea because they are relatively bland, they can provide some nutrition, and they may contain significant amounts of water. These foods include: clear liquids, canned fruits, toast, crackers, yogurt, sherbet, pretzels, angel-food cake, oatmeal, skinned chicken (baked or broiled, but never fried). Even chewing and sipping ice chips is helpful.

If your athlete is nauseous, the following foods should always be avoided: fatty, greasy, and fried foods; foods with strong odors; and sweets such as candy, cookies, and most types of cake.

In addition to the types of food a nauseated athlete chooses, how one eats or drinks can also affect nausea symptoms. To lessen the symptoms of nausea, encourage athletes to:

Eat smaller amounts of food than normal, but more frequently.
Drink less with meals to avoid feeling bloated.
Sip liquids through the day.
Drink cold beverages.
Avoid hot foods since they may cause nausea (room-temperature items may be easier to tolerate).
Rest after meals.
Sit up for one hour after eating.
Wear loose fitting clothes.

Although many people choose ginger ale when nauseated, it may actually worsen symptoms due to its carbonation. In general, athletes should avoid carbonated soft drinks and sparkling water. In many cases, tea made from grated ginger, or chewing on a small piece of candied ginger may help to relieve nausea.

For vomiting, athletes should be advised to withhold food or beverages until vomiting has subsided and then proceed as follows:

Start by drinking clear liquids. Drink one teaspoon every 10 minutes, then increase to one tablespoon every 20 minutes. Finally, begin drinking two tablespoons every 30 minutes until the athlete feels better.

For constipation, it is important to realize that normal bowel movements vary considerably from person to person, ranging from a frequency of three times a day to three times a week. True constipation is defined as dramatic changes in bowel movements or continual painful straining to eliminate small hard stools.

Events and conditions that can trigger constipation include:
Changes in activity, such as inactivity due to an injury.
Straining during bowel movements.
Hormonal fluctuations during the menstrual cycle.
Medications such as diuretics, calcium- or aluminum-based antacids, iron and calcium supplements, antihistamines, and pain medications with codeine.

There are several nutrition solutions to choose from that can alleviate constipation. A popular solution entails adding fiber to the diet of the affected person, either by eating more fiber-rich foods or by consuming fiber supplements. Adding fiber provides additional bulk to the stool, which causes it to push against the intestinal wall, thus forcing waste through. If supplements are chosen, affected athletes should add at least 20 grams of fiber to their diet per day. Also, encourage the athlete to consume more high-fiber foods such as bran, prunes, prune juice, or figs. Even caffeine may stimulate bowel movements, but consume a little at a time.

It's also important for those suffering from constipation to drink plenty of fluids, which help keep stools soft and easier to evacuate. Warm or even hot food and drink can be the most helpful. For example, suggest that the affected athlete drink a hot beverage or eat hot cereal 30 minutes before the time he or she would have a bowel movement.

There are many commercial supplements, such as bulk-forming laxatives, that can help. However, these supplements can also cause bloating. A similar, and equally useful option, is to add ground flaxseed or flaxmeal to cereal or applesauce. Start with one teaspoon per day and gradually build up to a dose of two tablespoons per day.

Certain high-fiber foods, particularly cascara and senna, can cause nausea and cramping and should not be used to alleviate constipation. In addition, cascara and senna can be mildly habit forming and therefore, should never be used in an ongoing basis.

The opposite of constipation, diarrhea, is an increase in the frequency, fluidity, and volume of usual bowel movements. Diarrhea can be caused by many factors, including viral or bacterial infections, parasites, reaction to medication (especially antibiotics), excessive caffeine or alcohol (caffeine relaxes the muscle between the stomach and esophagus, which can stimulate diarrhea), and eating excessive amounts of fatty or sugar-containing foods.

