Running and Gastrointestinal

Discomfort:
Causes and Cures
by Kris Osterberg, M.S., R.D.

Senior Scientist, Gatorade Sports Science Institute

Many athletes have experienced

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

FACTORS THAT CONTROL

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

GASTRIC EMPTYING RATE

AND EXERCISE:
Gastric emptying rate is not
substantially affected at intensities lower
than 70-75% of maximal effort or
VO2MAX. That’s good news for most of
your runs in which hydration is an
important factor, such as during half or
full marathons or long training runs.
Your choice of food and fluid is an
important consideration to help prevent
GI discomfort during these longer
efforts; for that reason, we’ll explore
how these principles relate to your
training. First, let’s backtrack a bit and
talk about why fluid and carbohydrate
are important while you exercise.
Your body requires fluid to replace
sweat losses and help maintain blood
volume while carbohydrates fuel your
muscles and brain during exercise.
Carbohydrate is your muscles’ preferred
fuel during moderate- to high-intensity
exercise and is stored in two locations in
your body in the form of glycogen: your
liver, which helps control blood sugar
(glucose) levels between meals, and
your muscles. The carbohydrate that is
stored in muscles is only used during
exercise; an athlete can store 300-400
grams of carbohydrate in the muscles if
they are eating a high carbohydrate diet.
This is enough energy to fuel 90-100
minutes of moderate- to high-intensity
exercise. If no carbohydrate is ingested
during exercise to supplement the
carbohydrate stored in the body, the
muscles will be forced to rely on fat for
fuel. Fat is plentiful even in the leanest
athlete, but is broken down slowly and
requires so much oxygen to convert it
into fuel, that running speed must
drastically decrease if fat becomes the
predominant fuel. Running low on
carbohydrate during a race is what
runners know as ‘hitting-the-wall’ or
‘bonking’ because the switch to
predominantly fat metabolism limits the
muscles ability to produce energy
quickly. Therefore, it is crucial to have
some sort of fluid and carbohydrate
intake during training and races. And if
your intake is not carefully planed, you
could end up with GI discomfort!
As mentioned above, the amount of
energy (i.e., the number of calories) you
choose to consume at any one time will
impact the rate of gastric emptying.
Research has shown that beverages that
contain 1-6% carbohydrate (6 grams per
100 ml of water; 14 grams per 8-oz)
empty from the stomach at the same rate
as water. Water has no calories and
empties from the stomach quickly but
does not provide any fuel for the muscle.
Beverages with carbohydrate
concentrations greater than 6% impede
gastric emptying. Again, the faster fluids
leave your stomach, the less likely they
are to cause problems such as sloshing
and bloating. Fluids that remain in the
stomach and intestine due to high caloric
content are not readily available to
provide hydration and fuel for the body
and more likely to cause GI discomfort.
From a practical standpoint, water and
sports drinks with carbohydrate
concentrations less than or equal to 14
grams per 8 oz fall into the 0-6%
category. Other macronutrients (i.e.,
protein or fat) added to carbohydrate are
additional calories and, unless the
carbohydrate concentration is very low,
will impede gastric emptying. Gels and
sports bars are commonly consumed
during training and racing. Care must be
taken when using these products,
however, because they contain a very
concentrated form of carbohydrate. Gels
and bars should be ingested judiciously
by taking in only a portion at a time and
in combination with water. Washing
down a gel with a sports drink increases
the carbohydrate content of both which
can impede gastric emptying; so it is
best to use water when consuming a gel
or a bar. Again, from a practical
standpoint, a gel packet that contains 25
grams of carbohydrate should be diluted
with 14 oz of water to bring it down to
the 6% carbohydrate level. Consuming
half of the gel packet would bring your
recommended fluid intake to about 7oz
of water, making fluid intake more
manageable. Most energy bars contain
about 45 grams of carbohydrate so a bar
should be chased with 22 oz of water to
dilute them. Eating a portion of the bar
with 5-6 oz of water is a better
alternative when it comes to your GI
comfort.
Another factor which impacts gastric
emptying during exercise is hydration
status. As an individual dehydrates,
gastric emptying slows, increasing the
risk of upper GI problems such as
burping, sloshing, and bloating.
Therefore, you’re much more likely to
experience GI discomfort toward the end
of a race than at the beginning.
Replacing sweat losses early in a race
will be beneficial later in the race not
only because hydration helps maintain
cardiovascular and thermoregulatory
function, but also because any calories
taken in toward the end of the race will
be better tolerated.