If an athlete complains of having diarrhea, recommend that he or she:
Increase fluids to mitigate dehydration.
Eat small amounts of food throughout the day.
Consume foods and beverages containing sodium and potassium. Good choices are broth, sports drinks, pediatric electrolyte solutions, bananas, nectars, and boiled or mashed potatoes.

Certain low-fiber foods can also help alleviate diarrhea. These foods include: yogurt, rice, noodles, creamed wheat, grape juice, smooth peanut butter, white bread, lean meats, cottage cheese, and cream cheese. In addition to these foods, recommend that your affected athletes drink room-temperature beverages, reduce caffeine intake, avoid concentrated sweets, limit the intake of sorbitol-containing foods such as apple juice, avoid dried fruit and prune juice, and avoid products with senna or cascara in them. Also avoid antacids that contain magnesium.

For athletes who have to take antibiotics, probiotics (the bacteria found in certain foods) may help prevent antibiotic-associated diarrhea. The recommendation is to eat two cups per day of yogurt that contains live cultures of lactobacillus acidophilus (the label should indicate this). Don't eat yogurt within two-to-three hours of taking tetracycline because the calcium interferes with tetracycline's absorbability. Anyone taking tetracycline or any other antibiotic should consult with a physician or pharmacist about which foods to avoid.

Another recommendation is pectin. It is sold in the grocery stores under many product names and it should be mixed as follows: Mix one tablespoon of pectin into one-quarter cup of water or lemon juice. Drink it about 20 minutes before a meal. This solution can help slow the emptying of the bowel after meals.

Problems with gas and bloating can be both embarassing and uncomfortable, but the pain associated with gas and bloating is most bothersome.

Passing gas is a very normal occurrence for the body. Bloating, however, is analagous to a gastrointestinal traffic jam: it typically occurs when the intestine cannot effectively move food and fluid through the digestive tract.

Bloating should not be confused with belching. Belching is usually the result of a person swallowing excessive amounts of air. Often, this is a result of gulping down liquids or eating too fast. It is harmless most of the time, and may be more of a nervous habit than a medical concern.

The following foods may contribute to excessive intestinal gas: cabbage-family foods such as broccoli, Brussels sprouts, cabbage, cauliflower, and kohlrabi; fructose-containing foods, including most fruits; plus sorbitol- and mannitol-containing foods such as sugar-free gums, mints, and apple juice.

In addition to eating certain foods, changes in eating habits or patterns can induce excessive intestinal gas. For example, suddenly adding a lot of fiber to a diet or going on a fad diet can kick intestinal gas production into high gear.

Many commercial medications and supplements cater to those seeking to reduce intestinal gas. The most effective medications include activated charcoal, bismuth-containing stomach remedies, and simethicone.

Activated charcoal may absorb some of the gas to produce less bloating, but it does not seem to be effective in reducing flatulence. Since charcoal may interfere with the absorption of medications, it should be taken two hours before or after other medications. Bismuth preparations can not only ease gas production, they can also reduce intestinal gas odor, because the bismuth binds with the sulfur in intestinal gas to absorb odors. Simethicone may help to break up the gas bubbles, but does not help with intestinal gas odor. Antacids do not decrease intestinal gas, and products containing bicarbonate or carbonate may actually make gas worse.

Some dietary supplements can be beneficial in treating intestinal gas, including enzymes, nutra flora, and chlorophyll. Enzyme supplements are often advertised as providing relief from flatulence, which is basically true. These enzymes break down the indigestible carbohydrates in foods such as beans, dried fruits, and cabbage-family vegetables, before they reach the colon. The result is less gas.

These enzymes are available in tablet form or as drops. Tablets need to be taken before meals. The drops can be added to food right before eating, but cannot be added to food that is steaming hot. Heat destroys the enzyme, and thus the effectiveness of the supplement.

Chlorophyll may be helpful with fecal odor, but it may turn your stools green. Nutra flora is a carbohydrate that can reduce odor, but it may also cause gas and bloating in some people.