INTESTINAL ABSORPTION:
Intestinal absorption is the final
barrier fluids and nutrients face before
entering the bloodstream. Like gastric
emptying, the rate at which a fluid is
absorbed is also dependent upon several
factors. As previously stated, the
carbohydrate concentration will
determine, in part, the rate at which a
fluid is absorbed - concentrations at or
below 6% are absorbed at the same rate
as plain water. Another important
consideration is osmolality, which is just
a fancy word referring to the number of
particles in a solution. Inside the small
intestine, water is attracted into areas of
greater particle concentration. When you
ingest a fluid that is near the osmolality
of the blood (hypo- or isotonic), water
will generally flow out of the small
intestine and into the blood. When you
ingest a beverage that has a significantly
greater osmolality than the blood, water
moves from the blood and into the small
intestine. This is not what you want
during exercise because water drawn
into the small intestine usually results in
runner’s trots (i.e. diarrhea). The good
news is you can prevent this from
happening by regulating the osmolality
of the liquids you intake. Many factors
affect osmolality, including the amount
as well as the type of carbohydrate
ingested. The small intestine has
transporters specific to carbohydrate
type, primarily glucose and fructose.
Glucose is actively transported while
fructose is absorbed passively through a
process called facilitated diffusion.
When both sugars are present in a sports
drink the body can activate multiple
transporters, allowing a greater amount
of carbohydrate and fluid into the blood
which leads to greater fluid replacement
(i.e. preventing dehydration) and
providing fuel for the muscle.
Maintaining hydration as well as
optimizing carbohydrate delivery to the
muscle will allow you to run faster for a
longer period of time. If a beverage
contains only one type of sugar, the
transporters are quickly saturated and
absorption slows, increasing your chance
of GI discomfort. Fructose should not be
confused with high fructose corn syrup
(HFCS), however. HFCS is a
combination of glucose and fructose and
entirely appropriate for a sports drink
formulation as long as the ratio of
glucose to fructose is equal to or greater
than one (i.e. glucose > fructose).
Unfortunately, there is no easy way to
determine the ratio of glucose to fructose
in your drink as it will not be indicated
on the label. However, you can contact
the company that makes the product and
they will provide you with that
information.

INTESTINAL ABSORPTION,
EXERCISE, AND
CARBOHYDRATE
OXIDATION:
Improving intestinal absorption of
fluid and carbohydrate is not only an
important consideration for hydration
and reducing GI distress but also for the
delivery of carbohydrate to the muscle
for use as fuel. Researchers from the
University of Birmingham in the UK
have published several ground breaking
studies investigating the effects of
ingesting different types of sugars on
carbohydrate oxidation; the amount of
carbohydrate being used by the body
during exercise. They have found that
when only one type of carbohydrate
(e.g., glucose) was ingested during
cycling, carbohydrate oxidation peaked
at about 1 gram of carbohydrate per
minute or 60 grams per hour. When
subjects ingested a mixture of
carbohydrate (e.g., glucose and fructose)
while cycling, carbohydrate oxidation
increased to 1.75 grams of carbohydrate
per minute or a 50% increase over
glucose alone. (For more info see
Mueller’s article in 16.3 May/June
2007.) The practical implications of this
study are clear in that a mixture of
carbohydrate improves intestinal
absorption and carbohydrate oxidation.
However, the rate at which carbohydrate
was ingested in this study (1.8 grams per
minute) may have impacted gastric
emptying in subjects exercising at a
higher intensity. Nevertheless, improving
absorption ultimately improves blood
glucose levels and provides the muscle
with fuel to continue to exercise at a
high intensity.
Whether a running neonate or veteran,
we all have one thing in common: we
would all like to feel good every time
we run. Though many factors contribute
to the quality and enjoyment of our runs,
GI discomfort, is one that can be
controlled once you know the principles
at work. Train your GI system in the
right way and you will be able to
eliminate one “unknown” from your
mental checklist.

The End
The End