Dietary and herbal supplements are very popular, and athletes consume them for many reasons. However, several types of dietary supplements can actually increase gas or bloating. If an athlete complains of these symptoms, ask if he or she regularly consumes any supplements. For example, products such as pectin, probiotics, and S-adenosyl-methionine can produce gas, while bone meal, borage oil, calcium, evening primrose oil, fructo-oligosaccharides, glucomannan, and psyllium husk produce both gas and bloating.

As with most gastrointestinal conditions, there are certain eating habits, foods and beverages that can cause excessive gas. Foods that can create gas include dried beans (kidney, lima, navy, pinto, black, garbanzo), cabbage-family vegetables, bran, cucumbers, carbonated beverages, sugary alcoholic drinks, wheat, oats, corn, lactose (if one is lactose intolerant), and fatty foods (fried meats and vegetables, doughnuts, cream sauces, oily sauces).

Eating habits that can induce intestinal gas production include chewing gum, gulping foods, talking while eating, and drinking through a straw.

The problem of heartburn actually is gastroesophageal reflux disease, which is also referred to as GERD, indigestion, or inflammation of the walls of the esophagus. There is a valve between the esophagus and stomach called the lower esophageal sphincter (LES). When this valve is doing its job, it relaxes only to allow swallowed food to pass from the esophagus to the stomach. With GERD, this valve is weakened, and it relaxes at the wrong time. The result is that acidic stomach content backs up into the esophagus. This acid is very irritating to the esophagus and can result in inflammation as well as pain.

Eating habits are a major contributor to heartburn. When people skip meals, they tend to overeat at the subsequent eating episode, which can distend the stomach. A distended stomach can cause the lower esophageal sphincter to relax and create GERD.

Certain foods and beverages relax the LES, such as peppermint candy or gum, chocolate, and alcohol. Often, people assume that acidic-tasting foods or beverages such as citrus or tomato products are the only items to limit. It may surprise your athletes to learn that coffee and alcohol also increase the production of the offending stomach acid.

Other foods that potentially can cause reflux problems include fatty foods, capsaicin (the active ingredient in cayenne pepper), citrus drinks and juices, and high-protein diets. Alhough fat-containing foods do not promote reflux, some people find them to be bothersome. Citrus drinks and juices do not cause reflux, but the acidity of these foods may stimulate irritable sensory nerves in the inflamed esophagus.

Reflux problems can be worsened when people take certain dietary supplements and medications. The following medications and supplements may worsen symptoms: large doses of vitamin C, non-aspirin anti-inflammatories and pain medications, aspirin, white willow bark, theophylline, and some antibiotics.

If an athlete suffers from gastroesophageal reflux, recommend the following nutrition strategies that can provide relief: Have the athlete eat smaller, but more frequent meals. Evening meals should be lighter than normal. For between-meal snacks, fluids are better than solid foods. Chewing gum can stimulate saliva, which neutralizes stomach acid.

After eating a meal, have the athlete sit upright. Lying down on a couch after a large dinner increases the likelihood of gastroesophageal reflux occurring. Conversely, don't vigorously exercise after eating.

Lactose intolerance refers to a condition in which your body cannot properly digest lactose, which is the sugar found in dairy products. Normally, lactose is broken down by the enzyme lactase. When there is not enough lactase, the body cannot digest lactose. As the undigested lactose reaches the gut, it is broken down by bacteria and hydrogen gas is released. One in three individuals who think they are lactose intolerant are not. Instead, they are feeling bloated or have excessive gas due to other reasons.

Generally, lactose intolerance produces gastrointestinal symptoms such as excessive gas, diarrhea, and abdominal pain. Viral infestions may cause an increase in lactose intolerance, though it usually is temporary.

Treating lactose intolerance or maldigestion is based upon severity of symptoms, but typically, it involves changing one's diet by reducing the amount and frequency of lactose consumed, eating lactose-reduced foods, and taking supplemental lactase enzymes when eating lactose-containing foods.

A common question is, should a lactose-intolerant athlete avoid dairy foods altogether? The problem with avoiding dairy products is the elimination of a valuable source of calcium, protein, and other minerals from the diet. If your athlete must forego dairy foods, recommend the following non-dairy foods that are high in calcium: sardines, canned salmon, tofu, shellfish, turnip greens, collards, kale, dried beans, broccoli, calcium-fortified orange juice, and calcium-fortified soy milk.

Fortunately, almost everyone can adapt to lactose and increase their tolerance of it in their diets. However, it will take time and it will require careful diet management. If your athlete has been avoiding lactose, it is important to proceed slowly. Here are some suggestions to improve tolerance:

Start with small amounts of dairy products, such as a half cup of milk or an ounce of cheese. At first, include one dairy food item a day, and gradually increase to one lactose-containing food per meal. Be sure to start with foods that contain low levels of lactose.

Milk or dairy foods should be consumed with a meal or snack, not alone. This slows the emptying time of the stomach and it gives your system more time to process the lactose.

Suggest warm milk. Some people find that heating the milk improves tolerance.

Lactose-free or lactose-reduced milk can be helpful. Adding lactase enzyme drops to milk is also effective (this must be done 24 hours before you plan on drinking the milk), or take lactase tablets immediately before you eat dairy foods.

Cheddar, Swiss, or aged cheeses are naturally lower in lactose than processed cheese, such as American.

Yogurt contains bacteria that naturally break down the lactose, and may be easier to digest.

Buttermilk may also be easier to tolerate as it is a fermented dairy food in which the lactose is already broken down by the fermentation process.

Teach your lactose-intolerant athletes to read labels carefully for words that can indicate the presence of lactose. For example, the following ingredients in foods typically indicate the presence of varying levels of lactose: butter and buttermilk, cheese, cream, milk (including chocolate, condensed, powdered, non-fat, and evaporated), goat's milk, ice cream and ice milk, margarine, milk chocolate, milk solids, sherbet, whey, and yogurt.

Although lactose intolerance and other gastrointestinal problems may be unavoidable, they do not have to keep an athlete from his or her sport. Work with your athletes by helping them to identify food triggers as well as troublesome eating habits. An athlete with gastrointestinal problems may benefit from a consultation with a registered dietitian as well. A happy athlete is one with a well functioning gut!

Irritable Bowel Syndrome, or IBS, is a very common, yet serious gastrointestinal problem. It affects one in 10 individuals, primarily women. IBS symptoms can include lower abdominal pain, constipation, diarrhea, alternating constipation and diarrhea, and bloating. IBS sufferers often report mucus in the stools. In general, people with IBS have very sensitive gastrointestinal tracts that cause symptoms in response to certain triggers, including stress, unusual physical activity, diet, and hormonal changes.

Women who have IBS may notice that their symptoms are worse around the time of the menstrual cycle. This is because the body secretes substances called prostaglandins, which can lead to an increase in abdominal cramps and diarrhea.

Some athletes with IBS find that physical activity creates the onset of symptoms such as cramping or diarrhea. IBS sufferers may find that jogging or aerobics leads to a dash to the toilet. Probably not the destination the jogger had in mind. The answer to this problem may be to reduce the other triggers such as stress or dietary factors.

Since one of the triggers for IBS symptoms is eating, many people with irritable bowel syndrome make drastic changes in food choices or meal size and frequency. When we eat, the stomach stretches and releases hormones which prepare the intestine for food digestion. For those with IBS, a few bites of food can cause the bowel to react, leading to pain or a need to rush to the bathroom. Obviously, that is something that needs to be treated by a physician or registered dietician.

When treating IBS, symptom relief while achieving and maintaining good nutritional health are the primary goals. Treatment needs to be individualized, but typically includes medications, carefully selected diet and eating habits, pain management, and, in some cases, supplements.

Medications prescribed for IBS depend on the symptoms, but the following are some of the commonly prescribed medications:

For pain, antispasmodic medications are taken before a meal to decrease the reactivity of the bowel. Consult with your physician about which medications to take. People wishing to avoid prescription and over-the-counter drugs can try peppermint oil capsules or tea during meals. However, if your athlete is experiencing heartburn, you should not use peppermint oil because it can aggravate this condition.

For diarrhea, products containing loperamide, cholestyramine (cholestyramine is available by prescription), and bismuth are useful. Again, consult with a physician.

For constipation related to IBS, treatment is similar to normal constipation, with recommendations that athletes add the following to their diets as necessary: fiber, osmotic laxatives, stool softeners, and cisapride (cisapride is available by prescription).

To decrease intestinal sensitivity to food, activity, and stress, tricyclic antidepressants are sometimes prescribed.

Nutrition solutions to IBS begin with the elimination of foods that can trigger symptoms. Potential trigger foods include fried foods, dried beans, caffeine, carbonated beverages, alcohol, cabbage-family vegetables, sugar alcohols (sorbitol, mannitol in sugar-free products, apple juice), fructose (in fruits and juices), and lactose.

The goal is not to eliminate all the foods listed above. Instead, encourage the athlete to pick those eaten most frequently, and remove them from the diet for two weeks to see if there is a difference in symptoms. Then, reintroduce these foods and see what happens. The emphasis should be on what your athletes can have, not what they can't have. Whenever experimenting with the diet as described above, have your athletes make any changes gradually. The bowel is already in a super sensitive state, so making sweeping changes in diet almost always leads to more symptoms. Proceed slowly, one bite at a time, and one food at a time.

Since outside stress can trigger IBS, it is very important to make mealtimes relaxed and as stress free as possible. Affected athletes should sit down, turn off the computer, avoid the phone, and try to concentrate on enjoying the food. In addition, work with the athletes to help them establish an eating schedule.

Pain management for IBS is important. If your athlete is very uncomfortable after meals, he or she may want to try a heating pad or hot water bottle wrapped in a towel on the abdomen. The warmth may help to lessen abdominal spasms and decrease pain. Some people find that relaxation techniques such as biofeedback and deep breathing can help with pain management. Progressive muscle relaxation can help athletes to learn how to calm the gut.

Some people find that when they are in pain, but don't need to rush to the bathroom, physical exercise can be an effective diversion. When one exercises, blood circulates to other areas of the body away from the bowel. Exercise may help to normalize intestinal contractions. A pleasant walk, a swim, or even a bike ride may help. Exercises such as T'ai Chi and yoga can also be very soothing to the gut.

There are several supplements that may be of benefit in reducing abdominal pain, but one must experiment gradually, trying one item at a time to see if there is any symptom relief. For example, some people have found relief with enteric coated peppermint oil capsules. The dosage is 0.2 ml of peppermint oil taken three times a day, 15 to 30 minutes before meals.

Chamomile can also be useful for decreasing abdominal spasms. A tablespoon of the dried herb can be mixed with eight ounces of boiling water and consumed as a tea. To make a medicinal tea, pour eight ounces of boiling water over the herb, cover, and let stand for five to 10 minutes, then strain and drink. The tea can be consumed up to four times a day. If your athletes have hay fever or are sensitive to pollens, they should not use chamomile.

Some people have found that probiotics can be extremely helpful. Probiotics are friendly bacteria that live in the digestive tract. They may help to alleviate the symptoms of IBS. The most well known probiotics are acidophilus and bifidum which are commonly found in yogurts with live cultures. Probiotic supplements should contain 4-10 billion CFUs (Colony Forming Units). Since probiotics are alive, be sure to check the expiration date on the package and check the label to see if you need to refrigerate the supplement. Encourage athletes to use yogurt with live active cultures.